Term
| Risk factors for pediatric adverse drug reactions are? |
|
Definition
| Hx of past ADRs, extremes of age, impaired drug clearance, polypharmacy, female sex, higher drug dose, certain genetic polymorphisms |
|
|
Term
| Risk of ceftriaxone in 3 day old full-term infant is |
|
Definition
|
|
Term
| Lungs continue to grow and mature until what age? |
|
Definition
|
|
Term
Which is most likely to cause an altered pharmacodynamic drug response in infants?
A. Skin surface area?
B. Pulmonary surface area
C. Reduced receptor number
D. Impermeable blood-brain barrier |
|
Definition
| C. Reduced receptor number |
|
|
Term
| PO absorption factors with children are? |
|
Definition
| stomach pH, transit time and diet |
|
|
Term
| When does acid secretion start to occur with infants? |
|
Definition
| Weeks to months; born neutral |
|
|
Term
| What are the hepatic Phase 1 enzymes? |
|
Definition
|
|
Term
| What are the hepatic Phase 2 enzymes? |
|
Definition
| Sulfation, methylation, acetylation |
|
|
Term
| What are the renal phase 2 enzymes? |
|
Definition
| Glucuronidation, methylation and acetylation |
|
|
Term
| What are the pulmonary phase 2 enzymes? |
|
Definition
| Acetylation, glucuronidation and methylation |
|
|
Term
| What are four drug distribution differences in children? |
|
Definition
Body composition (water, adipose tissue)
Protein binding
Drug transporters (p-glycoprotein)
Drug factors |
|
|
Term
| What is the general cytochrome P450 activity in term neonates? |
|
Definition
| Low activity at birth with gradual increase |
|
|
Term
| Activity level of CYP 1A2 ? |
|
Definition
Minimal fetal activity
Increased in childhood and then back to adult activity by 4-5 months
Ex. Methylxanthines |
|
|
Term
| Activity level of CYP 2C9 ? |
|
Definition
Low activity at birth
Exceeds adult activity during childhood and then returns to adult activity
Ex. NSAIDS |
|
|
Term
|
Definition
Activity rapidly increases within first 2 weeks of life
Ex. PPIs, AEDs |
|
|
Term
|
Definition
Low to absent in fetus
Rapid acuisition of activity (about 2 weeks; mature by 10 years
Ex. Many drugs, including codeine
Ethnic differences |
|
|
Term
|
Definition
Fetal efficiency is 30- 70% of adult and increases during the first year
Ex. Many drugs |
|
|
Term
| Tubular excretion slowly matures until what age? |
|
Definition
|
|
Term
| Codeine is a prodrug converted by CYP2D6 to what drug? |
|
Definition
|
|
Term
| The FDA has issued a warning regarding the use of codeine in children after what surgery and why? |
|
Definition
| Tonsillectomy and/or adenoidectomy due to the higher risk of respiratory adverse effects because of the recent surgery involving the upper airways. |
|
|
Term
| What are the risk factors for pediatric adverse drug reactions? |
|
Definition
History of past ADRs
Extremes of age
Impairment of drug clearance
Polypharmacy
Female sex
Higher drug dose
Certain genetic polymorphisms |
|
|
Term
| Name 3 age associated pathophysiology and disease. |
|
Definition
|
|
Term
| What is the most common malignancy in childhood? |
|
Definition
| Leukemia 26% of all cancers in children |
|
|
Term
| What are the 2 major types of childhood leukemia and the incidence of each? |
|
Definition
ALL Acute Lymphoblastic Leukemia 80%
AML Acute Myelogenous Leukemia 20% |
|
|
Term
| T or F ALL is the leading cause of childhood cancer death despite improvements in outcome and very good overall survivial rates |
|
Definition
|
|
Term
| Etiology of pediatric ALL? |
|
Definition
| Unknown, but results in proliferation of abnormal lymphoblasts of precursor B-call or T-cell lineage. Also genetic aberrations contribute to the development of abnormal clones resulting in biological subtypes of ALL |
|
|
Term
| Epidemiology of pediatric ALL? |
|
Definition
Peak incidence 2 to 4 years old
More common in males than females: white and hispanic more than African Americans |
|
|
Term
| Presentation of pediatric ALL? |
|
Definition
Non-specific clinical presentation that may mimic other childhood diseases.
Fever, bleeding, bone pain,lymphadenopathy, hepatoslenomegaly, abnormal hematopoiesis. |
|
|
Term
| T or F Poorer prognosis for pediatric ALL if less than 1 year of age, greater than 10 years of age at diagnosis and total leukocyte cell count > 50K/mm3 |
|
Definition
|
|
Term
| Three drug induction therapy for standard risk ALL is ? |
|
Definition
| Vincristine, dexamethasone and pegasparaginase (CNS prophylaxis with intrathecal therapy) |
|
|
Term
| High risk/Very High risk induction therapy for pediatric ALL is ? |
|
Definition
Vincrisine, steroid,pegasparaginase and daunorubicin.
steroid = dexamethasone for < 10 yo and prednisone for >= 10 yo |
|
|
Term
| What are the 4 phases of therapy for Post-Induction treatment of ALL? |
|
Definition
Consolidation
delayed intensification
Interim maintenence
Maintenence (targeting ANC with thiopurines)
Depends on risk category and can be 2.5-3 years |
|
|
Term
| BCR/ABL 1 chromasome test is an indicator for pediatric AML. T or F |
|
Definition
| False, for ALL, BCR/ABL 1 is also known as the Philadelphia translocation (Ph+). |
|
|
Term
| Treatment of Ph+ ALL may include what class of drugs but pediatric studies data lags that of adults? |
|
Definition
tyrosine kinase inhibitors
-Imatinib
-Dasatinib |
|
|
Term
| T or F? Outcomes of adolescent and young adult ALL are improved when they are treated with adult protocols, rather than pediatric protocols. |
|
Definition
|
|
Term
| What side effect does dexamethasone have when used in children > 10 yo for ALL induction therapy? |
|
Definition
|
|
Term
| There is an increased risk of fungal disease when using dexamethasone with what ALL induction medication? |
|
Definition
|
|
Term
| What is the Bedside Schwartz Equation? |
|
Definition
GFR (ml/min/1.73m2) = 0.14 x L/SCR
Recommended in 2009 due to overestimation of GFR |
|
|
Term
|
Definition
| The development of an individual from fertilization to maturity. |
|
|
Term
| Mercaptopurine pharmacogenomic risk? |
|
Definition
| Patients with reduced TPMT ( thiopurine S methyl transferase) likely to get toxicity i.e. Neutropenia) |
|
|
Term
| What do the genetic variations of codeine cause in children? |
|
Definition
| Changes in metabolism. Rapid metabolizers of codeine to morphine can cause opiate toxicity. |
|
|
Term
| What drug is more effective for certain CF patients and why? |
|
Definition
Ivacaftor (Kalydeco or VX-770)
It is more effective with patients with the G551D mutation genotype |
|
|
Term
| What drugs will have minimal effect if given in the small bowel (jejeunum)? |
|
Definition
| Antacids. Sucralfate. Bismuth. Because they bypassed the stomach. |
|
|
Term
| What type of drugs have greater absorption and systemic effect when given in the jejeunum? |
|
Definition
| Drugs that undergo extensive first pass metabolism i.e. Opioids, tricyclic antidepressants |
|
|
Term
| What are the advantages of sublingual drug route? |
|
Definition
| Bypasses first-pass metabolism, bypasses destruction by the stomach. |
|
|
Term
| What is the disadvantage of sublingual route in peds patients? |
|
Definition
| They will chew or swallow the drug |
|
|
Term
| What are the risk factors for pediatric adverse drug reactions? |
|
Definition
History of past ADRs
Extremes of age
Impaired drug clearance
Polypharmacy
Female sex
Higher drug dose
Certain genetic polymorphisms |
|
|
Term
| Name 3 age associated pathophysiology and disease. |
|
Definition
RDS. Lack of surfactant
Apnea. Centrally mediated in neonates. Obstructive or mixed in adults
Acne. Pubertal changes. Adults- systemic disease |
|
|
Term
| What are the 3 most common types of cancer in children? |
|
Definition
Leukemia 26%
CNS tumors 18%
Lymphomas 14%
2nd leading cause of death in children 5-14 yo
Accidents #1 |
|
|
Term
|
Definition
Peak incidence 2-4 yo
Males > Females
Whites/Hispanics > African Americans |
|
|
Term
|
Definition
Non specific presentation may mimic other childhood illnesses
Fever, bleeding, bone pain, lymphadenopathy, hepatosplenomegaly, abnormal hematopoesis |
|
|
Term
| The 2 major types of leukemia are |
|
Definition
ALL Acute Lymphoblastic Leukemia 80%
AML Acute Myelogenous Leukemia 20% |
|
|
Term
T or F
ALL is leading cause of childhood cancer death despite improvements in outcome and very good survival rates. |
|
Definition
T
Secondary to relapse rates and increased total number of patients with the disease |
|
|
Term
|
Definition
|
|
Term
T or F
ALL is more common in industrialized countries |
|
Definition
T
Possibly due to maternal exposure to paint, parental cigarette smoking, and higher birth weight |
|
|
Term
| ALL is caused by the proliferation of |
|
Definition
B and T cells
Genetic aberrations contribute to the development of abnormal clones and various subtypes. Origin unknown. |
|
|
Term
| Genetic risk factors of ALL are |
|
Definition
Down's syndrome (10-20 x increase)
Bloom syndrome
Dancing anemia
Nijmegen breakage syndrome
Immunodeficiency syndromes |
|
|
Term
| ALL poor prognostic features are |
|
Definition
Less than 1 yo or > 10 yo at diagnosis
WBC > 50,000 at diagnosis
Presence of CNS or testicular involvement
Poor response to induction therapy
Unfavorable MLL rearrangements, hypodiplody, Philadelphia chromasome aka t(9,22), Ph+, or BCR/ABL
Intrachromasomal amplification of chromasome 21 (iAMP21) |
|
|
Term
| Pathology evaluation of ALL includes |
|
Definition
| Blood and bone marrow evaluation for blasts and cytogenic abnormalities |
|
|
Term
| Favorable genetic abnormalities for ALL |
|
Definition
Trisomy 4 and 10
ETV6/RUNX1 |
|
|
Term
| Standard Risk ALL 3 drug induction therapy is |
|
Definition
Vincristine, dexamethasone, pegasparaginase
CNS prophylaxis with intrathecal therapy |
|
|
Term
| High Risk ALL Induction drug treatment is |
|
Definition
Vincristine, steroid, pegasparaginase, daunorubicin
Steroid = dexamethasone < 10 yo
10 yo &> = prednisone |
|
|
Term
| Why do adolescents with high risk ALL receive prednisone instead dexamethasone? |
|
Definition
| Dexamethasone can cause osteonecrosis in adolescents |
|
|
Term
| Consolidation therapy for ALL generally uses what 3 drugs ? |
|
Definition
Cyclophosphamide
Low/intermed cytarabine
Thiopurine |
|
|
Term
| Interim maintenance therapy ALL |
|
Definition
Methotrexate
Intermittent dexamethasone |
|
|
Term
| Length of maintenance therapy ALL |
|
Definition
2-3 years
Pulses of therapy depending on ANC
Compliance to oral therapy reduces relapse risk |
|
|
Term
| Why do patients receive prophylaxis CNS therapy during induction ALL therapy |
|
Definition
| CNS serves as a sanctuary site for disease-- contributes to relapse |
|
|
Term
T or F
BMT is standard therapy for ALL |
|
Definition
F
Only for specific high risk failures or after relapse or progressive disease |
|
|
Term
| What drug is added for BCR/ABL1 ALL disease and what is the major side effect? |
|
Definition
Imatinib
Transaminitis. Give 2 weeks on/2 weeks off
Dasatinib shows promise in clinical trials, data not mature |
|
|
Term
T or F
Results of clinical trials have shown that adolescents and young adults with ALL have improved outcomes when they use adult protocols |
|
Definition
F
Pediatric protocols better
May be due to increased intensity of therapy |
|
|
Term
Infants with ALL have better outcomes than young children
T or F |
|
Definition
F
Due to high frequency of ALL rearrangements and high rate of relapse/recurrence
Death during induction rates are higher |
|
|
Term
| What drug side effect of methotrexate in patients with Downs and ALL is more frequent ? |
|
Definition
Mucositis
Give leucovorin after induction and consolidation MTX. Lower MTX dosing. |
|
|
Term
T-cell ALL patients have better outcomes than B-cell patients.
T or F |
|
Definition
F
Trials have included nelarabine |
|
|
Term
| What issues do ALL survivors have? |
|
Definition
Growth deficiency
Neurocognitive deficits
Endocrinopathies
Increased rate of secondary cancers |
|
|
Term
|
Definition
Unknown but results in abnormal myeloid, erythronium, monocytic and megakaryocytic cell precursors
Hispanic>other races |
|
|
Term
|
Definition
Similar to ALL - fever, malaise, bone pain, cytopenias, plus other characteristics (chloromas)
Acute oromyelocytic leukemia (APL) may present with coagulopathies |
|
|
Term
|
Definition
| similar to ALL - pathologic evaluation of blood and bone marrow |
|
|
Term
| Name the 2 clinically relevant subtypes of AML |
|
Definition
| APL and Downs-associated AML |
|
|
Term
| T or F Treatment of AML is shorter and more intense than treatment of ALL |
|
Definition
|
|
Term
| What are the phases of AML treatment? |
|
Definition
Induction and intensification (or post-remission). Each phase uses includes cytarabine with 1 or more conventional chemotherapeutic agents (daunorubicin, mitoxantrone)
Maintenance therapy generally not done, except APL
HSCT (allogenic hematopoetic stem cell transplant) indicated for high risk disease after 2-3 courses chemo in first remission |
|
|
Term
|
Definition
Collaborative trial between COG and CALGB investigated addition of tretinoin (all-trans-retinoic acid, ATRA)to extended maintenance
Therapy includes several cycles of cytarabine, an antracycline, tretinoin and maintenance
Arsenic trioxide in consolidation has been looked at to reduce and reduction of anthrcycline exposure. |
|
|
Term
|
Definition
Low risk- Core-binding factor (CBF) leukemias: t(8,21) inv 16
High risk- Chromasomal deletions: monosomy 5,6, 5qdel, FLT3/ITD
Special Populations- APL, Myloid leukemia of Downs Syndrom MLDS |
|
|
Term
| T or F MLDS has 10-20x more likelihood of developing leukemia |
|
Definition
T
but have higher survival and lowe relapse rate possibly due to greater sensitivity to cytarabine due to incr blasts and genetic mutations |
|
|
Term
| Late complications of AML are |
|
Definition
Treatment related mortality, particularly infectious- adolescent and young adults, higher in obese and higher BMI
Relapse
Late effect in survivors-- anthracycline induced cariotoxicity and secondary malignancies |
|
|
Term
|
Definition
| similar to ALL - pathologic evaluation of blood and bone marrow |
|
|
Term
| Name the 2 clinically relevant subtypes of AML |
|
Definition
| APL and Downs-associated AML |
|
|
Term
| T or F Treatment of AML is shorter and more intense than treatment of ALL |
|
Definition
|
|
Term
| What are the phases of AML treatment? |
|
Definition
Induction and intensification (or post-remission). Each phase uses includes cytarabine with 1 or more conventional chemotherapeutic agents (daunorubicin, mitoxantrone)
Maintenance therapy generally not done, except APL
HSCT (allogenic hematopoetic stem cell transplant) indicated for high risk disease arter 2-3 courses chemo in first remission |
|
|
Term
|
Definition
Collaborative trial between COG and CALGB investigated addition of tretinoin (all-trans-retinoic acid, ATRA)to extended maintenance
Therapy includes several cycles of cytarabine, an antracycline, tretinoin and maintenance
Arsenic trioxide in consolidation has been looked at to reduce and reduction of anthrcycline exposure. |
|
|
Term
|
Definition
Low risk- Core-binding factor (CBF) leukemias: t(8,21) inv 16
High risk- Chromasomal deletions: monosomy 5,6, 5qdel, FLT3/ITD
Special Populations- APL, Myloid leukemia of Downs Syndrom MLDS |
|
|
Term
| T or F MLDS has 10-20x more likelihood of developing leukemia |
|
Definition
T
but have higher survival and lowe relapse rate possibly due to greater sensitivity to cytarabine due to incr blasts and genetic mutations |
|
|
Term
| Late complications of AML are |
|
Definition
Treatment related mortality, particularly infectious- adolescent and young adults, higher in obese and higher BMI
Relapse
Late effect in survivors-- anthracycline induced cardiotoxicity and secondary malignancies |
|
|
Term
|
Definition
| similar to ALL - pathologic evaluation of blood and bone marrow |
|
|
Term
| Name the 2 clinically relevant subtypes of AML |
|
Definition
| APL and Downs-associated AML |
|
|
Term
| T or F Treatment of AML is shorter and more intense than treatment of ALL |
|
Definition
|
|
Term
| What are the phases of AML treatment? |
|
Definition
Induction and intensification (or post-remission). Each phase uses includes cytarabine with 1 or more conventional chemotherapeutic agents (daunorubicin, mitoxantrone)
Maintenance therapy generally not done, except APL
HSCT (allogenic hematopoetic stem cell transplant) indicated for high risk disease arter 2-3 courses chemo in first remission |
|
|
Term
|
Definition
Collaborative trial between COG and CALGB investigated addition of tretinoin (all-trans-retinoic acid, ATRA)to extended maintenance
Therapy includes several cycles of cytarabine, an antracycline, tretinoin and maintenance
Arsenic trioxide in consolidation has been looked at to reduce and reduction of anthrcycline exposure. |
|
|
Term
|
Definition
Low risk- Core-binding factor (CBF) leukemias: t(8,21) inv 16
High risk- Chromasomal deletions: monosomy 5,6, 5qdel, FLT3/ITD
Special Populations- APL, Myloid leukemia of Downs Syndrom MLDS |
|
|
Term
| T or F MLDS has 10-20x more likelihood of developing leukemia |
|
Definition
T
but have higher survival and lowe relapse rate possibly due to greater sensitivity to cytarabine due to incr blasts and genetic mutations |
|
|
Term
| Late complications of AML are |
|
Definition
Treatment related mortality, particularly infectious- adolescent and young adults, higher in obese and higher BMI
Relapse
Late effect in survivors-- anthracycline induced cariotoxicity and secondary malignancies |
|
|
Term
|
Definition
| similar to ALL - pathologic evaluation of blood and bone marrow |
|
|
Term
| Name the 2 clinically relevant subtypes of AML |
|
Definition
| APL and Downs-associated AML |
|
|
Term
| T or F Treatment of AML is shorter and more intense than treatment of ALL |
|
Definition
|
|
Term
| What are the phases of AML treatment? |
|
Definition
Induction and intensification (or post-remission). Each phase uses includes cytarabine with 1 or more conventional chemotherapeutic agents (daunorubicin, mitoxantrone)
Maintenance therapy generally not done, except APL
HSCT (allogenic hematopoetic stem cell transplant) indicated for high risk disease arter 2-3 courses chemo in first remission |
|
|
Term
|
Definition
Collaborative trial between COG and CALGB investigated addition of tretinoin (all-trans-retinoic acid, ATRA)to extended maintenance
Therapy includes several cycles of cytarabine, an antracycline, tretinoin and maintenance
Arsenic trioxide in consolidation has been looked at to reduce and reduction of anthrcycline exposure. |
|
|
Term
|
Definition
Low risk- Core-binding factor (CBF) leukemias: t(8,21) inv 16
High risk- Chromasomal deletions: monosomy 5,6, 5qdel, FLT3/ITD
Special Populations- APL, Myloid leukemia of Downs Syndrom MLDS |
|
|
Term
| T or F MLDS (myeloid leukemias of Downs syndrome) has 10-20x more likelihood of developing leukemia |
|
Definition
T
but have higher survival and lowe relapse rate possibly due to greater sensitivity to cytarabine due to incr blasts and genetic mutations |
|
|
Term
| Late complications of AML are |
|
Definition
Treatment related mortality, particularly infectious- adolescent and young adults, higher in obese and higher BMI
Relapse
Late effect in survivors-- anthracycline induced cariotoxicity and secondary malignancies |
|
|
Term
All malignant lymphomas exclusive of Hodgkin Lymphoma are Non-Hodgkins Lymphomas (NHL)
Name 3 types |
|
Definition
Burkitt or Burkitt-like lymphomas (40%)
Lymphoblastic lymphomas (35%)
Anaplastic Large Cell Lymphomas ALCL (8-13%)
Median age 10 yo
Males > females
White > black |
|
|
Term
| Hodgkins Lymphoma HL etiology |
|
Definition
|
|
Term
| Presentation of Hodgkins Lymphoma |
|
Definition
Similar to adults--
Painless lymphadenopathy cervical or supraclavicular
Generalized pruritis
Fatigue
Anorexia
Weight loss, fevers, night sweats |
|
|
Term
T or F
Non Hodgins Lymphomas are usually low-grade lymphomas |
|
Definition
F
Different than adults (low-grade) |
|
|
Term
|
Definition
Conventional chemo, possible monoclonal antibodies and tyrosine kinase inhibitors (trials ongoing)
Lymphoblastic lymphoma treated like ALL, longer duration, Burkitts -- shorter more intensive therapy -- ALCL short and intensive, amint therapy did not change long-term outcomes; Watch for tumor lysis syndrome with bulky disease |
|
|
Term
| Treatment Hodgkins Lymphoma |
|
Definition
Conventional chemotherapy and radiation
ABVE Doxo(Adria) bleomycin, vincristine, etoposide
ABVE-PC ABVE plus prednisone, cyclophosphamide
BEACOPP Bleo, etoposide, doxo, cyclophos, vincristine (Oncovin), prednisone, procarbazine
COPP Cyclophos, vincristine, prednisone, procarbazine
COP-DAC Cyclophosphamide, vincristine, prednisone, dacarbazine
OEPA/OPPA Vincristine, etoposide ( or procarbazine, prednisone, doxo
VAMP Vinblastine, doxo, methotrexate, prednisone |
|
|
Term
| Late complications of Hodgkins Lymphoma |
|
Definition
Pulmonary disease
cardiac disease
thyroid disease
secondary malignancies (i.e. breast)
Infertility |
|
|
Term
| How many courses of treatment for Hodgkins Lymphoma? |
|
Definition
| 2-4, depending on staging, with (sometimes without) radiation |
|
|
Term
| Survival of Hodgkins Lymphoma in % |
|
Definition
97% cure with new diagnosis
50% of relapse patients survive, relapse in first 12 months of initiating therapy carries poor prognosis |
|
|
Term
| Epidemiology of CNS tumors |
|
Definition
2nd most common cancer in children, 3rd most in adolescents
categorized by type of cells or tissues affected and aggressiveness of tumor- medulloblastoma: most common CNS tumor in children, median age 5-6 years old; Gliomas, 2nd most CNS 20-25% 5-10 yrs median; Ependymomas 3rd most (9 molecularly different disease states) |
|
|
Term
| Benign brain tumors do not present with significant symptomatology T or F |
|
Definition
|
|
Term
| Increase in the incidence of CNS tumors increased in the mid 1980s. What do experts think that caused it |
|
Definition
MRI machines and computer guided biopsy techniques
Association between radiation therapy various genetic syndromes (Li_Fraumeni, neurofibromatosis) |
|
|
Term
T or F
consumption of cured meats during pregnancy has not been shown to have an association with CNS tumors |
|
Definition
|
|
Term
| Symptomatology of CNS tumors |
|
Definition
| Atatxia, seizures, headache, hydrocephalus, diplopia, changes in vision, behavioral changes, significant N/V |
|
|
Term
| Treatment of medulloblastoma |
|
Definition
| Surgery, post-op radiation in age-eligible patients (>3 yo, chemo and supportive care; Survival 60-80% |
|
|
Term
|
Definition
Limited treaments for high=grade or brain stem gliomas
Surgery not possible
Radiation usually palliative
Chemo considered palliative but trials have shown chemo and targeted agents may improve response to radiation; Survival brainstem gliomas (DIPG) 10%, less 1 yr, other giomas vary |
|
|
Term
|
Definition
Surgery, goal of total resection + radiation to prevent recurrence.
Chemo limited benefit, except for situations were total resection not possible (under investigation) |
|
|
Term
| T or F Neuroblastoma is the most common extracranial solid tumor of childhood |
|
Definition
| T 7% of all childhood cancer |
|
|
Term
| Epidemiology of neuroblastoma |
|
Definition
non-Hispanic whites > other races, ethnicities
Male > female
Peak incidence before 4 yo, median diagnosis 19 months |
|
|
Term
| Pathophysiology and risk factors Neuroblastoma |
|
Definition
originates in adrenal medulla or paraspinal sites (i.e.from sympatheic nervous system)
spectrum of differentiation_ benign gangioneuroma to gangioneuroblastoma (malignant neuroblastoma)
1-2% familial
germline mutations in the ALK gene in up to 12% cases |
|
|
Term
| Presentation of neuroblastoma |
|
Definition
Abdominal mass or distension, pain, fever, weight loss, hypertension.
Also pancytopenia, periorbital ecchymosis, Horner syndrome, heterochromia,spinal cord compression, proprosis and nontender, bluish subcutaneous nodules
catecholamine screening in urine does not increase mortality, not recommended |
|
|
Term
|
Definition
Low-risk: Surgery, observation
Intermediate risk: surgery, multi-agent chemotherapy (4-8 cycles)
High Risk: Induction- Multi-agent standard chemotherapy (5-6 cycles) Consolidation- surgery, radiation, high dose chemotherapy, Autologous stem cell transplant; -Maintenance -immunotherapy (6 cycles of combo of ch 14.18, sargramostim, aldesleukin and isotretinoin) |
|
|
Term
|
Definition
| chimeric anti-disialoganglioside (GD2) antibody. GD2 is a glycolipid expressed on surface of neuroblastoma cells. Ch14.18 mediates anti-body dependent cellular cytotoxicity. FDA recently approved dinutuximab (Unituxin) and can increase survival of 20% of high risk patients |
|
|
Term
| Epidemiology of Wilms tumor (nephroblastoma) |
|
Definition
Most common renal tumor
Females > males
Black > other ethinicities
Peak incidence 2-3 yo, almost all cases < 6 yo
Mostly unilateral, 5-10% bilateral (bilateral usual familial) |
|
|
Term
|
Definition
Surgery (nephrectomy), radiation and conventional chemotherapy; depending on staging of disease and histology
VCR, doxo/dctino, cyclosporine, etoposide, carboplatin,irinotecan;
note: infatns vincristine dosing should be mg/kg dosing, not m2 |
|
|
Term
| Complications of Wilms tumor |
|
Definition
secondary malignancies
heart failure (doxo)
females: pregnancy related hypertension, premature labor, LBW infants |
|
|
Term
| Name the 2 most common bone cancers in children |
|
Definition
1. Osteosarcoma
2. Ewing sarcoma |
|
|
Term
| Epidemiology and presentation osteosarcoma |
|
Definition
3-5% childhood malignancies
peak incidence 2 decade of life
males > females
black > white
pain, mass or sweeling of joint or bone, 10-15% w/fractures, 50% in long bones |
|
|
Term
|
Definition
-pre-op chemo (cisplat/doxo with alternation HD MTX)
-local control = surgery, radiation
-post-op chemo, prevents relapse of localized tunors; no advantage to add interferon or ifos/etop |
|
|
Term
| Metastatic osteosarcoma has well defined treatment regimens T or F |
|
Definition
F
Survival metastatic 20-50%
non-metastatic 60-70% |
|
|
Term
| Ewing sarcoma epidemiology and presentation |
|
Definition
2nd most common bone cancer in children
median age 15 yo
mom-Hispanic whites > blacks
males = females
pain/swelling of affected area
25% have metastatic disease
symptoms, esp. with metastatic disese--anorexia, fatigue, weight loss, site-specific complications
positive for EWS/FL1 oncoprotein |
|
|
Term
| Prognostic features Ewing Sarcoma |
|
Definition
Negative: matastases, tumors > 8c, central/pelvic tumors, higher LDH, cytogenetics, Ewing's as a secondary neoplasm
Positive: distal exremeties, younger age, female |
|
|
Term
|
Definition
Similar to osteosarcoma (chemo-control-chemo)
Chemo: VDC/IE vincristine, doxo, cyclophos alternating with ifos and etoposide cycles alternate every 14 days (better than 21 day cycles)
Local control: surgery, radiation |
|
|
Term
| Rhabdomyosarcoma (RMS) epidemiology and symptoms |
|
Definition
most common soft tissue sarcoma in children
3% childhood cancers
peak age 2-5 yo
whites > blacks
signs and symptoms depend on site of disease |
|
|
Term
| Treatment of rhabdosarcoma |
|
Definition
Depends on staging
Low risk subset A: Vincristine + dactinomycin (VA) + radiation
Low risk subset B: Vincristine + dactinomycin + cyclophos (VAC) + radiation
Intermediate risk: VAC + radiation
High risk: VAC + radiation
Adding other chemo agents or increasing to high dose chemo has not shown benefit; surgery also an option to radiation |
|
|
Term
| Retinoblastoma epidemiology/etiology |
|
Definition
Most common ocular tumor in children
2% pediatric malignancies
median age unilateral boys 2yo, girls 1yo
bilateral 1 yo both
May be sporatic or heritable (40% ?)RBI germline mutation
present with leukora, strabismus, eye inflammation,anterior chamber changes |
|
|
Term
| Children with family hx of retinoblastoma shoud receive eye examinations when? |
|
Definition
At birth
6 weeks of age
every 2-3 months until 2 yo
every 4 months until 3 yo
hereditary retinoblastoma usually diagnosed by 2.5 yo |
|
|
Term
| Treatment retinoblastoma, depending on staging, location and metasteses |
|
Definition
Surgery
Radiation
Chemo: carboplatin, etoposide, vincristine (reduce etoposide to reduce secondary AML and other malignancies-- but low in this population) local chemo being investigated to reduce whole body exposure and spare vision |
|
|
Term
| Late effects of retinoblastoma treatment |
|
Definition
| decreased orbital growth, visual field defects, chemo-induced hearing loss and secondary malignancies (most common secondary cause of death incl. osteosarcoma, soft tissue sarcoma and melanoma-- sarcomas due to radiation) |
|
|
Term
| Indications for HSCT are the same between children and adults T or F |
|
Definition
|
|
Term
| Indications for allogenic HSCT |
|
Definition
leukemias
sickle cell disease
metabolic storage disorders
Fanconi anemia
Severe Combined immunodeficiency syndrome (SCID)
Best result with matched sibling donor |
|
|
Term
| Indication for autologous HSCT |
|
Definition
Solid tumors i.e. high risk neuroblastoma, medulloblastoma, germ cell tumors
Best to be in remission or minimal disease |
|
|
Term
| Patients who had allogenic HSCT do not need GVHD prophylaxis T or F |
|
Definition
|
|
Term
All malignant lymphomas exclusive of Hodgkin Lymphoma are Non-Hodgkins Lymphomas (NHL)
Name 3 types |
|
Definition
Burkitt or Burkitt-like lymphomas (40%)
Lymphoblastic lymphomas (35%)
Anaplastic Large Cell Lymphomas ALCL (8-13%)
Median age 10 yo
Males > females
White > black |
|
|
Term
| Hodgkins Lymphoma HL etiology |
|
Definition
|
|
Term
| Presentation of Hodgkins Lymphoma |
|
Definition
Similar to adults--
Painless lymphadenopathy cervical or supraclavicular
Generalized pruritis
Fatigue
Anorexia
Weight loss, fevers, night sweats |
|
|
Term
T or F
Non Hodgins Lymphomas are usually low-grade lymphomas |
|
Definition
F
Different than adults (low-grade) |
|
|
Term
|
Definition
Conventional chemo, possible monoclonal antibodies and tyrosine kinase inhibitors (trials ongoing)
Lymphoblastic lymphoma treated like ALL, longer duration, Burkitts -- shorter more intensive therapy -- ALCL short and intensive, amint therapy did not change long-term outcomes; Watch for tumor lysis syndrome with bulky disease |
|
|
Term
| Treatment Hodgkins Lymphoma |
|
Definition
Conventional chemotherapy and radiation
ABVE Doxo(Adria) bleomycin, vincristine, etoposide
ABVE-PC ABVE plus prednisone, cyclophosphamide
BEACOPP Bleo, etoposide, doxo, cyclophos, vincristine (Oncovin), prednisone, procarbazine
COPP Cyclophos, vincristine, prednisone, procarbazine
COP-DAC Cyclophosphamide, vincristine, prednisone, dacarbazine
OEPA/OPPA Vincristine, etoposide ( or procarbazine, prednisone, doxo
VAMP Vinblastine, doxo, methotrexate, prednisone |
|
|
Term
| Late complications of Hodgkins Lymphoma |
|
Definition
Pulmonary disease
cardiac disease
thyroid disease
secondary malignancies (i.e. breast)
Infertility |
|
|
Term
| How many courses of treatment for Hodgkins Lymphoma? |
|
Definition
| 2-4, depending on staging, with (sometimes without) radiation |
|
|
Term
| Survival of Hodgkins Lymphoma in % |
|
Definition
97% cure with new diagnosis
50% of relapse patients survive, relapse in first 12 months of initiating therapy carries poor prognosis |
|
|
Term
| Epidemiology of CNS tumors |
|
Definition
2nd most common cancer in children, 3rd most in adolescents
categorized by type of cells or tissues affected and aggressiveness of tumor- medulloblastoma: most common CNS tumor in children, median age 5-6 years old; Gliomas, 2nd most CNS 20-25% 5-10 yrs median; Ependymomas 3rd most (9 molecularly different disease states) |
|
|
Term
| Benign brain tumors do not present with significant symptomatology T or F |
|
Definition
|
|
Term
| Increase in the incidence of CNS tumors increased in the mid 1980s. What do experts think that caused it |
|
Definition
MRI machines and computer guided biopsy techniques
Association between radiation therapy various genetic syndromes (Li_Fraumeni, neurofibromatosis) |
|
|
Term
T or F
consumption of cured meats during pregnancy has not been shown to have an association with CNS tumors |
|
Definition
|
|
Term
| Symptomatology of CNS tumors |
|
Definition
| Atatxia, seizures, headache, hydrocephalus, diplopia, changes in vision, behavioral changes, significant N/V |
|
|
Term
| Treatment of medulloblastoma |
|
Definition
| Surgery, post-op radiation in age-eligible patients (>3 yo, chemo and supportive care; Survival 60-80% |
|
|
Term
|
Definition
Limited treaments for high=grade or brain stem gliomas
Surgery not possible
Radiation usually palliative
Chemo considered palliative but trials have shown chemo and targeted agents may improve response to radiation; Survival brainstem gliomas (DIPG) 10%, less 1 yr, other giomas vary |
|
|
Term
|
Definition
Surgery, goal of total resection + radiation to prevent recurrence.
Chemo limited benefit, except for situations were total resection not possible (under investigation) |
|
|
Term
| T or F Neuroblastoma is the most common extracranial solid tumor of childhood |
|
Definition
| T 7% of all childhood cancer |
|
|
Term
| Epidemiology of neuroblastoma |
|
Definition
non-Hispanic whites > other races, ethnicities
Male > female
Peak incidence before 4 yo, median diagnosis 19 months |
|
|
Term
| Pathophysiology and risk factors Neuroblastoma |
|
Definition
originates in adrenal medulla or paraspinal sites (i.e.from sympatheic nervous system)
spectrum of differentiation_ benign gangioneuroma to gangioneuroblastoma (malignant neuroblastoma)
1-2% familial
germline mutations in the ALK gene in up to 12% cases |
|
|
Term
| Presentation of neuroblastoma |
|
Definition
Abdominal mass or distension, pain, fever, weight loss, hypertension.
Also pancytopenia, periorbital ecchymosis, Horner syndrome, heterochromia,spinal cord compression, proprosis and nontender, bluish subcutaneous nodules
catecholamine screening in urine does not increase mortality, not recommended |
|
|
Term
|
Definition
Low-risk: Surgery, observation
Intermediate risk: surgery, multi-agent chemotherapy (4-8 cycles)
High Risk: Induction- Multi-agent standard chemotherapy (5-6 cycles) Consolidation- surgery, radiation, high dose chemotherapy, Autologous stem cell transplant; -Maintenance -immunotherapy (6 cycles of combo of ch 14.18, sargramostim, aldesleukin and isotretinoin) |
|
|
Term
|
Definition
| chimeric anti-disialoganglioside (GD2) antibody. GD2 is a glycolipid expressed on surface of neuroblastoma cells. Ch14.18 mediates anti-body dependent cellular cytotoxicity. FDA recently approved dinutuximab (Unituxin) and can increase survival of 20% of high risk patients |
|
|
Term
| Epidemiology of Wilms tumor (nephroblastoma) |
|
Definition
Most common renal tumor
Females > males
Black > other ethinicities
Peak incidence 2-3 yo, almost all cases < 6 yo
Mostly unilateral, 5-10% bilateral (bilateral usual familial) |
|
|
Term
|
Definition
Surgery (nephrectomy), radiation and conventional chemotherapy; depending on staging of disease and histology
VCR, doxo/dctino, cyclosporine, etoposide, carboplatin,irinotecan;
note: infatns vincristine dosing should be mg/kg dosing, not m2 |
|
|
Term
| Complications of Wilms tumor |
|
Definition
secondary malignancies
heart failure (doxo)
females: pregnancy related hypertension, premature labor, LBW infants |
|
|
Term
| Name the 2 most common bone cancers in children |
|
Definition
1. Osteosarcoma
2. Ewing sarcoma |
|
|
Term
| Epidemiology and presentation osteosarcoma |
|
Definition
3-5% childhood malignancies
peak incidence 2 decade of life
males > females
black > white
pain, mass or sweeling of joint or bone, 10-15% w/fractures, 50% in long bones |
|
|
Term
|
Definition
-pre-op chemo (cisplat/doxo with alternation HD MTX)
-local control = surgery, radiation
-post-op chemo, prevents relapse of localized tunors; no advantage to add interferon or ifos/etop |
|
|
Term
| Metastatic osteosarcoma has well defined treatment regimens T or F |
|
Definition
F
Survival metastatic 20-50%
non-metastatic 60-70% |
|
|
Term
| Ewing sarcoma epidemiology and presentation |
|
Definition
2nd most common bone cancer in children
median age 15 yo
mom-Hispanic whites > blacks
males = females
pain/swelling of affected area
25% have metastatic disease
symptoms, esp. with metastatic disese--anorexia, fatigue, weight loss, site-specific complications
positive for EWS/FL1 oncoprotein |
|
|
Term
| Prognostic features Ewing Sarcoma |
|
Definition
Negative: matastases, tumors > 8c, central/pelvic tumors, higher LDH, cytogenetics, Ewing's as a secondary neoplasm
Positive: distal exremeties, younger age, female |
|
|
Term
|
Definition
Similar to osteosarcoma (chemo-control-chemo)
Chemo: VDC/IE vincristine, doxo, cyclophos alternating with ifos and etoposide cycles alternate every 14 days (better than 21 day cycles)
Local control: surgery, radiation |
|
|
Term
| Rhabdomyosarcoma (RMS) epidemiology and symptoms |
|
Definition
most common soft tissue sarcoma in children
3% childhood cancers
peak age 2-5 yo
whites > blacks
signs and symptoms depend on site of disease |
|
|
Term
| Treatment of rhabdosarcoma |
|
Definition
Depends on staging
Low risk subset A: Vincristine + dactinomycin (VA) + radiation
Low risk subset B: Vincristine + dactinomycin + cyclophos (VAC) + radiation
Intermediate risk: VAC + radiation
High risk: VAC + radiation
Adding other chemo agents or increasing to high dose chemo has not shown benefit; surgery also an option to radiation |
|
|
Term
| Retinoblastoma epidemiology/etiology |
|
Definition
Most common ocular tumor in children
2% pediatric malignancies
median age unilateral boys 2yo, girls 1yo
bilateral 1 yo both
May be sporatic or heritable (40% ?)RBI germline mutation
present with leukora, strabismus, eye inflammation,anterior chamber changes |
|
|
Term
| Children with family hx of retinoblastoma shoud receive eye examinations when? |
|
Definition
At birth
6 weeks of age
every 2-3 months until 2 yo
every 4 months until 3 yo
hereditary retinoblastoma usually diagnosed by 2.5 yo |
|
|
Term
| Treatment retinoblastoma, depending on staging, location and metasteses |
|
Definition
Surgery
Radiation
Chemo: carboplatin, etoposide, vincristine (reduce etoposide to reduce secondary AML and other malignancies-- but low in this population) local chemo being investigated to reduce whole body exposure and spare vision |
|
|
Term
| Late effects of retinoblastoma treatment |
|
Definition
| decreased orbital growth, visual field defects, chemo-induced hearing loss and secondary malignancies (most common secondary cause of death incl. osteosarcoma, soft tissue sarcoma and melanoma-- sarcomas due to radiation) |
|
|
Term
| Indications for HSCT are the same between children and adults T or F |
|
Definition
|
|
Term
| Indications for allogenic HSCT |
|
Definition
leukemias
sickle cell disease
metabolic storage disorders
Fanconi anemia
Severe Combined immunodeficiency syndrome (SCID)
(matched sibling donor most optimal)
Best result with matched sibling donor |
|
|
Term
| Indication for autologous HSCT |
|
Definition
Solid tumors i.e. high risk neuroblastoma, medulloblastoma, germ cell tumors
Best to be in remission or minimal disease |
|
|
Term
| Patients who had allogenic HSCT do not need GVHD prophylaxis T or F |
|
Definition
|
|
Term
| What can to done to prevent hemorrhagic cystitis in patients receiving ifosphamide? |
|
Definition
| Give over 1 hour, hydrate and give Mesna at hour 0 3 6 9 and 12 at start of dose. Mesna dose is 20% of ifosphamide dose |
|
|
Term
| What are the acute cardiac effects of anthracyclines? Late effects? |
|
Definition
Transient ECG changes
Late: LV dysfunction and cardiac failure, possibly needing heart transplant |
|
|
Term
| Cardiac toxicities of anthracyclines generally only happen with high dose therapy. T or F |
|
Definition
| F Can happen with any dose. Contributing risk factors: high single dose, longer follow up time, mediastinal radiation, female sex, tumor type-- rhabdosarcoma, Wilms and concurrent cardiotxic medications |
|
|
Term
| What is dexrazoxane used for? |
|
Definition
| Cardioprotection anthracyclines. Contraversial FDA says not for childrens, Europe chooses not to use it, however, some protocols do use it for children and adolescents. |
|
|
Term
| Cisplatin wastes what electrolytes? |
|
Definition
|
|
Term
| Ifosphamide wastes what electrolytes? |
|
Definition
|
|
Term
| What is a well-known risk for vinca alkaloids (VCR) and platinum agents (Cisplat) ? |
|
Definition
Peripheral neuropathy
Incr risk with cumulative doses> No max cumulative doses set but neuropathy is graded on Balis scale, with interventions and dose modifications based on grade of neuropathy. |
|
|
Term
| Hearing loss and tinnitis are generally reversible for patients receiving cisplatin and carboplatin. T or F |
|
Definition
F
Associated with incr cummulative dose- all children should receive hearing tests before, during and after therapy. Watch other ototoxic drugs during therapy. |
|
|
Term
| Most common chemo drugs to cause nephrotoxicity? |
|
Definition
Cisplatin and Methotrexate
Estimated GFR may not correlate closely with actual GFR in children with cancer. Monitor! |
|
|
Term
| Hemorrhagic cystitis is an adverse effect associated with acrolein, a toxic metabolite of which 2 chemo agents? |
|
Definition
Cyclophosphamide and ifosfamide
Ifosphamide > cyclophosphamide
Less incidents when mesna used and hydration.
Higher risk with high dose therapy or prior Busulfan
Prophy Dose for prevention or minimized disease is 60-200% ifos/cyclophose dose mg/mg.
Always use with ifos, also use with high dose cyclophos (>1000-1200 mg/m2).
Mesna is either given continuous, or fractionated into 3-5 doses.
Mesna is a ketone and can affect urinalysis ketone levels.
TREATMENT of hemorrhagic cystitis-- can use mesna and hydration-- cont dose or higher dose. |
|
|
Term
| What is sinusoidal obstruction syndrome (SOS)? |
|
Definition
| disorder after HSCT or after busulfan or dactinomycin --- incr bili, wt gain, heptomegaly, ascites, RUQ pain. Prophylax with ursodiol, low dose heparin in some centers. Defibrotide used for treatment and prophylaxis for HSCT in some centers. |
|
|
Term
| Should dexamethasone be used in children with ALL? |
|
Definition
| Use prednisone in patients 10 or greater due to osteonecrosis. Use discontinuous dexamethasone in older children and adults in the delayed intesification phase ALL. |
|
|
Term
| What drug is preferred for pneumocystis porphylaxis in chemo patients and for how long? |
|
Definition
| Bactrim, from start of therapy and 6 months after completion |
|
|
Term
| If patient cannot take bactrim for pneumocystis prophylaxis for myelotaxic therapy, what should they take? |
|
Definition
| pentamidine or atovaquone (sulfa allergy, severe pancreatitis). Watch QT with atovaquone. Seperate metotrexate and bactrim by 24h |
|
|
Term
| Treatment of febrile neutrapenia? |
|
Definition
| Institution specific-- broadspectrum antipseudomonal B lactam, with ot without other agents. Fevers for 3-5 days, evaluate for fungal etiology. Stream line and taper when cltures identified and clinical picture improves. |
|
|
Term
| What are the negative consequences for chemo induced N/V in children and adolescents? |
|
Definition
| Reduced quality of life, dehydration, anxiety or concern of receipt of chemotherapy |
|
|
Term
| POGO (Ped Onc Group Ontario) guidelines for evidence based chemo n/v based on emetogenicity are... |
|
Definition
Minimal: to treatment
Low: single agent ondansetron, granisetron
Moderate: If corticosteroids permitted-- dexamethasone + ondan/granis
not permitted-- ondan/granis + chlorpromazine, metoclopramide or nabilone
High risk: corticosteroids permitted--dexamethasone + ondan/granis; add aprepitant if 12 yo or greater and not on chemotherapy that interacts with aprepitant. If corticosteroids not permitted-- ondan/granis + chlorpromazine or nabilone |
|
|
Term
| Causes acute pain for heme/onc patients? |
|
Definition
1.Tumor related pain (compression of nerves, inflammation, pressure or obstruction of tissues)
2. procedural pain- bone marrow aspiration, LP, post-surg pain 3. Mucositis--treat with TPN, soft toothbrush, mouthwashes 4. spinal cord compression 5. vaso-occlusive crises with SS dx |
|
|
Term
| What is the 2 step strategy for treating pediatric pain? |
|
Definition
Step 1: mild pain, acetaminophen or ibuprofen (if appropriate)
Step 2: Mod to severe pain, treat with strong opiate (morphine). Three step approach recently abandoned due to use of weak opiate (codeine not recc anymore and tramadol not studied enough-- not licensed for children in several countries. Rotation of opiates not recommended, only if no response. |
|
|
Term
| Adjuvant agents for pain are recommended for neuropathic pain in children (TCAs, SSRIs, ketamine, local anesthetics, anticonvusants). T or F |
|
Definition
| WHO states that there is limited evidence and cannot recommend for or against. |
|
|
Term
| What is tumor lysis syndrome? |
|
Definition
| massive release of intracellular contents after tumor cell death. Can occur bore or after chemotherapy. Occurs more with aggressive disease states like newly diagnosed leukemia or Burkitts Lymphoma. Also alveolar rhabdomyosarcoma. Causaes hyperuricemia, hyperkalemia, hyperphosphatemia, or hypocalcemia. |
|
|
Term
| Treatment hyperuricemia of tumor lysis syndrome? |
|
Definition
| Na bicarb for help exrete uric acid has fallen out of favor due to risk of ca/phos ppt when rasburicase is used. Allopurinol can prevent hyperuricemia but does not treat it (blocks conversion to UA). High risk patients rasburicase is used. It catalyzes conversion of UA to allantoin, which is more soluble for renal elimination. |
|
|
Term
| Treatment of hyperkalemia in tumor lysis syndrome? |
|
Definition
| Cardiac monitor, restrict K in IV fluids, IV calcium is used to help stabilize myocardium with high K, but watch for Ca/Phos ppt, which worsens renal fx. |
|
|
Term
| Treatment of hyperphosphatemia in tumor lysis syndrome? |
|
Definition
| Reduce phos in diet, use oral phosphate binder sevelamer. Do not use calcium carbonate due to ca/phos ppt in renal tubules. |
|
|
Term
| Treatment of hypocalcemia in tumor lysis syndrome? |
|
Definition
| Primary treatment is to correct elevated phos level. Caution with calcium replacements due to ca/phos ppt and renal fx. Reserve use for symptomatic hypocalcemia and symptomatic hyperkalemia. |
|
|
Term
| Low risk for tumor lysis syndrome? |
|
Definition
| most solid tumors, indolent NHL, HL, AML with WBC < 25,000 and LDH 2x normal. Prophylaxis: hydration and allopurinol |
|
|
Term
| Intermediate risk for tumor lysis syndrome? |
|
Definition
| Select solid tumors with bulky or advanced disease (neuroblastoma, germ cell tumors), ALL WBC <100,000 and LDH < 2 times ULN, AML with WBC 25,000-100,000 or AML with WBCs <25,000 and LDH 2 times or > ULN, ALCL stage III and IV, intermediate grade NHL with LDH < 2 times the ULN, Burkitts lymphoma LDH < 2x ULN, lymphoblastic lymphomas, stage 1 or 2, with LDH < 2x ULN Prophylaxis: hydration and allopurinol |
|
|
Term
| High risk for tumor lysis syndrome? |
|
Definition
ALL with WBC 100,000 or > and LDH 2x or greater ULN, AML with WBC 100,000 or >, Burkitts lymphoma stage 3 or 4 and/or LDH > 2x ULN, lymphoblastic lymphoma stage 3 or 4 and/or LDH > 2x ULN, any intermediate risk patient with renal dysfunction, any intermediate risk with serum uric acid, K, or phos above the ULN
Prophylaxis: hydration plus rasburicase (or allopurinol for pts with G6pd deficiency) |
|
|
Term
| Epidemiology of sickle cell disease? |
|
Definition
| 100,000 persons in US with disease. Newborn screen in all 50 states, 1 in every 500 African American births, 1 in every 36,000 Hispanic births. SS trait in 1 in 12 births African Americans |
|
|
Term
| Preventive maintenance for SS disease? |
|
Definition
Penicillin (2 months to 5 yo and asplenia)and folate prophylaxis (chronic hemolysis)
Immunizations (on schedule)
hydroxurea (9 months and older)
Transfusions and iron chelation with severe disease
Rare cases need allogenic stem cell transplants, hard to find donors unaffected by disease |
|
|
Term
| What is hemophilia A and B? |
|
Definition
heritable x lin ked recessive disorders that result in absent or decreased levels of factor VIII(Hemophilia A) or factor IX (Hemophilia B or Christmas disease)
Incidence of A is 80-85% and B 15-20%.
Factor VIII and IX important to formation of thrombin and fibrin |
|
|
Term
|
Definition
| Prophylactic and acute factor replacement. Recombinant factors are used (VIII and IX). Factor &a is used for patients with inhibitors to factor VIII and IX, or other congential bleeding disorders including inherited factor VII deficiency. Hemophilia A patients (mild to moderate) can use DDAVP as adjunctive agent because it increases circulating factor VIII levels by releasing bound factor VIII systemically. Afibrinolyics have been used as adjunctive therapy (Amicar and TXA) to stabilize existing clot and useful for dental work, etc. |
|
|
Term
| Hypovolemic shock is caused by |
|
Definition
| Dehydration, hemorrhage Tachycardia, sodium and water retention through renin angiotensin aldosterone system |
|
|
Term
| Cardiogenic shock is caused by |
|
Definition
acid-base imbalance, severe electrolyte
disorders, poor myocardia function, heart failure.
Usually fluid overload states |
|
|
Term
| Distributive shock is caused by |
|
Definition
| sepsis, anaphylactic, neurogenic, spinal |
|
|
Term
| Obstructive shock is caused by |
|
Definition
| tamponade, aortic stenosis, etc |
|
|
Term
| Spectrum of severity of septic shock |
|
Definition
SIRS
Sepsis
Severe sepsis
Septic shock |
|
|
Term
|
Definition
Must have 2 of the following (one must be temp or leucocytes)
-temp < 36c or > 38.5C
-HR < 1 yo decreased, > 1yo increased
- incr RR
-leucocytes high or low |
|
|
Term
|
Definition
| SIRS + presence or suspicion of infection |
|
|
Term
| Definition of severe sepsis |
|
Definition
| Sepsis + CV dysfunction or acute resp distress or 2 other organ system dysfunctions--neuro( glasgow coma scale > 11 or incr 3 pts), hematologic (plts < 80,000, or INR >2), Renal (SCr x2 normal), Hepatic (Tbili 4or > or ALT 2x normal |
|
|
Term
| Definition of septic shock |
|
Definition
|
|
Term
|
Definition
| O2, IV access, fluid resiscitation (cap refill 2 sec or less, normal BP, UO >1, cariac index 3.3-6) give NS 20 mL/kg up to 60mL/kg within 10 minutes, antibiotics, vasopressors, corticosteroids, glucose control |
|
|
Term
| Vasopressor treatment of cold shock is |
|
Definition
Dopamine, epi if resistant
Dopamine increases SVR and cardiac index |
|
|
Term
|
Definition
norepinephrine
norepinephrine increases MAP and SVR with little cardiac effect |
|
|
Term
| Treatment of low cardiac output and low SVR |
|
Definition
epinephrine
increases SVR and contractility |
|
|
Term
| Treatment of high cardiac output and low SVR |
|
Definition
| Norepinephrine--- if SVR still low, consdier vasopressin but no real established role |
|
|
Term
| Corticosteroid dose for catecholamine refractory shock |
|
Definition
| hydrocortisone 50mg/m2/day (up to 100) divided q6h, alt doing 1-2 mg/kg/day |
|
|
Term
|
Definition
| Five percent of acetaminophen is metabolized by the cytochrome P450 system to the potentially toxic metabolite N-acetyl-para-benzoquinoneimine (NAPQI). NAPQI is then metabolized to nontoxic cysteine and mercaptate conjugates by glutathione. |
|
|
Term
| Why is NAPQI dangerous with acetaminophen overdose? |
|
Definition
| Following a large acetaminophen overdose, the ability to metabolize acetaminophen through glucuronidation and sulfation are overwhelmed. More acetaminophen is then metabolized via the cytochrome P450 system. Therefore excessive amounts of NAPQI are formed. Glutathione stores are depleted. Glutathione regeneration is a slow process and toxic NAPQI accumulates. |
|
|
Term
| What time frame does the maximum acetaminophen toxicity occur? |
|
Definition
| 72 - 96 hours after ingestion |
|
|
Term
| During what time frame is charcoal useful with acetaminophen overdose? |
|
Definition
|
|
Term
| What dose of acetaminophen is associated with hepatotoxicity? |
|
Definition
| Single ingestions of 140mg/kg or greater of acetaminophen have been associated with hepatotoxicity. Repeated ingestion of greater than 75mg/kg/day of acetaminophen have also been associated with hepatotoxicity. |
|
|
Term
| What is the Rumack-Matthew nomogram? |
|
Definition
A single serum acetaminophen level drawn at least 4 hours after ingestion is plotted on the Rumack-Matthew nomogram.
A serum acetaminophen level > 150 mcg/mL four hours after ingestion is indicative of a toxic serum concentration. |
|
|
Term
| Is there benefit to treating acetaminophen overdose > 24h after ingestion? |
|
Definition
| Yes, if hepatotoxicity present. |
|
|
Term
| Oral dose N-acetylcysteine? |
|
Definition
| 140 mg/kg/dose, followed by 70 mg/kg/dose every 4 hours for 17 doses |
|
|
Term
| Iv dose N-acetylcysteine? |
|
Definition
| 150 mg/kg/dose IV over 1 hour; 50 mg/kg/dose over 4 hours; 100 mg/kg/dose over 16 hours. |
|
|
Term
| Normal arterial (venous) blood pH |
|
Definition
| pH = 7.35-7.45 (7.32-7.42) |
|
|
Term
| Normal arterial (venous) blood pCO2 |
|
Definition
| pCO2 = 35-45 mmHg (38-52 mmHg) |
|
|
Term
| Normal arterial (venous) blood pO2 |
|
Definition
| pO2 = 80-100 mmHg (28-48 mmHg) |
|
|
Term
| Normal arterial (venous) blood HCO3- |
|
Definition
| HCO3- = 22-26 mEq/L (19-25 mEq/L) |
|
|
Term
| Normal arterial (venous) blood SaO2 |
|
Definition
| SaO2 = 95%-100% (50%-70%) |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Normal range = 8-16 mEq/L (determined by the local laboratory normal values). Significantly elevated AG = metabolic acidosis. AG helps to determine the cause of a mixed metabolic acidosis |
|
|
Term
|
Definition
| High pCO2 = respiratory acidosis |
|
|
Term
|
Definition
| Low pCO2 = respiratory alkalosis |
|
|
Term
|
Definition
| Low HCO3- and BE = metabolic acidosis |
|
|
Term
|
Definition
| High HCO3- and BE = metabolic alkalosis |
|
|
Term
| Low pH, high pCO2, normal HCO3- = |
|
Definition
| Low pH, high pCO2, normal HCO3- = acute respiratory acidosis/failure without metabolic compensation (HCO3- takes days to compensate) |
|
|
Term
| Normal pH, high pCO2, high HCO3- = |
|
Definition
| Normal pH, high pCO2, high HCO3- = chronic respiratory acidosis/failure with metabolic compensation |
|
|
Term
| Normal pH, low pCO2, low HCO3- = |
|
Definition
| Normal pH, low pCO2, low HCO3- = chronic respiratory alkalosis/tachypnea with metabolic compensation |
|
|
Term
| Low pH, low pCO2, low HCO3- = |
|
Definition
| Low pH, low pCO2, low HCO3- = metabolic acidosis with respiratory compensation (tachypnea) that is inadequate to fully correct the low pH |
|
|
Term
| High pH, high pCO2, high HCO3- = |
|
Definition
| High pH, high pCO2, high HCO3- = metabolic alkalosis with respiratory compensation (bradypnea) that is inadequate to fully correct the high pH |
|
|
Term
| causes Respiratory alkalosis |
|
Definition
AMISH a. A: anxiety or ammonia
b. M: medications (salicylates; progesterone)
c. I: intracranial pressure
d. S: sepsis
e. H: hypoxemia or hyperthermia |
|
|
Term
| Causes Metabolic acidosis (normal AG; hyperchloremic acidosis) |
|
Definition
a. Normal in premature neonates
b. D: diarrhea
c. U: ureteral diversion (urine directed into the colon from a fistula or surgery)
d. R: renal tubular acidosis
e. H: hyperalimentation (Cl:Acetate ratio)
f. A: acetazolamide (carbonic anhydrase inhibitors)
g. M: miscellaneous [pancreatic fistula; arginine HCl; chloride administration (NH3Cl; HCl; CaCl2; large amounts of NaCl administration); spironolactone] |
|
|
Term
| Causes Metabolic acidosis (increased AG) |
|
Definition
a. M: methanol
b. U: uremia
c. D: diabetic ketoacidosis or alcoholic d. P: propylene glycol
d. P: propylene glycol
e. I: inborn errors of metabolism, iron, ibuprofen, isoniazid
f. L: lactic acidosis
g. E: ethylene glycol
h. S: salicylates |
|
|
Term
| Causes Metabolic alkalosis |
|
Definition
a. Loop diuretics
b. Nasogastric suctioning
c. Vomiting
d. NaHCO3 administration |
|
|
Term
| Medications for metabolic acidosis |
|
Definition
Sodium bicarbonate (NaHCO3)
Parenteral systemic alkalinizer; proton acceptor
Na+ dissociates after administration, leaving HCO3- available to bind to H+
Can cause hypernatremia; every 1 mEq/kg of HCO3- delivers 1 mEq/kg Na+ to the patient
Use is controversial; unlikely to improve clinical outcome
Increases pCO2 which may:
Accumulate in patients with poor lung function
Cross cell membranes, causing intracellular acidosis
Inactivates catecholamines that are co-administered into the same intravenous line
Use 0.5 mEq/mL (4.2%; 1,000 mOsm/L) in infants (e.g., up to 1 year or 10 kg) due to the lower osmolarity and potential for fluid shifting; 1 mEq/mL (8.4%) is used for pediatric and adult patients
Tromethamine
Parenteral systemic alkalinizer; proton acceptor
Will not increase serum sodium or pCO2
Useful for the treatment of metabolic acidosis in patients with hypernatremia or lung disease
Useful for patients with a combined respiratory and metabolic acidosis
Greater osmotic effects than with sodium bicarbonate
Administration via umbilical venous catheter may cause hepatic necrosis |
|
|
Term
| Medications for metabolic alkalosis |
|
Definition
Adjust the chloride:acetate ratio in the TPN to favor chloride salts,Acetazolamide
First line treatment for metabolic alkalosis
Takes a day or two to for the effects of the drug to work
Safer alternative than other agents for metabolic alkalosis
Enteral or parenteral use
Causes renal elimination of HCO3- with increased retention of ammonia due to urinary alkalinization Arginine HCl
Useful in cases where acetazolamide fails to effectively treat metabolic alkalosis
Available as a sterile parenteral drug
Useful in patients with hyperammonemia
Infusion can cause irritation; central line preferred Ammonium chloride (NH4Cl)
Useful in cases where acetazolamide fails to effectively treat metabolic alkalosis
Available as a sterile parenteral drug
Causes an increase in blood ammonia concentration
Hydrochloric acid (HCl)
Useful in cases where other drugs have failed to correct a metabolic alkalosis
Useful for treatment of metabolic alkalosis in patients with hyperammonemia
Requires compounding a parenteral infusion from HCl that is not an approved drug (sterile; pyrogen free).
Requires compounding in a glass bottle; hazardous substance
Delivered as 0.1 N HCl in normal saline through a central line |
|
|
Term
|
Definition
| Onset of symptoms should be within 1 week of a clinical insult or new or worsening respiratory symptoms Bilateral opacities on chest radiograph not fully explained by effusions, lobar/lung collapse or nodules Respiratory failure not fully explained by cardiac failure or fluid overload |
|
|
Term
|
Definition
1. Direct injury to the lung
a. Bacterial or viral pneumonia (most common cause in pediatrics and adults)
b. Aspiration
c. Uncommon: smoke inhalation; reperfusion pulmonary edema; fat emboli
2. Indirect injury to the lung
a. Sepsis (associated with a higher ARDS disease severity and mortality)
b. Trauma
c. Uncommon: cardiopulmonary bypass; blood transfusions; pancreatitis; drug reactions; near drowning |
|
|
Term
|
Definition
A. 2.96 to 12.8 cases per 100,000 per year
B. Incidence varies according to ARDS definition used. It has changed over the years.
C. Similar risk factors for the development of ARDS in pediatrics and adults, but the actual incidence of the disease is lower in pediatrics than in adults
D. Mortality ranges from 18% to 36%. A higher mortality is seen in patients with pre-existing lung disease and immune suppression. Adults experience a higher mortality rate compared to pediatrics. |
|
|
Term
|
Definition
| Mechanical ventilation, fluid restriction, literature does not support the use of pulmonary surfactant for the treatment of pediatric ARDS. pediatric patients with ARDS have shown that while iNO may acutely reduce pulmonary vascular resistance and improve systemic oxygenation, it has no effect on duration of mechanical ventilation, intensive care unit days, organ failure or mortality but rescue agent for temporary improvement in patients with profound hypoxemia, corticosteriods sometimes used in adults but not possible to draw conclusions or offer an educated recommendation regarding the effectiveness of corticosteroids for pediatric ARDS. |
|
|
Term
|
Definition
Trauma is leading cause of death in all age groups < 21 years of age
12,000 deaths are annually attributed to head trauma in children < 19 yrs
70% of all lethal traumas are to the head
Motor vehicle accidents and falls are the two most common mechanisms of head injuries in children
Head trauma kills more children annually than all other neurologic diseases combined.
Head trauma kills five times more children than leukemia |
|
|
Term
| Main goals to prevent secondary injury from head trauma |
|
Definition
Avoid hypoxia
Avoid hypotension
Avoid situations that increase metabolism such as hyperthermia and seizures
Avoid brain herniation |
|
|
Term
| Intubate if the Glasgow Coma Score (GCS) is |
|
Definition
| Intubate if the Glasgow Coma Score (GCS) is < 8 |
|
|
Term
| ICP goal with head trauma? |
|
Definition
The goal ICP for patients with a closed head injury is ≤ 20 mm Hg. Some experts recommend a goal ≤ 15 mm Hg, but the benefit of this in unclear.
Brief increases in ICP may be insignificant; however, sustained increases (> 3 minutes) maybe significant and therefore warrant treatment. |
|
|
Term
| Non-pharmacologic management of increased intracranial pressure. |
|
Definition
| Elevate the head of bed to at least 30°Keep the patient’s head in a mid-line position, minimal stimulation environment,Maintain pC02 in the 35-40 mm Hg range. Dropping the pCO2 less than 35 mm Hg may cause too much vasoconstriction, leading to ischemia and further brain injury. |
|
|
Term
| Dose 3% saline for head trauma? |
|
Definition
Initial bolus dosing for 3% saline is: 4-6 mL/kg/dose IV over 15-30 minutes
Initial continuous infusion rate is: 0.1-2 mL/kg/hr |
|
|
Term
| Desired serum NA range for head trauma? |
|
Definition
| Serum sodium is usually maintained between 150-160 mEq/L. Serum osmolarity is usually maintained < 360 mOsm/L |
|
|
Term
| Mannitol dosing for head trauma |
|
Definition
Second line therapy
Same dosing regardless if using the 20% or 25% mannitol concentration
Initial dosing: 0.25 gm/kg/dose-1 gm/kg/dose IV every 6 hours
1 g/kg/dose IV for management of acute ICP spikes
Monitoring: Serum osmolarity < 320 mOsm/L |
|
|
Term
| Use of combination hypertonic saline and mannitol for head trauma? |
|
Definition
No literature to support the use of combination therapy.
May place patients at higher risk of nephrotoxicity. |
|
|
Term
| Barbiturates use with head trauma |
|
Definition
Barbiturates are used for the treatment of refractory intracranial hypertension, but not used to prevent intracranial hypertension.
The clinical effects of barbiturates include:
Decreasing metabolic rate in brain tissue
Altering the vascular tone
Improving oxygenation to the brain tissue
Decreasing the cerebral blood flow and blood volume.
Adverse drug effects associated with barbiturates include:
Decreased cardiac output
Hypotension
Hypoxia
Decreased CPP
Barbiturates may negatively impact the patient’s immune function. Decreased antibody levels have been demonstrated in animal models, in vitro.
Pentobarbital dosing
Bolus: 5 mg/kg
Continuous infusion: 1-2 mg/kg/hr |
|
|
Term
| Why is lidocaine used for head trauma patients? |
|
Definition
Lidocaine is sometimes used prior to endotracheal suctioning.
Coughing and/or gagging during suctioning increases ICP, decreases CPP and decreases oxygen saturation.
Lidocaine may be effective at decreasing the cough response.
Lidocaine may be administration intravenously or by endotracheal tube. ET more effective than IV. IV lidocaine (1.5 mg/kg) or ET lidocaine (2 mL of 4% lidocaine) |
|
|
Term
| Corticosteroids used for head trauma? |
|
Definition
| Studies have shown no difference in ICP or CCP, higher frequency of bacterial pneumonia in steroid treated patients |
|
|
Term
| Effect of Posttraumatic seizures? |
|
Definition
Three to five percent of civilian head injuries result in the development of seizures.
Young children have a higher incidence of seizures as compared to older children and adults after head injury.
Patients who develop seizures may subsequently develop epilepsy.
According to Tilford et al., the use of antiseizure medication(s) may also reduce mortality.
Seizures may also lead to secondary brain injury
Seizures increase metabolic demands of the brain
Seizures increase ICP |
|
|
Term
| Drugs used in the management of post traumatic epilepsy? |
|
Definition
| Drugs used in the management of posttraumatic epilepsy include: phenobarbital, Phenytoin/fosphenytoin, carbamazepine and levetiracetam. |
|
|
Term
| Use of H2 blockers and PPIs for head trauma? |
|
Definition
| Patient status-post closed head injuries are also at increased risk for stress-induced gastritis. It is appropriate to have these patients on H2 antagonists or proton pump inhibitors while they are NPO |
|
|
Term
| Therapeutic hypothermia for head trauma? |
|
Definition
Decreased cerebral metabolic demands
Decreased inflammation
Decreased free radical production
Decreased excitatory neurotransmitter release
Decreased seizure activity
Decreased cell death |
|
|
Term
| Hypothermia guidelines for head trauma |
|
Definition
Goal temperature range 32-34°C
Hypothermia should probably be started as early as possible, but definitely within 8 hours of injury
Patients should probably be kept in a hypothermic state for 24-72 hours
The patient should be slowly rewarmed by 0.5°C every 2 hours to a goal body temperature of 36°C |
|
|
Term
|
Definition
Vasopressin (antidiuretic hormone)
Disorders associated with serum sodium derangements and intravascular volume
Can occur following injury or damage to the central nervous system (CNS); particularly in the region of the hypothalamus and the pituitary gland
Can be associated with meningitis, encephalitis, open or closed head injury, non-accidental trauma, brain death, intracranial hemorrhage, brain tumors, craniofacial surgery, and CNS surgery
Can also occur with pulmonary disorders (pneumonia, asthma), medication administration (vinca alkaloids, opiates) or carcinomas (Ewing’s sarcoma, neuroblastoma)
Sherlock et al. determined that SIADH occurs in up to 63% of critically ill patients who develop hyponatremia. Cerebral salt wasting occurs in 7%. As much as 21% of patients with hyponatremia can have a mixed SIADH/CWS picture. |
|
|
Term
| Physiology Vasopressin (antidiuretic hormone; ADH) |
|
Definition
Formed by the hypothalamus
Secreted by the posterior pituitary gland
Primary role is in the regulation of serum osmolarity
Released in response to low blood pressure and/or increased serum osmolarity
Increases renal water reabsorption |
|
|
Term
| Physiology Natriuretic factors |
|
Definition
Multiple factors throughout the body including atrial natriuretic peptide, brain natriuretic peptide, C-type natriuretic peptide and dendroaspis natriuretic peptide
Atrial natriuretic peptide (ANP)
Secreted by the heart
Released in response to atria stretching due to hypervolemia
Primary role is in sodium homeostasis
Increases glomerular filtration rate and urinary sodium and water secretion
Brain natriuretic peptide (BNP)
Animal model initially led researchers to believe it was secreted by the brain, but it is primarily secreted by the heart
Released from ventricles in the heart in response to hypervolemia
Primary role is in sodium homeostasis
Increases glomerular filtration rate and urinary sodium and water secretion
Also released from the hypothalamus
Release may be increased when the hypothalamic region of the brain is damaged |
|
|
Term
|
Definition
Part of the renin-angiotensin system
Secreted by the adrenal cortex
Released in response to low arterial blood pressure, increased serum potassium concentrations, and decreased serum sodium concentrations
Causes sodium and water retention by the kidneys |
|
|
Term
|
Definition
Two types: central and nephrogenic
Central DI is the result of vasopressin deficiency or a lack of vasopressin release
Nephrogenic DI is due to a lack of sensitivity to vasopressin by the kidneys
Results in the formation of high volume, very dilute urine with hypernatremia and serum hyperosmolarity
Central DI as a consequence of central nervous system injury is much more common in the pediatric intensive care unit |
|
|
Term
| Syndrome of inappropriate anti-diuretic hormone secretion (SIADH) |
|
Definition
SIADH is the result of excess vasopressin secretion from the hypothalamus
Results in the formation of low volume, very concentrated urine with hyponatremia and hypoosmolarity in the serum. |
|
|
Term
| Cerebral salt wasting (CSW) |
|
Definition
Cause has not been clearly identified, but is probably multifactorial, including increased levels of ANP, BNP, and alterations to the renin-angiotensin-aldosterone system
Results in increased urinary secretion of sodium and decreased extracellular fluid volume |
|
|
Term
| Diagnosis Diabetes insipidus (DI) |
|
Definition
High urine output (>4 mL/kg/hr)
Dilute urine (specific gravity < 1.005; <300 mOsm/L)
High serum sodium (>145 mEq/L) and osmolarity (>300 mOsm/L)
The diagnosis of DI cannot be made if the patient has recently received furosemide or other diuretics
Signs of dehydration including tachycardia and hypotension
Untreated DI can cause hypovolemic shock |
|
|
Term
| Diagnosis Syndrome of inappropriate antidiuretic hormone secretion (SIADH) |
|
Definition
Low urine output (<0.5 mL/kg/hr)
Concentrated urine (specific gravity > 1.032)
Low serum sodium (<130 mEq/L) and osmolarity (<275 mOsm/L); dilutional hyponatremia
Headache, fatigue, weight gain without edema |
|
|
Term
| Diagnosis Cerebral salt wasting (CSW) |
|
Definition
Less common than DI and SIADH
Mild to moderate increases in urine output, but not as extensive as with DI
Low serum sodium
High urine sodium (>80 mEq/L)
Signs of dehydration including tachycardia and hypotension |
|
|
Term
| Treatment Diabetes insipidus (DI) |
|
Definition
initial treatment of central DI is IV fluid administration. Fluids should begin at 100% maintenance. Some experts recommend using up to 150% maintenance. Hypotonic IV fluids should be used cautiously even in patient with DI. Fluids containing at least one-half normal saline are usually appropriate to start with. Some patients may go on to need hypotonic IV fluids containing one-third or one-quarter normal saline. Large volume urine losses can be replaced using supplemental normal saline (e.g., 1 mL of normal saline administered for every 1 mL of urine output replaced every 4 hours).
ADH may be administered in a number of different forms and routes
Vasopressin, administered as a continuous intravenous infusion, is commonly used initially in the critical care setting.
Vasopressin dosing can be initiated at 0.25-1 milliunits/kg/hr and titrated until the hourly urine output is reduced to 1-3 mL/kg/hr and the serum sodium is between 140-145mEq/L. |
|
|
Term
| Treatment Syndrome of inappropriate antidiuretic hormone secretion (SIADH) |
|
Definition
Primary treatment is fluid restriction. Initially restricting fluids to 75% or 80% of maintenance is an appropriate starting point.
An IV fluid containing normal saline is usually recommended initially.
Hypertonic saline (e.g., 3%) may be administered if the patient is symptomatic due to hyponatremia (altered mental status, seizures)
Loop diuretics may be used if the patient is symptomatic |
|
|
Term
| Treatment Cerebral salt wasting (CSW) |
|
Definition
Treatment should be performed in two parts:
First, raise serum sodium to a safe level
Second, maintain the serum sodium and intravascular volume
Normal saline containing IV fluid administered at 100% maintenance is an appropriate starting point
Large volume urine losses can be replaced using supplemental normal saline (e.g., 1 mL of normal saline administered for every 1 mL of urine output replaced every 4 hours)
Sodium chloride can be replaced enterally when the patient is able to tolerate enteral medications. An example of initial enteral dosing is 1 mEq/kg/dose every 6 hours.
A mineralocorticoid such as fludrocortisone may be used to manage CSW. Almost all of the data supporting its use is from case reports.
The serum sodium concentration should not be increased by more than an average of 0.5 mEq/hour if the patient is not experiencing symptoms of hyponatremia. |
|
|
Term
| Neonatal indications for ECMO? |
|
Definition
Persistent pulmonary hypertension of the neonate
Congenital diaphragmatic hernia
Meconium aspiration
Respiratory distress syndrome
Sepsis |
|
|
Term
| Infant and children indications for ECMO? |
|
Definition
Low cardiac output or inability to wean from cardiopulmonary bypass following repair of congenital heart disease
Bridge to cardiac surgery or transplant
Sepsis or pneumonia
Acute respiratory distress with inability to oxygenate by mechanical ventilation |
|
|
Term
| Overall survival after ECMO support is ? |
|
Definition
Overall survival after ECMO support is 72%
Mortality primarily associated with bleeding, renal failure and infections
Prolonged ECMO support (>10 days) is associated with increased complications |
|
|
Term
| Venoarterial (VA) ECMO provides what kind of support? |
|
Definition
| Venoarterial (VA) ECMO provides both respiratory and cardiac support by removing blood from the venous system and returning it to the arterial system |
|
|
Term
| Venovenous (VV) ECMO provides what kind of support? |
|
Definition
| Venovenous (VV) ECMO provides respiratory support only by both removing blood from and returning blood to the venous system |
|
|
Term
|
Definition
Venous cannula; commonly placed in right atrium via the internal jugular vein or in a femoral vessel
Tubing; during initiation of ECMO the contact between artificial surfaces of the circuit and the blood initiates a cascade of inflammation similar to septic shock
Venous reservoir (bladder); traps air bubbles and clot
Pump; generates non-pulsatile flow
Oxygenator; permeable membrane that serves as the artificial lung to facilitate exchange of oxygen and carbon dioxide
Heat exchanger; water flows around ECMO tubing to heat blood prior to returning to the patient
Arterial cannula (VA ECMO only); commonly placed in aortic arch with tip directed toward descending aorta |
|
|
Term
| Pharmacokinetic and pharmacodynamics changes during ECMO are? |
|
Definition
Increased circulating blood volume
Volume of distribution (Vd) increased 5-100%
Volume to prime circuit (300-400 mL) up to double of infant’s blood volume (200-250 mL)
Requires more drug to get same blood concentration
Drug adsorption and sequestration onto plastic cannulae and/or silicone oxygenator
Effect is more significant with lipophilic drugs
Effect more pronounced at initiation or with circuit change
Altered renal, hepatic & cerebral blood flow
Decreased clearance (Cl) of both renally and hepatically cleared drugs
Non-pulsatile blood flow and previous injury to organs pre-ECMO
Patient is at more risk for concentration-dependent adverse effects |
|
|
Term
| Important considerations when reviewing ECMO literature are? |
|
Definition
Majority of studies are done with older circuit components: silicone membranes and centrifugal pumps. Newer polypropylene membranes have shown decreased drug loss.
Most pediatric studies were done with the neonatal population. Physiologic differences exist between neonates and other populations. Dosing and frequency data may not always be able to be extrapolated from existing studies.
Dosing recommendations do not take into account additional ultrafiltration or dialysis. |
|
|
Term
| sequestration % of heparin dose in ECMO circuit ? |
|
Definition
| Pediatric case series described sequestration of 50% of heparin dose in circuit. Use of heparin-bonded circuits and non-silicone membranes may reduce heparin requirements. |
|
|
Term
| Clearance rate of heparin decreases in ECMO patients ? T or F? |
|
Definition
F
Clearance rate of heparin doubles in ECMO patients |
|
|
Term
| Heparin requirements in ECMO patients are affected by what 2 factors? |
|
Definition
Heparin requirements are significantly affected by increased volume of distribution
Significant deficiencies of antithrombin in this population may also contribute to increased heparin requirements |
|
|
Term
| Drug effects of ECMO on aminoglycosides? |
|
Definition
Large number of studies in neonates and infants describe increased Vd and prolonged Cl
Required larger dose and prolonged interval
Dose: 2.5-3.5 mg/kg/dose IV q18-24h
Drug monitoring should be used to adjust dosing |
|
|
Term
| Drug effects of ECMO on Vancomycin? |
|
Definition
Multiple studies in neonates and infants indicate increased Vd and prolonged Cl
May or may not require higher doses but likely require prolonged intervals
Dose: 15-20 mg/kg IV q24h
Drug monitoring should be used to adjust dosing |
|
|
Term
| Drug effects of ECMO on midazolam? |
|
Definition
Significant increase in Vd (0.8 L/kg vs. 4.1 L/kg); patients require higher doses within first 24 hours
Mixed results on clearance
One study showed accumulation of midazolam after 48 hours on ECMO
One study showed increased clearance over time on ECMO
In vitro studies have shown significant drug loss of many sedatives in isolated circuit components, an effect that can be decreased by about 10% if the ECMO circuit is primed with albumin |
|
|
Term
| Drug effects of ECMO on fentanyl? |
|
Definition
| Fentanyl: up to 70% of the dose has been sequestered by the silicone membrane oxygenator, an effect that is likely less significant with non-silicone membrane oxygenators |
|
|
Term
| Drug effects of ECMO on morphine? |
|
Definition
Neonatal studies show doubled Vd
Neonatal studies show decreased clearance (34 mL/kg/min vs. 63 mL/kg/min) while on ECMO
Effect is particularly seen at initiation of ECMO, but Cl increases over time
Increased clearance after decannulation may contribute to withdrawal
Significant intra-patient variability, but still the preferred choice in neonates due to sequestration effects on fentanyl |
|
|
Term
| Clinical manifestations of liver dysfunction |
|
Definition
Esophageal varices
Edema
Impaired parenchymal function
Hepatic encephalopathy |
|
|
Term
| Causes of liver dysfunction |
|
Definition
Hepatitis viruses
Hepatitis A: fecal-oral acquisition
Hepatitis B: vertical transmission acquisition
Autoimmune
Wilson disease
Difficulty of copper excretion to bile duct from the liver cell
Non-alcoholic fatty liver disease
Obesity associated
Chronic TPN associated
Hemodynamic
Caused by shock or congestive heart failure |
|
|
Term
| Bilirubin role in liver failure |
|
Definition
otal bilirubin elevation is not a sensitive indicator of hepatic dysfunction or prognosis
Indirect (unconjugated) bilirubin: elevations due to increased bilirubin production by extra-hepatic sources or impaired up-take and processing by the liver
Direct (conjugated) bilirubin: direct hyperbilirubinemia is defined as > 50% of the total bilirubin being direct.
Increased levels due to obstruction of the biliary tract
Elevations typically accompany elevations in other hepatic enzymes and reflects underlying hepatobiliary disease (e.g., hepatocellular or cholestatic liver disease) |
|
|
Term
| Aminotransferases in liver failure |
|
Definition
Non-specific indicators of hepatic injury typically released from hepatocytes by necrosis or changes in cell membrane permeability allowing for enzyme leakage from the cells
Aspartate aminotransferase (AST): elevation of AST without concomitant elevated ALT suggests cardiac or muscle disease
Alanine aminotransferase (ALT): is more localized to the liver than AST and is, therefore, more specific to liver injury |
|
|
Term
| Alkaline phosphatase (ALP) in liver failure |
|
Definition
Refers to a group of enzymes whose exact function is not known
Found in many body tissues with about 80% coming from the liver and bone (adult data)
ALP elevations as high as 3x normal can occur in children and adolescents as a result of bone growth
Mechanism of hepatic ALP release in cholestatic disease is not fully elucidated. The current hypothesis is that bile accumulation appears to increase hepatic ALP synthesis, which then leaks into the serum. ALP elevations return to normal about 2-4 weeks after the obstruction is removed.
Does not help differentiate between intra- and extrahepatic disorders
ALP elevations should be taken into consideration with GGT and 5’-nucleotidase. If the GGT and 5’-nucleotidase are elevated with ALP elevations, then the ALP elevation is most likely of hepatic origin. |
|
|
Term
| Gamma glutamyl transpeptidase (GGT) in liver failure |
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Definition
| is a biliary excretory enzyme that aids in determination if the ALP elevation is hepatic in origin. |
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Term
| 5’-Nucleotidase in liver failure |
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Definition
| Not elevated in non-hepatic situations where ALP is elevated, it aids in distinguishing a hepatic origin of elevated ALP |
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Term
|
Definition
Protein synthesized in the liver
Helps to maintain plasma oncotic pressure
Reflects the synthetic function of the liver
Plasma concentrations of albumin can remain normal in many liver diseases when liver function is preserved
Plasma concentrations will progressively decline as liver damage progresses and the synthetic function declines |
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Term
| Prothrombin time (PT) in liver failure |
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Definition
ime required for a certain set of reactions in the extrinsic coagulation cascade to occur
Vitamin K dependent clotting factors are produced in the liver and measure its synthetic function
The PT will be prolonged if the liver is damaged and cannot produce the necessary clotting factors |
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Term
| Absorption of drugs in liver failure |
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Definition
ll drugs absorbed from the gastrointestinal tract are exposed to the metabolizing enzymes and bile excretory transport systems of the liver before reaching the systemic circulation
Drugs with an intermediate to high hepatic extraction ration will undergo significant hepatic metabolism before reaching the systemic circulation (the “first pass effect”)
Cirrhosis may lead to portosystemic shunts, decreasing the ability of drug-metabolizing enzymes and increasing the oral bioavailability of these drugs |
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Term
| Distribution of drugs in liver failure |
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Definition
Only unbound drug is capable of entering and leaving tissue compartments so decreases in circulating protein can lead to a larger volume of distribution of protein bound drugs
Water soluble drugs have a significant increase in volumes of distribution in patients with ascites |
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Term
| Metabolism of drugs in liver failure |
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Definition
Phase 1 reactions include cytochrome P450 enzymes. The activity of these enzymes is often reduced in patients with hepatic dysfunction.
Phase II conjugation reactions are often affected to a lesser extent than Phase 1 reactions in liver cirrhosis |
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Term
| Excretion of drugs in liver failure |
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Definition
Drugs and metabolites normally excreted to a significant extent via the bile may accumulate in patients with obstruction of the bile ducts
End stage liver cirrhosis is commonly complicated by renal artery vasoconstriction and failure (hepatorenal syndrome) and accumulation of renally eliminated drugs |
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Term
| Pharmacodynamic (PD) differences in liver dysfunction |
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Definition
Reductions in plasma protein production will reduce drug protein binding, increasing the free fraction and activity of the drug
Altered PD can result from changes independent of the pharmacokinetic changes
Changes in drug receptor binding
Changes in the affinity of a drug for its receptor
Changes in the intrinsic activity of a receptor
Hyperaldosteronism in cirrhosis causes loop diuretic resistance
Beta blockers are useful during the middle stage of hepatic cirrhosis when portal hypertension is a problem, but should be avoided in the latter stages of cirrhosis when cardiac reserve and renal function are diminished. |
|
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Term
| Child-Pugh scoring for liver dysfunction |
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Definition
Incorporates 5 variables to assess the severity of liver dysfunction (see table below)
Serum bilirubin
Serum albumin
PT
Presence of encephalopathy
Presence of ascites
Classification
Class A: mild dysfunction (5-6 points)
Class B: moderate dysfunction (7-9 points)
Class C: severe dysfunction (10-15 points) |
|
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Term
| Deficiency of Child-Pugh scoring in liver failure |
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Definition
| Lacks the sensitivity to quantitate the specific ability of the liver to metabolize individual drugs |
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Term
| Considerations when no recommendations for dosage adjustment are available for liver dysfunction |
|
Definition
Drugs with a high hepatic extraction ratio
Oral bioavailability significantly increased.
Drugs with low hepatic extraction and high protein binding (>90%)
Oral and intravenous clearance is determined by the intrinsic capacity of the hepatic elimination mechanism and the unbound drug fraction in blood or plasma
Increased free fraction of drug leads to increased drug effectiveness. Lower dosing may be required even though total plasma concentrations are normal.
Drugs with low hepatic extraction ratio and low plasma protein binding (<90%)
The oral and intravenous clearance of these drugs is determined by the intrinsic capacity of the hepatic elimination mechanisms and the unbound drug fraction in blood or plasma
Fluctuations in unbound drug fraction in plasma are small and will not significantly affect blood clearance of drug
Dosage adjustments may be necessary and should be aimed at maintaining normal total plasma concentrations
The elimination of drugs that are partly excreted in unchanged form by the kidneys will be impaired in patients with hepatorenal syndrome. Creatinine clearance significantly overestimates the glomerular filtration rate in these patients
The volume of distribution of hydrophilic drugs may be increased in patients with chronic liver disease who have edema or ascites. These drugs may require a higher loading dose.
Extreme caution is recommended when using narrow therapeutic index drugs in patients with liver dysfunction. |
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Term
|
Definition
Leading cause of death for infants: congenital anomalies; sudden infant death syndrome; premature birth
Leading cause of death for children: injury
Leading cause of pediatric cardiac arrest: progressive respiratory failure
Leading cause of pediatric shock: hypovolemia (including hemorrhage) |
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Term
|
Definition
New = Circulation, Airway, Breathing (CAB); Old = Airway, Breathing, Circulation (ABC)
Circulation: compressions at a rate of at least 100 per minute; care should be taken to avoid interruptions in chest compressions
Airway: head tilt-chin lift (jaw thrust for trauma)
Breathing: 2 breaths
Compression-to-ventilation ratio: 30:2 (15:2 for 2 rescuers in children and infants)
Breaths every 6-8 seconds with an advanced airway
Attach and use a defibrillator as soon as possible |
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Term
|
Definition
Primary patient assessment in PALS
Airway: maintainable or not maintainable?
Breathing: respiratory rate, pattern and effort; air movement; lung sounds; oxygen saturation
Circulation: heart rate, rhythm, pulses; capillary refill time; skin color, temperature, blood pressure
Disability: patient responsiveness; pupil size, blood glucose
Exposure: body temperature; appearance of the skin (e.g., rash; trauma) |
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Term
|
Definition
Secondary patient assessment in PALS
Signs
Allergies
Medications
Past medication history
Last meal eaten and liquids taken (time)
Evaluation |
|
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Term
|
Definition
inability of the body to meet the oxygen requirements of the tissues
leads to accumulation of lactic acid from anaerobic metabolism |
|
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Term
|
Definition
Hypovolemic shock
low blood pressure secondary to low blood volume
dehydration; administer isotonic crystalloid (e.g., normal saline; lactated ringer’s)
blood loss as a cause (hemorrhagic shock); administer blood
Cardiogenic shock (see section II below)
cardiac etiology of low blood pressure
heart failure; administer inotropes, vasodilation and diuretics
arrhythmia; treat the arrhythmia
Distributive shock
blood volume is inappropriately distributed to body tissues
septic shock
endotoxin and cytokine mediated vasodilation
The mainstay of therapy is volume expansion to enhance cardiac output. Delays in doing this are associated with the development of refractory tissue hypoxia.
neurogenic shock – central nervous system injury leading to loss of sympathetic tone, causing vasodilation and bradycardia (from unopposed vagal tone) |
|
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Term
| Fluid and drug routes of delivery for PALS |
|
Definition
Intravenous (IV): peripheral access is usually attempted first in an emergency
Intraosseous (IO)
Should be used if IV access cannot be obtained immediately
Useful for administration of all drugs and blood
Endotracheal (ET)
Lidocaine, epinephrine, atropine and naloxone (LEAN)
Follow drug administration with a 5 mL normal saline flush
Absorption is not uniform
Absorption is not complete
Lidocaine, atropine and naloxone doses should be tripled
Epinephrine dose should be increased by 10-fold |
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Term
|
Definition
| Lidocaine, epinephrine, atropine and naloxone-- drugs given via ET during emergency |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| Epinephrine dose should be increased by 10-fold |
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Term
| Volume resuscitation in PALS |
|
Definition
For hypovolemic shock, septic shock and metabolic acidosis
Crystalloid (normal saline or Lactated Ringer’s solution) is typically selected for early volume resuscitation
Colloid (5% albumin) is reserved for patients with hypoalbuminemia
Half the normal fluid dose is used in patients with heart failure or calcium channel blocker overdose
Restore blood and fluid needs before administering drugs to support blood pressure |
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Term
| Drug dose calculation in PALS |
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Definition
All health care systems should be prepared to rapidly and accurately determine drug doses and volumes for pediatric emergencies
Broselow Tape: quick determination of patient weight and common drug doses according to patient height; portable; limited number of drugs; no drug volumes
Hospital developed manuals: quick determination of a broad range of drug doses and volumes by patient weight; simple to use; portable; no electronic interface or special training needed
eBroselow system: web based, bar code enabled system that is linked to the hospital electronic medical record; calculates doses and volumes of a broader range of drugs; works with tablets and smart phones |
|
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Term
| Special drug considerations in PALS for adenosine |
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Definition
drug of choice after vagal maneuvers in a hemodynamically stable patient with supraventricular tachycardia (SVT; intravenous verapamil in infants with SVT can cause cardiovascular collapse and cardiac arrest)
administer through a vein that is close to the heart (e.g., antecubital)
half-life less than 30 seconds; administer via 2-syringe method (fast push normal saline flush immediately after pushing in drug via a 3-way stopcock)
therapeutic failure may occur if the drug is infused too slowly |
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Term
| Special drug considerations in PALS for Amiodarone |
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Definition
Used after defibrillation and epinephrine for ventricular fibrillation (VF) and ventricular tachycardia (VT)
may cause hypotension from vasodilation if infused rapidly in a patient with a perfusing rhythm; normally infused over 60 minutes
give as a rapid bolus in patients with a non-perfusing rhythm (e.g., asystole; VF; pulseless VT) |
|
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Term
| Special drug considerations in PALS for Atropine |
|
Definition
increases heart rate and atrioventricular conduction
useful in vagal mediated bradycardia (e.g., endotracheal intubation) or after epinephrine for symptomatic bradycardia
PALS guidelines recommend a minimum dose of 0.1 mg to prevent a paradoxical bradycardia. However, the evidence supporting this practice at all pediatric ages, particularly in premature neonates, is lacking. |
|
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Term
| Special drug considerations in PALS for Calcium |
|
Definition
indicated for hypocalcemia, calcium channel blocker overdose, hypermagnesemia and hyperkalemia (stabilizes the myocardium)
should not be used routinely for cardiac arrest |
|
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Term
| Special drug considerations in PALS for Dextrose |
|
Definition
for hypoglycemia
hyperosmolar; use D10W in infants (less than 10 kg), D25W in toddlers and children and D50W in adults |
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Term
| Special drug considerations in PALS for Epinephrine |
|
Definition
drug of first choice for VF or VT that has failed to convert to normal sinus rhythm after defibrillation (lowers the defibrillation threshold), asystole, pulseless electrical activity, and symptomatic bradycardia
Use 1:10,000 (0.1 mg/mL) concentration for IV and IO doses; 1:1,000 (1 mg/mL for ET doses; if the correct concentration is selected, the correct dose will always be 0.1 mL/kg/dose, no matter the route of administration
high dose epinephrine does not confer a survival benefit in patients with life threatening conditions with the exception of cases of beta-blocker overdose
half-life less than 2 minutes; repeat dosing every 3-5 minutes as long as an indication exists |
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Term
| Special drug considerations in PALS for Lidocaine |
|
Definition
considered a second line agent behind amiodarone for VF and VT
amiodarone has been shown to be more effective in return to spontaneous circulation or survival to hospital admission in adults with defibrillation and epinephrine resistant VF |
|
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Term
| Special drug considerations in PALS for Magnesium |
|
Definition
| administer rapidly (over several minutes) for torsades de pointes VT |
|
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Term
| Special drug considerations in PALS for Naloxone |
|
Definition
used in opiate overdose
The PALS recommended dose to awaken and recover an overdosed patient is 0.1 mg/kg, but doses as small as 0.005-0.01 mg/kg have been used to reduce respiratory depression while preserving pain control and avoiding acute opiate withdrawal. |
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Term
| Special drug considerations in PALS for Sodium bicarbonate |
|
Definition
routine use is not recommended
consider use in patients with severe metabolic acidosis, hyperkalemia or sodium channel blocker overdose
generates pCO2; the patient should be well ventilated (i.e., able to exhale CO2)
repeated use can cause hypernatremia, hyperosmolarity (associated with third space fluid shifting), hypokalemia, and impaired tissue oxygen delivery
Use the 4.2% (0.5 mEq/mL) concentration for infants (less than 10 kg) and 8.4% (1 mEq/mL) in toddlers and older children
flush before and after dose; inactivates catecholamines and precipitates calcium salts |
|
|
Term
| Special drug considerations in PALS for Vasopressin |
|
Definition
not included in any PALS algorithms
insufficient evidence to support a role in pediatric cardiac arrest |
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|
Term
| Volume resuscitation in PALS |
|
Definition
Crystalloid (normal saline or Lactated Ringer’s solution) is typically selected for early volume resuscitation
Colloid (5% albumin) is reserved for patients with hypoalbuminemia
Half the normal fluid dose is used in patients with heart failure or calcium channel blocker overdose |
|
|
Term
| Four phases of cardiac arrest |
|
Definition
Pre-arrest – conditions leading to arrest; clinical decline
No-flow – survival is directly related to the time until competent CPR
Low flow – begins at introduction of CPR
Post-resuscitation
Begins at return of spontaneous circulation (ROSC)
Three phases
Immediate post-arrest phase: first 20 minutes after ROSC
Early post-arrest phase: 20 minutes-12 hours after ROSC
Intermediate phase: 12-72 hours after ROSC
Recovery phase: >3 days after ROSC |
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Term
| Pediatric Early Warning Scores (PEWS) |
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Definition
Behavior, Cardiovascular, Respiratory 0-3 score for each category
5-9 = Need rapid response (red)
4 = Consider rapid response (orange)
For asthma patients automatically get a score of 3 in respiratory category |
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Term
| 2015 Recommendations—New for use of atropine in PALS |
|
Definition
Theavailable evidencedoesnot support
the routineuseofatropinepreintubation
of critically ill infants and children. It may be reasonable for practitioners to use
atropine as a premedication in specific
emergency intubations when there is
higher risk of bradycardia (eg, when
giving succinylcholine as a neuromuscular
blocker to facilitate intubation)
(Class IIb, LOE C-LD). A dose of 0.02 mg/kg
of atropine with no minimum dose may
be considered when atropine is used as
a premedication for emergency intubation
(Class IIb, LOE C-LD). This new
recommendation applies only to the
use of atropine as a premedication for
infants and children during emergency
intubation.
Atropine 0.02 mg/kg (no minimum dose) 3-5 minutes prior to sedative and paralytic drugs for RSI for patients who are:
Bradycardic
Age <12 months
<5 years and receiving succinylcholine
Receiving a 2nd dose of succinylcholine (generally for the second attempt at endotracheal intubation) |
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Term
|
Definition
Asystole starts with A, ends with E
Atropine Epinephrine |
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Term
| Amiodarone or Lidocaine for V fib and V tach? |
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Definition
| shock-refractory V fib or pulseless v tach, you can choose either amiodarone or lidocaine – but based on at least this single study, Lidocaine seems to be the more attractive option. |
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Term
| Primary elements of the post-cardiac arrest syndrome |
|
Definition
Brain injury
Signs: seizures, cognitive dysfunction, coma, death
Diminished cerebral perfusion; tissue ischemia and death
Myocardial dysfunction
Signs: systemic hypotension, arrhythmias
Diminished contractility with normal coronary blood flow
Myocardial recovery occurs in most pediatric patients after cardiac arrest
Less severe than in adults
Systemic ischemia/reperfusion response
Signs: fever, hyperglycemia, hypotension
Tissue ischemia
Inflammatory cytokine release similar to the sepsis syndrome
Increased coagulation
Adrenal suppression |
|
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Term
| Goals of treatment cardiac arrest |
|
Definition
Normothermia: every 1o C above normal is associated with increasing risk of worse clinical outcome; therapeutic hypothermia should be considered in patients who remain comatose after ROSC
Normoglycemia: administer insulin to maintain blood glucose less than 180 mg/dL
Normocarbia without hyperoxemia: maintain oxygen saturation between 94% and 99%; excessive inspiratory pressures increase intrathoracic pressure and can reduce cardiac performance; excessive oxygen can contribute to free radical tissue damage
Normotension |
|
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Term
|
Definition
| serum iron 300-500 mcg/dL represents an important ingestion, concentrations less than 500 mcg/dL generally do not cause moderate or severe clinical toxicity. |
|
|
Term
| Lead level that requires chelators? |
|
Definition
| Clinical research does not support the use of a chelator for BLL < 45 mcg/dL |
|
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Term
| Treatment of choice of TCA overdose? |
|
Definition
| Sodium bicarbonate uncouples TCAs from the alpha subunit of the cardiac myocyte voltage-gated sodium channel, widening the QRS interval and decreasing the risk of cardiac arrhythmias. The sodium in the dose will increase the rate of sodium influx through non-TCA-blocked channels on the cardiac myocyte. Sodium bicarbonate is as or more effective than sodium loading |
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Term
|
Definition
| Blood pressure (BP) = cardiac output (CO) x systemic vascular resistance (SVR) |
|
|
Term
|
Definition
| CO = stroke volume (SV) x heart rate (HR) |
|
|
Term
|
Definition
| SV = end diastolic volume – end systolic volume |
|
|
Term
|
Definition
Contractility
The strength of cardiac muscle contraction
Can be increased by medications that directly cause an increase in cardiac contractility (inotropes)
Preload
The fluid pressure pushing to entering the heart from the venous system
SV can be increased in cases where preload is insufficient (fluids for hypovolemia)
Afterload
The fluid pressure the heart must beat against in the aorta and pulmonary arteries
SV can be increased in cases where afterload is excessive (diuretics for fluid overload; systemic vasodilators to increase left ventricular SV; pulmonary vasodilators to increase right ventricular SV as in the case of pulmonary hypertension) |
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Term
|
Definition
| SVR can be increased by medications that cause vasoconstriction (pressors) |
|
|
Term
|
Definition
| HR can be increased by medications that directly cause the heart tissue to beat faster (chronotropes) or by vasodilators that cause a reflex response by the heart to increase HR |
|
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Term
|
Definition
Beta-1 agonism – inotropy; some tachycardia
Beta-2 agonism – vasodilation; direct tachycardia; reflex tachycardia; bronchodilation; hypokalemia (shifts potassium intracellularly); glycogenolysis
Alpha-1 agonism – pressor effect; increases SVR; reduces SV
Dopamine-1 agonism – renal and mesenteric vasodilation; increased urine output |
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Term
| Fluids for cardiovascular support |
|
Definition
| A basic tenet for blood pressure support is to ensure that adequate fluid is circulating in the intravascular space. Fluid boluses should be employed, as needed, prior to administration of medications for cardiovascular support. Isotonic crystalloid solution (e.g., normal saline) is used during the acute management of hypotension. Albumin 5% is selected if it is known that the patient has hypoalbuminemia. Half of the normal dose should be used in patients with severe heart failure to avoid the possibility of causing fluid overload. |
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|
Term
| General characteristics of Catecholamines |
|
Definition
Short half-lives (~2 minutes); rapidly titratable
Degraded by alkaline solution; do not infuse directly with sodium bicarbonate
All possess alpha agonist (pressor) activity in high concentrations and will cause local tissue ischemia and extravasation injury if infiltrated. Infuse these via a central line.
Tissue infiltration should be treated with the alpha antagonist phentolamine to avoid extravasation injury
Catecholamines increase myocardial oxygen demand, increasing the risk of cardiac ischemia and arrhythmias in low cardiac output syndrome |
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|
Term
|
Definition
Dose dependent effects; dopamine agonism (2-3 mcg/kg/min); beta-1 agonism beginning at about 5 mcg/kg/min; alpha-1 agonism beginning at about 10 mcg/kg/min
Doses less than 5 mcg/kg/min designed to selectively increase urine output are not believed to have a beneficial effect on clinical outcome
Doses greater than 10 mcg/kg/min in patients with low cardiac output syndrome may be harmful due to the alpha-1 effect (reduced SV through vasoconstriction) |
|
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Term
|
Definition
Dose-dependent beta-1 agonism with weak beta-2 and alpha-1 activity
Titratable inotropy (weak to very potent), some tachycardia, but with a minimal pressor effect at therapeutic doses |
|
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Term
|
Definition
Potent beta-1, beta-2 and alpha-1 activityBeta-2 effects predominate at low doses
Usually reserved for use in patients with low cardiac output states after milrinone and another inotrope have failed to maintain normotension |
|
|
Term
|
Definition
An inodilator (containing both inotropic and systemic/pulmonary vasodilatory effects)
Good for patients with a low cardiac output state (post-cardiopulmonary bypass; post-cardiac arrest; chronic heart failure)
Neutral on myocardial oxygen demand
Mild-to-moderate inotropy; will need to add a more potent, titratable medication to milrinone if more inotropy is desired
Acts synergistically with beta agonists in the cardiac myocyte by inhibiting the degradation of cyclic adenosine monophosphate (cAMP)
Half-life = 1.5-2.5 hours; less ability to acutely titrate to effect |
|
|
Term
|
Definition
A nitric oxide based vasodilator that is primarily used in the intensive care setting for the acute management of hypertensive emergency and crisis
Useful in patients with low cardiac output states at very low doses for afterload reduction to increase SV
Half-life = <10 minutes; drip is titratable to effect
High doses (>4 mcg/kg/min) are associated with cyanide (CN) toxicity. The risk of this can be greatly diminished with the co-administration of sodium thiosulfate in the same bag as sodium nitroprusside. Sodium thiosulfate acts as a sulfur donor for the liver to conjugate free CN to thiocyanate (SCN). A standard drip concentration of this contains a ratio of 1:5 or 1:10 sodium nitroprusside to sodium thiosulfate.
Thiocyanate is renally eliminated with a half-life of about 3 days. Prolonged infusions (>5 days) of sodium nitroprusside are associated with thiocyanate toxicity. Thiocyanate will accumulate more quickly in patients with renal dysfunction. |
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|
Term
| Diuretics use with cardiac disease/failure |
|
Definition
| Diuresis is almost always needed for treatment of fluid overload in patients with low cardiac output syndrome. Fluid overload causes increased afterload pressures. Increased afterload diminishes SV and CO. Diminished CO leads to hypotension. Hypotension leads to the release of renin from the juxtaglomerular apparatus in the kidney. Renin acts on angiotensinogen (liver) to form angiotensin I. Angiotensin I is converted to angiotensin II via the angiotensin converting enzyme. Angiotensin II has multiple effects that cause worsening of severe heart failure including systemic vasoconstriction, stimulation of antidiuretic hormone (renal water retention) from the posterior pituitary gland, secretion of aldosterone (sodium and water retention) from the adrenal cortex. |
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|
Term
| Loop diuretics use for cardiovascular issues |
|
Definition
Loop diuretics are used in patients with heart failure and intravascular fluid overload. Diuresis reduces afterload pressure, increasing left ventricular cardiac output. Loop diuretics are preferred in patients with severe heart failure and low systemic blood pressure where thiazide type diuretics will not be as effective.
Furosemide is often selected as a drug of first choice for diuresis in patients with low cardiac output syndrome because more information exists regarding dosing as a bolus and continuous infusion in pediatric patients. |
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|
Term
| Thiazide type diuretics for cardiovascular issues |
|
Definition
| Thiazide type diuretics such as chlorothiazide or metolazone act synergistically with loop diuretics in cases of low cardiac output syndrome with loop diuretic resistant fluid overload. |
|
|
Term
| Bumetanide use for cardiovascular issues |
|
Definition
| Bumetanide is usually selected as a second line loop diuretic in patients who fail to respond adequately to continuous infusion furosemide combined with a thiazide type diuretic. Bumetanide is able to elicit an increased diuresis in some patients who fail to respond adequately to furosemide. |
|
|
Term
| Side effect loop diuretics |
|
Definition
| ll loop diuretics have the ability to cause ototoxicity. The risk is the greatest with ethacrynic acid, lower with furosemide and the least with bumetanide. Ototoxicity presents as a temporary event in some patients where middle ear fluid is diminished during diuretic therapy. Permanent ototoxicity is rare, but more commonly presents in cases where high doses and prolonged courses of loop diuretics are used in patients who are also receiving other ototoxic medications. |
|
|
Term
| Mean arterial pressure (MAP) = |
|
Definition
Mean arterial pressure (MAP) = [(SBP − DBP)/3] + DBP, where SBP is systolic blood pressure and DBP is diastolic blood pressure. DBP constitutes a larger percentage of MAP because perfusion (especially coronary) occurs during diastole.
A normal MAP is age dependent and provides an idea of organ perfusion
Blood pressure (BP) or MAP usually directly correlates with volume status because:
BP = cardiac output (CO) × systemic vascular resistance (SVR)
CO is directly related to HR and stroke volume (SV).
Stroke volume correlates with preload.
Preload provides an indication of volume status |
|
|
Term
|
Definition
Central venous pressure (CVP; the pressure in the thoracic vena cava near the right atrium) can reflect preload
CO is “ideal” at a CVP of 8–12 mm Hg.
CVP as an indicator of preload and fluid responsiveness is controversial
Positive end-expiratory pressure (PEEP) can affect CVP in the setting of mechanical ventilation.
Improvement in CVP after a fluid challenge is a positive response in patients with intravascular volume depletion. |
|
|
Term
| Indicators of Blood Flow and Heart Function |
|
Definition
CO: amount of blood the heart pumps in 1 minute
Cardiac index (CI) = CO/body surface area
CVP and PCWP: These pressures can be a measure of heart function: as the CO is reduced, the volume is increased because of a reduction in the forward flow of blood. As volume is increased, the pressure will increase. CVP and PCWP may be elevated in heart failure. |
|
|
Term
| Indicators of Oxygen Transport and Use |
|
Definition
Lactic acid
Lactic acid is formed during anaerobic metabolism.
During states of reduced perfusion, the tissues receive less blood and oxygen.
When there is less oxygen for the tissues, anaerobic metabolism happens resulting in production of lactic acid.
Central venous oxygen saturation (ScvO2) and mixed venous oxygen saturation (SvO2) |
|
|
Term
| Indicators of Vascular Tone: SVR |
|
Definition
VR is a calculated measurement of arteriolar tone and is not an actual measured value
SVR is directly related to BP and indirectly related to CO.
SVR can be used as a diagnostic tool
SVR is low in sepsis
SVR is high in hypovolemic shock |
|
|
Term
| Definitions and clinical signs of sepsis |
|
Definition
Signs and symptoms of inflammation with suspected or proven infection
Hyper- or hypothermia
Rectal temperature > 38.5oC or < 35oC
Tachycardia-age dependent
Altered organ function (at least one of the following):
Altered mental status
Hypoxemia
Increased serum lactate
Bounding pulses |
|
|
Term
| Hypovolemic shock treatment goal |
|
Definition
fill up the tank”- maximize intravascular volume status
Crystalloids and colloids are considered equivalent in the acute setting. Crystalloids are usually given first line from a cost-effectiveness perspective.
Blood products can be given in the setting of hemorrhagic shock.
Vasopressors/Vasoactive agents should be considered if volume resuscitation does not reverse the hypotension
.Vasoactive efficacy will be reduced when patients are not fluid resuscitated appropriately. |
|
|
Term
| Early goal-directed therapy for hypovolemic phase of shock |
|
Definition
Capillary refill ≤ 2 seconds
Normotension for age
Normal pulses with no difference between peripheral and central pulses
Urine output > 1 mL/kg/hour
Warm extremities
Normal mental status
Central venous oxygen saturation (ScvO2) ≥ 70% or mixed venous oxygen saturation (SvO2) ≥ 65%
Cardiac index between 3.3 and 6.0 L/min/m2
Normalization of lactate for patients presenting with elevated lactate is also a resuscitation goal |
|
|
Term
| Why are Hydroxyethyl starches (e.g., hetastarch) are not recommended for fluid resuscitation in septic shock? |
|
Definition
| not recommended for fluid resuscitation due to an increased risk of acute kidney injury. |
|
|
Term
| Fluid resuscitation for shock |
|
Definition
Isotonic crystalloids: boluses of 10-20 mL/kg (i.e., normal saline or lactated Ringer’s) over 5-10 minutes, titrate to reversing hypotension, increasing urine output, attaining normal capillary refill, peripheral pulses and level of consciousness without inducing hepatomegaly or rales, with total volumes up to at least 60 mL/kg within the first hour
5% albumin can be considered if the patient is known or suspected to have a low albumin concentration. If the ScvO2 target is not achieved, a transfusion of packed red blood cells targeting hemoglobin of 10 g/dL, and/or an inotrope infusion can be considered. |
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Term
| Vasopressors may be necessary to maintain the blood pressure target for age if a fluid challenge fails to restore BP and organ perfusion. What is the drug of choice? |
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Definition
| Dopamine is the initial vasopressor of choice for fluid refractory shock. |
|
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Term
T or F
Vasopressors should be used after the intravascular volume is normalized for shock |
|
Definition
T
In certain circumstances, patients with septic shock and hypoperfusion may need the addition of vasopressors during fluid resuscitation to optimize organ perfusion. Once the volume status is optimized, the vasopressors should be weaned when possible. |
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Term
| What is the second vasopressor added in the setting of cold shock, after dopamine? |
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Definition
Epinephrine is the second vasopressor added in the setting of cold shock
Cold shock with normal BP: consider volume loading and adding a vasodilator if ScvO2 still < 70%.
Cold shock with low BP
Consider norepinephrine if still hypotensive.
Consider dobutamine, milrinone, or levosimendan if ScvO2 still < 70% |
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Term
| What is the second vasopressor added in the setting of warm shock? |
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Definition
Norepinephrine is the second vasopressor added in the setting of warm shock
Warm shock with low BP
Consider vasopressin if still hypotensive
Consider low dose epinephrine if ScvO2 still < 70% |
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Term
| When shock persists despite adequate fluid resuscitation and appropriate doses of vasoactive what drug may be added? |
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Definition
| hydrocortisone therapy should started for patients at risk for absolute adrenal insufficiency |
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Term
| What class of drugs may be necessary to improve cardiac function in patients with myocardial dysfunction such as elevated cardiac filling pressures and low CO after fluid resuscitation? |
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Definition
Inotropes
Inotropes may be necessary to improve cardiac function in patients with myocardial dysfunction such as elevated cardiac filling pressures and low CO after fluid resuscitation.
Inotropes can also be considered in patients with persistent signs of hypoperfusion despite restoration of intravascular volume and a normal BP for age. |
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Term
T or F?
Intravenous antimicrobials should be initiated as early as possible and always within the first hour of recognizing severe sepsis and septic shock and with a spectrum of activity that covers the most common infecting pathogens. |
|
Definition
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Term
| Common sources of infection for septic shock are? |
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Definition
| lung, abdomen, blood, and urinary tract. |
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Term
| When should empiric anti fungal therapy be started in cases of septic shock? |
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Definition
should be considered if patients have several risk factors;
Recent abdominal surgery
Indwelling central venous catheter
Recent treatment with broad-spectrum antibiotics
Immunocompromised patients (e.g., chronic corticosteroids or other immunosuppressants; neutropenia; malignancy; organ transplant).
An echinocandin is preferred in patients recently treated with antifungal agents or if Candida glabrata is suspected. |
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Term
| Other considerations for septic shock |
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Definition
Clindamycin and anti-toxin therapies are suggested for toxic shock syndromes with refractory hypotension.
Appropriate antimicrobials do not preclude the importance of emergency source control by drainage, debridement, or device removal as needed.
De-escalation should occur with respect to culture data and clinical judgment.
Empiric use of combination therapy should not be administered for longer than 3–5 days if de-escalation to a single agent is appropriate.
Discontinuing antimicrobials in 7–10 days should be considered unless there is slow response, undrainable foci, immunosuppression, or multidrug-resistant pathogens.
Blood cultures will be negative in most patients despite a bacterial or fungal origin of sepsis. Clinical judgment is needed when considering the discontinuation of antimicrobials.
Procalcitonin can be used as a guide for antibiotic therapy.
Discontinue antimicrobials if no infectious cause is found.
Antiviral therapy with oseltamivir or zanamivir should be initiated as early as possible for patients with suspected or confirmed influenza. |
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Term
| Indication for corticosteroids for patients with shock? |
|
Definition
Eligible patients are children with fluid refractory, catecholamine resistant shock and suspected or proven absolute adrenal insufficiency
The risks (hyperglycemia, infection) of corticosteroids outweigh the benefits in patients who do not have septic shock.
The typical dose of hydrocortisone is 50 mg/m2/day (maximum 200 mg/day). The 2012 guidelines suggest using a continuous infusion of hydrocortisone instead of the intermittent bolus doses to avoid hyperglycemia and hyponatremia (a grade 2D recommendation meaning weak recommendation based on very low-quality evidence).
Obtaining a serum cortisol level at the time empiric hydrocortisone is administered may be helpful
Patients should be weaned off steroid therapy once vasopressors are no longer required |
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Term
| Sedation and analgesia for shock |
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Definition
sedation goal in critically ill mechanically ventilated patients is recommended.
Drug toxicity labs should be routinely monitored because drug metabolism is reduced during severe sepsis putting children at risk for adverse drug-related events. |
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Term
| Glycemic control for shock |
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Definition
| Hyperglycemia should be controlled to ≤ 180 mg/dL. A glucose infusion should accompany insulin therapy in newborns and children. |
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Term
| Diuretics and renal replacement therapy for shock |
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Definition
Diuretics should be used to reverse fluid overload when shock resolves.
Continuous venovenous hemofiltration or intermittent dialysis should be used to prevent greater than 10% total body weight fluid overload if diuretics are not able to achieve this goal. |
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Term
| Stress ulcer prophylaxis for shock? |
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Definition
No formal recommendation in pre-pubertal children
No compelling evidence suggesting a difference between a histamine-2-receptor antagonist (H2RA) and a proton pump inhibitor (PPI) |
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Term
| Deep vein thrombosis (DVT) prophylaxis for shock? |
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Definition
No formal recommendation in pre-pubertal children
Most DVTs are the result of a central venous line
Data regarding unfractionated or low molecular weight heparin for DVT prophylaxis does not exist in the setting of pediatric sepsis and septic shock |
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Term
| Extracorporeal membrane oxygenation (ECMO) role with septic shock? |
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Definition
| consider in the setting of refractory septic shock and respiratory failure |
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Term
To compare the pain control offered by two different analgesics in pediatric patients, the author selected
the Wong-Baker FACES pain rating scale as the primary end point. Before beginning the clinical trial, the authors sought to validate this ordinal scale by showing a correlation with a previously validated visual analog scale. Which statistical test is most appropriate to assess whether a correlation exists between these two measures?
A. Pearson correlation.
B. Analysis of variance (ANOVA).
C. Spearman rank correlation.
D. Regression analysis. |
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Definition
Answer: C
The Spearman rank correlation is a nonparametric test of the strength of an association between two ordinal or continuous variables (Answer C is correct). Answer A is incorrect because the Pearson correlation requires the variables of interest to be continuous, and Answer D is incorrect because regression analysis is used to develop predictive models and requires continuous data. Answer B is incorrect because the ANOVA is used to test for differences between three or more groups, not correlation between two variables. |
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Term
Which statement best describes why journals prefer that investigators report confidence intervals (CIs)
versus p values when comparing groups?
A. The p value reports neither the statistical significance nor an estimate of the magnitude of the difference observed between groups.
B. The CI reports the observation of statistical significance as well as an estimate of the magnitude of the difference between groups.
C. Although the CI does not show whether statistical significance was observed, it does report an estimate of the magnitude of the difference
between groups.
D. The p value reports an estimate of the magnitude of the difference observed between groups, but it does not show whether the investigators
observed a statistical significance |
|
Definition
Answer: B
Answer B is correct and Answer C is incorrect because the CI can be used to determine whether a statistically significant difference was observed between groups and to estimate the size of the difference. Answer A is incorrect because the p value can be used to determine whether there is a statistically significant difference between groups, and Answer D is incorrect on both accounts; the p value shows statistical significance but does not give the reader an estimate of the size of the difference between groups. |
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Term
Investigators have chosen the Wong-Baker FACES pain rating scale to show that a new analgesic works better than placebo in children. The authors plan to randomize subjects to two separate groups. Which is the most appropriate statistical test?
A. Student t-test.
B. Paired Student t-test.
C. Wilcoxon rank sum.
D. Pearson correlation. |
|
Definition
Answer: C
The Wong-Baker FACES pain rating scale is an ordinal scale, and the Wilcoxon rank sum is a nonparametric test that can be used to compare ordinal data between two independent groups (Answer C is correct). Answers A and B are incorrect because both the Student t-test and the paired Student t-test are parametric tests and would not be appropriate for data on an ordinal scale. Answer D is incorrect because the Pearson correlation test is used to determine the strength of association between two continuous variables. |
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Term
Investigators have chosen the Wong-Baker FACES pain rating scale to show that a new analgesic works better than placebo in children. The authors plan to randomize subjects to two separate groups. While designing this study, the investigators realized that they did not have a large enough budget to
support the sample size estimated. Which statistical test is best if they decide to use a paired design to decrease the number of subjects required while maintaining similar power?
A. Paired Student t-test.
B. Wilcoxon rank sum.
C. Wilcoxon signed rank.
D. McNemar test. |
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Definition
Answer: C
Even though both the Wilcoxon signed rank and the Wilcoxon rank sum tests can be used for ordinal data, the Wilcoxon signed rank test is for paired samples (Answer C is correct), whereas the Wilcoxon rank sum test is designed for independent groups (Answer B is incorrect). Answer A is incorrect; although the paired Student t-test can be used in a paired design, the criteria for using this parametric test include continuous, normally distributed data. The McNemar test can be used for a study that has a paired design; however, Answer D is incorrect because the test is designed for nominal versus ordinal data, and use of this test would result in less power to find a difference |
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Term
Drug X has just received FDA (U.S. Food and Drug Administration) approval for lowering the low-density lipoprotein cholesterol (LDL-C) in adults. You would like to design a clinical trial to see whether the new drug is effective in your pediatric population. To gather some preliminary evidence, you have measured the LDL-C in children who have been treated with drug X at baseline and after 3 months of therapy and observed the data to be
normally distributed. Which descriptive statistics would be best to summarize the baseline LDL-C in your subjects?
A. Median and interquartile range (IQR).
B. Mean and standard deviation (SD).
C. Mean and standard error (SE).
D. Mode and range. |
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Definition
Answer: B
For a continuous variable that is normally distributed, using the mean and SD is the most
informative way to report the results compared with the other options listed (Answer B is correct). By reporting these two parameters, the reader will be able to re-create the distribution of the results. Although Answer A would not be an incorrect way of reporting the results, it is not the best answer because median and IQR would not be as informative and do not require that the results be normally distributed. Answer C is incorrect because the SE is not a reflection of the distribution of the sample data; rather, it is an estimate of how well the investigator estimated the mean of the population sampled. Mode represents the most frequent result. Although the mode would be expected to be equal to the mean if the data were normally distributed,it is rarely reported in the clinical literature and, if reported with the range, would not be as informative as the mean and SD; therefore, Answer D is incorrect. |
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Term
Drug X has just received FDA (U.S. Food and Drug Administration) approval for lowering the low-density lipoprotein cholesterol (LDL-C) in adults. You would like to design a clinical trial to see whether the new drug is effective in your pediatric population. To gather some preliminary evidence, you have measured the LDL-C in children who have been treated with drug X at baseline and after 3 months of therapy and observed the data to be
normally distributed. Your next objective is to compare the baseline
LDL-C with the LDL-C collected after administering drug X for 3 months. Which statistical test would be best if the goal were to maximize the likelihood of avoiding a type II error?
A. Paired Student t-test.
B. Wilcoxon signed rank.
C. ANOVA.
D. Chi-square test. |
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Definition
Answer: A
The paired Student t-test is the best option because the investigators have results for each subject before and after the use of drug X (Answer A is correct). Although the Wilcoxon signed rank test is designed to compare paired samples,Answer B is incorrect because it is a nonparametric test and would have less power. Answer C is incorrect because although the ANOVA test could be used, this test assumes that groups are not paired, and it would have less power to find a difference. The chi-square test is a nonparametric test for nominal data; therefore, Answer D is incorrect |
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Term
Drug X has just received FDA (U.S. Food and Drug Administration) approval for lowering the low-density lipoprotein cholesterol (LDL-C) in adults. You would like to design a clinical trial to see whether the new drug is effective in your pediatric population. To gather some preliminary evidence, you have measured the LDL-C in children who have been treated with drug X at baseline and after 3 months of therapy and observed the data to be
normally distributed. After analyzing your data, you have determined
that you have enough preliminary evidence to warrant designing a clinical trial at your practice. Considering your limited budget, you would like to do everything possible to decrease your sample
size estimate while maintaining the same power or likelihood to detect a difference after 1 year of treatment.
Which is best to achieve this goal?
A. Decrease the α.
B. Increase the delta.
C. Choose an outcome measure that has increased
variability compared with the LDL-C.
D. Choose a parallel versus a paired study design. |
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Definition
Answer: B
Estimating the sample size needed to achieve a predetermined power (power = (1 − β)) or the likelihood of finding a difference depends on several factors. Increasing the delta or the difference the investigator feels a priori is the minimal clinically significant difference will decrease the sample size estimate, allowing the investigators to stay within their limited budget (Answer B is correct). Answers A, C, and D are incorrect because choosing a smaller α (risk of error you will tolerate when rejecting H0), an outcome measure that has increased variability compared with the LDL-C, or a parallel versus a paired study design will result in a decrease in power; therefore,the investigators will have to increase the sample size to maintain the same power to detect a difference between groups, which is the opposite of their goal. |
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Term
Drug X has just received FDA (U.S. Food and Drug Administration) approval for lowering the low-density lipoprotein cholesterol (LDL-C) in adults. You would like to design a clinical trial to see whether the new drug is effective in your pediatric population. To gather some preliminary evidence, you have measured the LDL-C in children who have been treated with drug X at baseline and after 3 months of therapy and observed the data to be
normally distributed. After collecting data comparing the ability of drugs
X and Y to decrease the LDL-C in two separate groups of children after 1 year of treatment, you are prepared to present your results at a scientific meeting. The abstract submission guidelines for this meeting limit you to 250 words. Which is best to report the difference between groups?
A. The difference between groups in LDL-C reduction from baseline after 1 year of treatment and the 95% CI of this estimate.
B. The change in LDL-C compared with baseline after 1 year of treatment for subjects treated with drugs X and Y and the 95% CI of each of these estimates.
C. The mean LDL-C in each group after 1 year of treatment, together with 95% CI of this estimate.
D. The difference between groups in LDL-C reduction from baseline after 1 year of treatment and the p value of this estimate. |
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Definition
Answer: A
Answer D is not the best answer because the 95% CI will allow readers to better estimate the clinical significance of the reported difference and how that may apply to their practice goals in addition to determining whether the difference reported is statistically significant (Answer A is correct); the p value will report only the latter. Answers B and C are incorrect because neither reports whether a difference was observed between treatment groups; Answer B estimates the change from baseline in each group separately, and Answer C is a descriptive statistic of the LDL-C in each group after 1 year of treatment |
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Term
Drug X has just received FDA (U.S. Food and Drug Administration) approval for lowering the low-density lipoprotein cholesterol (LDL-C) in adults. You would like to design a clinical trial to see whether the new drug is effective in your pediatric population. To gather some preliminary evidence, you have measured the LDL-C in children who have been treated with drug X at baseline and after 3 months of therapy and observed the data to be
normally distributed. Your results show that compared with drug Y use,
the use of drug X decreases the LDL-C more in children after 1 year of treatment, and you would like to determine whether this effect holds up after considering the influence of one or more covariates. Which would best allow you to achieve this aim?
A. Analysis of covariance (ANCOVA).
B. Mann-Whitney U test.
C. Student t-test.
D. ANOVA. |
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Definition
Answer: A
The ANCOVA test is a multiple regression model that includes both continuous (covariates) and categorical (factors) independent variables, which will allow the investigators to discern the effect of drug X while controlling for the effects of one or more continuous variables (Answer A is correct). The ANCOVA test allows the investigator to determine whether a continuous dependent variable differs between groups while controlling for other continuous or categorical dependent
variables; although not a choice listed, multiple linear regression would be an acceptable method as well. Answers B, C, and D are incorrect because they are all statistical tests for determining differences between
groups that do not allow the investigator to control for covariates. |
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Term
Drug X has just received FDA (U.S. Food and Drug Administration) approval for lowering the low-density lipoprotein cholesterol (LDL-C) in adults. You would like to design a clinical trial to see whether the new drug is effective in your pediatric population. To gather some preliminary evidence, you have measured the LDL-C in children who have been treated with drug X at baseline and after 3 months of therapy and observed the data to be
normally distributed. Now that there is enough published evidence showing
that drug X is effective in decreasing the LDL-C in your pediatric population, you are asked to participate in a multicenter clinical trial to determine whether drug X decreases time to mortality. Which
statistical test would be most appropriate to achieve this aim?
A. Repeated-measures ANOVA.
B. Chi-square test.
C. Kruskal-Wallis test.
D. Cox proportional hazards model. |
|
Definition
Answer: D
Survival analysis allows investigators to study the time between study entry and an event such as death. The Cox proportional hazards model is a method of survival analysis that compares survival in two or more groups after adjusting for the effect of other variables (Answer D is correct). Answers A, B, and C are incorrect because they are all statistical tests for determining differences between groups; unlike survival analysis, they do not allow investigators the ability to include censored and uncensored data. |
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Term
Using a regression model, investigators were able to show that children with cancer had an odds ratio
(OR) of 1.5 (95% CI, 1.2–2.0) compared with children without cancer. Which is the best interpretation of the reported results?
A. Children with cancer had 1.5 times the odds of having the outcome compared with children without cancer, but the difference was not statistically significant.
B. Children with cancer had 1.5 times the odds of having the outcome compared with children without cancer, and the difference was statistically
significant.
C. Children without cancer had 1.5 times the odds of having the outcome compared with children with cancer, and the difference was statistically
significant.
D. Without a p value, the reader cannot discern whether the difference between groups was statistically significant. |
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Definition
Answer: B
An OR greater than 1 indicates an increase in the odds of having an outcome (Answer B is correct). Answers A and D are incorrect because the 95% CI does not include 1;therefore, the difference in odds is statistically significant,and a p value does not need to be reported. Answer C is incorrect because children without cancer have a lower versus higher odds of having the outcome. |
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Term
A randomized controlled trial was performed to determine whether there was a difference in outcome between drug A and drug B in children. The
100 subjects who completed the trial were divided equally between the two treatment groups. Thirty children who received drug A experienced the outcome, whereas only 20 children who received drug B experienced the outcome. Which statement is the best estimate of the relative risk comparing the outcome in children who received drug A with the outcome in children who received drug B?
A. 0.44.
B. 1.5.
C. 2.25.
D. 15. |
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Definition
Answer: B
Outcome
Yes
Outcome
No Total
Drug A 30 (a) 20 (b) 50
Drug B 20 (c) 30 (d) 50
Total 50 50 100
The relative risk or risk ratio is the ratio of the incidence observed in each group ((30/50)/(20/50)) (Answer B is correct). Answer C is incorrect because it is the OR; the difference in results between Answer C and Answer B emphasizes how the OR differs from the relative risk or risk ratio when the incidence is not rare. The OR is calculated by cross-multiplying and dividing the observed number of events (ad/bc). Answer A is incorrect because it is the calculation of the OR of drug B compared with drug A, and Answer B is incorrect because it is the relative risk or risk ratio. Answer D is incorrect because of a decimal point error, making the answer 10 times too large. |
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Term
A study was designed to evaluate the efficacy and safety of risperidone long-acting injectable (LAI)for preventing the recurrence of mood episodes in patients with type I bipolar disorder. After a 12-week
open-label period with risperidone LAI, patients who did not experience a recurrence entered an 18-month randomized, double-blind period with risperidone LAI, placebo, or oral olanzapine. The primary end point was time to recurrence of any mood episode for risperidone LAI versus placebo in the study period. Which type of data is being evaluated?
A. Interval.
B. Ordinal.
C. Nominal.
D. Ratio. |
|
Definition
Answer: D
Continuous data have a constant and defined unit of measure, with an equal distance between increments,and include both interval and ratio data. Ratio data have an absolute zero point (e.g., time, as in this question)(Answer D is correct). Interval data have an arbitrary zero point assigned (e.g., degrees Fahrenheit) (Answer A is incorrect). Ordinal data have an implied rank or order,but they are limited in the number of categories (Answer B is incorrect). Nominal data do not have an implied rank or order and are categorical (Answer C is incorrect). |
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Term
Identify the trial design from the following description:
It is hypothesized that proton pump inhibitors (PPIs) contribute to development of hospital-onset
Clostridium difficile. A study was conducted to test this hypothesis. Medical charts from a group of patients with C. difficile were compared with medical charts from a group of patients without C. difficile.
The groups were matched by age, sex, date of admission, and other confounding factors, such as antibiotic use. The use of PPIs in each group was assessed and compared.
A. Cohort study.
B. Case-control study.
C. Randomized controlled trial.
D. Meta-analysis. |
|
Definition
Answer: B
Case-control studies are observational studies that serve to compare patients with a disease or outcome to those without the disease or outcome to evaluate the effect of an exposure to a risk factor (Answer B is correct). Although a cohort study is similar to a case-control study in its observational approach to examination, a cohort study is used when subjects are selected on the basis of their exposure to a risk factor (Answer A is incorrect). A randomized controlled trial evaluates the impact of an intervention (Answer C is incorrect). A meta-analysis includes the results from several trials (Answer D is incorrect). |
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Term
Identify the trial design from the following description:
After the 1986 accident at the Chernobyl nuclear power plant in the Soviet Union, epidemiologists examined differences in the frequency of thyroid
tumors between children living downwind of the reactor and children living upwind of the reactor. During the 5 years after the accident, the frequency of thyroid tumors increased only among children exposed to the radiation.
A. Cohort study.
B. Case-control study.
C. Randomized controlled trial.
D. Meta-analysis. |
|
Definition
Answer: A
A cohort study is appropriate when subjects are selected on the basis of their exposure to a risk factor (e.g., radiation,as in this case) (Answer A is orrect). Although casecontrol studies are observational, they serve to compare patients with a disease or outcome to those without the disease or outcome to evaluate the effect of exposure to a risk factor (Answer B is incorrect). A randomized controlled trial evaluates the impact of an intervention (Answer C is incorrect). A meta-analysis includes the results from several trials (Answer D is incorrect). |
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Term
Identify the study design from the following description:
A paper documents emerging posttraumatic obsessive-compulsive disorder in 13 Israeli military veterans with a diagnosis of both obsessive-compulsive disorder (OCD) and posttraumatic stress disorder,
for whom the onset of OCD was clearly associated with the trauma. The data presented include four detailed patient histories that delineate the relationship between the symptomatologies of the two disorders.
The clinical and theoretical implications of the data are discussed.
A. Case control.
B. Case report.
C. Case series.
D. Cross-sectional. |
|
Definition
Answer: C
A case series is a descriptive, not an experimental, design that allows documentation and communication of an experience of several patients (Answer C is correct). A case report describes a single patient (Answer B is incorrect). A case-control design is an explanatory design appropriate for examining the etiology, efficacy, and cause using a comparison strategy (Answer A is incorrect). A cross-sectional study is appropriate for gathering information relevant to the prevalence of health-related states and conditions (Answer D is incorrect). |
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Term
A study is conducted of a new oral chemotherapy agent (group A) compared with an existing oral chemotherapy agent (group B). Patients are assigned to group A or B and are unaware of treatment assignment. The primary outcome is tumor regression, as assessed by a radiologist. All study investigators are unaware of the treatment assignment. This study is:
A. Single-blinded.
B. Double-blinded.
C. Triple-blinded.
D. Double-dummy. |
|
Definition
Answer: C
In a triple-blind design, the subject, investigator, and third party (e.g., the radiologist) are all blinded to treatment assignment (Answer C is correct). Single-blind and double-blind designs are appropriate for the blinding of one or two groups (e.g., subjects, investigators) in a study,respectively (Answers A and B are incorrect). A doubledummy design is appropriate for comparing treatments available in different dosage forms (e.g., oral dosage form vs. subcutaneous injection) to blind the treatment allocation (Answer D is incorrect). |
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|
Term
Identify the trial design from the following description:
A study was conducted to estimate the incidence of rhabdomyolysis in patients treated with different
statins and fibrates, alone and in combination, in the ambulatory setting. Claims data from managed care
health plans were used to identify statin and fibrate users. Which type of study design is this?
A. Cohort study.
B. Case-control.
C. Randomized controlled trial.
D. Meta-analysis. |
|
Definition
Answer: A
A cohort study is appropriate when subjects are selected
on the basis of their exposure to a risk factor (e.g.,
medication exposure, as in this case) (Answer A is
correct). Although case-control studies are observational, they serve to compare patients with a disease or outcome to those without the disease or outcome to evaluate the effect of an exposure to a risk factor (Answer B is incorrect). A randomized controlled trial evaluates the impact of an intervention (Answer C is incorrect). A meta-analysis includes the results from several trials (Answer D is incorrect). |
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|
Term
Identify the trial design from the following description:
A literature review was conducted and a study was performed on data retrieved from studies that followed
patients with inflammatory bowel disease (IBD) who received immunosuppressive therapy for more than 1 year. The incidence of newly developed malignancy was documented. Then, a literature search was performed using MEDLINE and the Cochrane Library. Nine cohort studies met the inclusion criteria for this study. Analysis of these studies
showed no discernible difference in the incidence of any type of malignancy in patients with IBD who
received immunosuppressive therapy compared with those who did not receive immunosuppressants.
A. Cohort study.
B. Case-control.
C. Randomized controlled trial.
D. Meta-analysis. |
|
Definition
Answer: D
A meta-analysis describes the systematic evaluation of the results of a group of clinical trials and the combining of the results (Answer D is correct). A cohort study is appropriate when subjects are selected on the basis of their exposure to a risk factor (Answer A is incorrect). Case-control studies are observational studies that compare patients with a disease or outcome to patients without the disease or outcome to evaluate the effect of an exposure to a risk factor (Answer B is incorrect). A randomized controlled trial evaluates the impact of an intervention (Answer C is incorrect). |
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Term
A 5-year parallel, randomized, double-blind study compared metformin with glipizide in patients with type 2 diabetes mellitus. In this study, an intention-to-treat analysis would:
A. Be appropriate to clearly establish the effect of completing therapy with the medications.
B. Be appropriate to estimate the effects of the two medications in a clinical setting.
C. Not be appropriate because it would overestimate the efficacy of the medication.
D. Not be appropriate because this type of analysis excludes subjects with protocol violations |
|
Definition
Answer: B
An intention-to-treat analysis compares an outcome according to the intended initial subjects’ assignments and determines the effect of a treatment under usual conditions (Answer B is correct). A per-protocol analysis is appropriate to clearly establish the effect of completing therapy with the medications as prescribed because only data from subjects who precisely followed the protocol are included in the final analysis (Answer A is incorrect). An intention-to-treat analysis provides a conservative estimate of the true treatment difference (Answer C is incorrect). Intention-to-treat analyses include all data points, whereas per-protocol analyses exclude subjects from the final analysis if there are protocol violations (Answer D is incorrect). |
|
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Term
Investigators conducted a clinical trial to evaluate the impact of nebulized hypertonic saline compared
with nebulized 0.9% normal saline on admission rates and length of stay in infants with bronchiolitis.
Which strategy performed at study enrollment ensures that subjects have an equal chance of receiving the active intervention?
A. Blinding.
B. Exclusion criteria.
C. Randomization.
D. Inclusion criteria. |
|
Definition
Answer: C
Randomization is used to ensure that each subject has an equal chance of being in any of the treatment arms (Answer C is correct). Blinding is used to prevent the placebo effect and to reduce investigator bias from assessing/treating one patient group differently from the other (Answer A is incorrect). Inclusion and exclusion criteria are defined to select the most appropriate patient population for the study (Answers B and D are incorrect). |
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Term
Investigators conducted a trial to evaluate the optimal blood glucose concentrations in critically ill
patients. Within 24 hours of admission to an intensive
care unit (ICU), adults who were expected to
require treatment in the ICU for 3 or more consecutive
days were randomly assigned to undergo either
intensive glucose control, with a target blood glucose
range of 81–108 mg/dL, or conventional glucose
control, with a target of 180 mg/dL or less.
The primary end point was defined as death from
any cause within 90 days after randomization. All
patient outcomes were included in the final analysis,
even if there were deviations from the protocol.
Which type of control group was used in this study?
A. Placebo.
B. Active.
C. Historical.
D. Open-label. |
|
Definition
Answer: B
An active control is used in this study, given that all patients received active treatment (Answer B is correct). A placebo control is an inactive comparator (Answer A is incorrect). A historical control is selected from a comparison group that was observed in the past or can be evaluated from patient records (Answer C is incorrect). Open-label does not describe which type of control used the study; instead, it describes the lack of blinding of treatment assignment (Answer D is incorrect). |
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Term
Investigators conducted a trial to evaluate the optimal blood glucose concentrations in critically ill
patients. Within 24 hours of admission to an ICU,adults who were expected to require treatment in the ICU for 3 or more consecutive days were randomly assigned to undergo either intensive glucose control, with a target blood glucose range of 81–108 mg/dL, or conventional glucose control, with a target of 180 mg/dL or less. The primary end point was defined as death from any cause within 90 days after randomization. All patient outcomes were included in
the final analysis, even if there were deviations from the protocol. Which type of variable is the primary outcome in this study?
A. Continuous.
B. Ordinal.
C. Nominal.
D. Interval. |
|
Definition
Answer: C
Nominal data are named categories with no implied rank of order—in this example, death from any cause or survival (Answer C is correct). Continuous data have a constant and defined unit of measure, with an equal distance between increments (Answer A is incorrect). Ordinal data have an implied rank or order but are limited in the number of categories (Answer B is incorrect). Interval data are continuous with a predetermined order and an arbitrary zero point assigned (Answer D is incorrect). |
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Term
A study was designed to assess the effect of hypertonic saline on mucus flow in infants with acute
bronchitis and evaluate a change in bronchiolitis
severity score. Patients were randomized to receive
either 7% saline or 0.9% saline, both with epinephrine.
Which type of study is this?
A. Crossover.
B. Parallel.
C. Cohort.
D. Case-control. |
|
Definition
Answer: B
Parallel and crossover describe study perspectives. A parallel design, as in this case, describes a study in which the subject receives either the study treatment or the control treatment throughout the study (Answer B is correct). By contrast, in a crossover design, each subject serves as his or her own control and receives both the study and control treatments throughout (Answer A is incorrect). Cohort and case-control are both observational study types and do not incorporate the use of an intervention (Answers C and D are incorrect). |
|
|
Term
Which type of analysis risks underestimating the treatment effect observed in a clinical trial?
A. Intention-to-treat.
B. As-treated.
C. Per-protocol.
D. Historical. |
|
Definition
Answer: A
An intention-to-treat analysis compares outcomes according to the subjects’ intended initial assignments and gives a conservative estimate of the true difference, but provides a better idea of how the treatment will perform in clinical practice (Answer A is correct). An as-treated analysis compares outcomes according to the treatment subjects received in the study and provides a more accurate estimate of the true treatment difference compared with intention-to-treat (Answer B is incorrect). A per-protocol analysis compares outcomes according to subjects who precisely followed the study protocol and provides the most accurate estimate of the true treatment difference (Answer C is incorrect). Historical is a type of control, not a type of study analysis (Answer D is incorrect). |
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|
Term
Formulary management in pediatric patients requires an additional skill set to ensure comprehensive and safe medication use for pediatric patients. Which best reflects the responsibility of the pediatric pharmacy representative to the pharmacy and therapeutics (P&T) committee?
A. Evaluate medication monographs for the inclusion of all pertinent pediatric data.
B. Extrapolate a recommended dosing regimen for all medications recommended for formulary addition.
C. Recommend age-based restrictions for any medication without pediatric data.
D. Design workarounds for the use of medications in pediatric patients after the development of implementation plans for adults. |
|
Definition
Answer: A
Pediatric representatives should ensure that the data available are included in drug monographs for an accurate evaluation of the medications recommended for addition to the formulary (Answer A is correct). Lack of data does not preclude the use of a medication in pediatric patients; however, extrapolating a dosing regimen for all medications that may be added to the formulary is neither safe nor appropriate (Answer B is incorrect). Age-based restrictions should be implemented for medications that pose a risk to certain age groups of pediatric patients, but broad restrictions for all drugs that lack data in pediatric patients underscore the likelihood of off-label use of some medications and downplay the pediatric pharmacist’s abilities to evaluate the appropriate use of medications on a case-by-case basis (Answer C is incorrect). Often, implementation plans may need to vary from the adult population to the pediatric population. Separate implementation plans should be developed as needed to prevent workarounds that may put patients at risk experiencing medication errors (Answer D is incorrect). |
|
|
Term
Which is most likely to ensure change in practice or processes after the completion of a medication use evaluation (MUE)?
A. Adult and pediatric populations are assessed
using the same outcomes.
B. A multidisciplinary team of key stakeholders
participates.
C. High-cost medications are evaluated.
D. The scope of the evaluation is expanded once data collection begins. |
|
Definition
Answer: B
Medication use evaluations are most effective when a multidisciplinary team of key stakeholders are involved from the development of the plan through the distribution of outcomes (Answer A is correct). Scope and outcomes of the MUE should be determined before data collection (Answer D is incorrect). However, outcomes for adult and pediatric populations may vary depending on the medication to be evaluated (Answer A is incorrect). Although high-cost medications may be evaluated, many other indicators for medications or medication use processes should be identified for evaluation, such as safety risk and adherence to protocols (Answer C is incorrect). |
|
|
Term
You are a pediatric clinical pharmacy specialist at a freestanding pediatric institution. You have been ask to identify a multidisciplinary team to develop, perform, and disseminate the results of a MUE for anticoagulants used for venous thromboembolism
(VTE) prophylaxis after the recent implementation of a VTE risk assessment in adolescents at your
institution. Which would be most essential to the team?
A. Nurse.
B. Operations pharmacy manager.
C. Clinical nurse specialist.
D. Pediatric hematologist. |
|
Definition
Answer: D
Although all of these disciplines would offer something unique to the MUE, a pediatric hematologist would be essential for identifying appropriate outcomes for assessment and would be key to reevaluating the assessment tool as well as disseminating information to the medical staff about the results (Answer D is correct). A clinical nurse specialist, especially whose focus is in hematology, would be useful to provide input on developing the risk assessment and developing a plan for implementation of the risk assessment as well as any protocol re-work that may be appropriate, given the results of the MUE (Answer C is incorrect). A bedside nurse and operations pharmacy manager would provide expertise in implementing the plans affecting each discipline (Answers A and B are incorrect). |
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|
Term
Medication use guidelines help standardize care for specific populations or disease states. When pediatric data are not available, which might be the best strategy used by the pediatric pharmacist to develop a medication use guideline?
A. Recommend against development of these guidelines when pediatric efficacy data are not available.
B. Incorporate adult data when extrapolation is appropriate.
C. Evaluate adherence to the guideline when adult data are extrapolated.
D. Develop education and implementation plans for all disciplines. |
|
Definition
Answer: B
In the ideal situation, medication use guidelines for pediatric patients are developed from pediatric data; however, a lack of pediatric data may not preclude the off-label use of a medication in pediatric patients, and a medication use guideline may enhance the safety of that use (Answer A is incorrect). In these instances, appropriate adult data should be extrapolated to facilitate guideline development (Answer B is correct). The guideline and its implementation plan should be developed in a multidisciplinary fashion (Answer D is incorrect). All guidelines should be evaluated after implementation for adherence and safety, whether developed from adult or pediatric data (Answer C is incorrect). |
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|
Term
Which most accurately depicts a barrier to the provision of pharmaceutical care to pediatric patients?
A. Enteral medications available in both liquid and solid dosage forms.
B. Standard medication dosing regimens.
C. Innovative drug delivery devices.
D. Interpretation of available pediatric data. |
|
Definition
Answer: C
Use of innovative drug delivery devices for delivering medications to the pediatric population enhances the complexity of care for these patients (Answer C is correct). Standard medication-dosing regimens and commercially available liquid products help facilitate the care of pediatric patients (Answers A and B are incorrect). Medical data require adequate skills to interpret; however, the barrier in care of pediatric patients is more commonly the paucity of data than the pharmacist’s ability to interpret data (Answer D is incorrect). |
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|
Term
Which would be the best medication use process used by pharmacies to provide optimal inpatient medication dispensing services for pediatric patients?
A. Multidose vials available in automated dispensing cabinets.
B. Standardized dose nomograms for commonly used oral liquids.
C. Multiple concentrations for continuous infusions.
D. Individual patient-specific doses for intermittent medications. |
|
Definition
Answer: B
Standardization of doses and concentrations will minimize the risk of error, which is heightened in the pediatric medication use process (Answer B is correct). Some dose individualization will be necessary to meet the unique needs of pediatric patients; however, use of prepackaged doses and standardized doses help optimize the efficiency and enhance safety in the medication use process (Answer D is incorrect). Medications should be dispensed in ready-to-administer doses (Answer A is incorrect), and the number of concentrations available should be standardized and minimized (Answer C is incorrect). |
|
|
Term
Pediatric pharmacists providing pharmacy services in an ambulatory care setting should have an understanding of the unique medication needs of patients and their caregivers. Which should be considered
the most essential component in the provision of ambulatory services to pediatric patients and their caregivers?
A. Education of pediatricians on poison
prevention.
B. Drug information education for nurses and
providers.
C. Medication education for caregivers on accurate
medication measurement.
D. Knowledge of commercially available
medications. |
|
Definition
Answer: C
Although all of these would be included in the provision of pediatric ambulatory care pharmacy services, in-depth medication education for caregivers focusing on the accurate measurement of medications would be the most essential component to provide caregivers and patients (Answer C is correct). Knowledge of commercially available products is important in providing care, but without appropriate education of the caregivers, this will not ensure adequate care to patients (Answer D is incorrect). Providing drug information to nurses and providers and educating providers on poison prevention will affect the care provided to pediatric patients in the ambulatory setting; however, this would not be considered the most essential component to provide patients and their caregivers (Answers A and B are incorrect). |
|
|
Term
Computerized physician order entry (CPOE) is designed to decrease the risk of medication errors at the point of the medication use process with the
highest risk of error. Which best depicts the point in the medication use process when risk of error is the
highest?
A. Prescription.
B. Transcription.
C. Verification.
D. Dispensing. |
|
Definition
Answer: A
When developed and implemented in an optimal fashion, CPOE systems are designed to minimize the risk of error at the point of prescribing by removing handwriting errors (Answer A is correct) and minimizing the need for transcription by secretaries, nurses, and pharmacists (Answer B is incorrect). Computerized order entry does not minimize errors in verification because this function ensures perfection of the order delivered to the pharmacist either manually or electronically (Answer C is incorrect). Dispensing as a step in the medication use process is not enhanced by CPOE because other human errors can result in inaccurate dispensing; risks of dispensing error are minimized through technologies such as bar coding or pharmacy workflow managers (Answer D is incorrect). |
|
|
Term
As commercial CPOE systems are designed for use in adult patients, customization is often needed to ensure optimal use in pediatric patients. Which customization would best optimize the CPOE system for
use in pediatric patients?
A. Weight-based dosing order sentences.
B. Age-related dosing algorithms.
C. Many options for route of administration for each medication.
D. Extensive clinical decision support. |
|
Definition
Answer: B
Age-related dosing algorithms can help direct providers to dosing regimens that consider the developmental differences in pediatric patients of different ages and stratify dosing appropriately (Answer B is correct). Weight-based dosing order sentences are valuable but must be incorporated with fixed dosing and direction for patient use (Answer A is incorrect). Forcing functions such as route of administration to only acceptable routes of administration for a dosing product versus providing all routes of helps optimize the system and enhance safety (Answer C is incorrect). Clinical decision support should be thoughtfully used to provide the most useful data without creating alert fatigue (Answer D is incorrect). |
|
|
Term
Smart infusion pumps help enhance the safe delivery of intermittent and continuous-infusion parenteral medications. Pediatric pharmacists should be highly involved in developing the drug library content for these pumps. Which would best be routinely evaluated to optimize the infusion pump library?
A. Unnecessary alerts.
B. Needed workarounds.
C. Nursing desire to use library.
D. Changes to dosing in library based on new guidelines. |
|
Definition
Answer: A
Nursing barriers to use and subsequent workarounds should be assessed, but workarounds should not intentionally be developed (Answer B is incorrect). One major benefit of assessing the smart pump library is to evaluate for unnecessary alerts (Answer A is correct), which can be streamlined to prevent alert fatigue and workarounds. Although optimization of the library through minimization of alerts should enhance compliance with use, desire to use technology that enhances safety is not the ideal reason for routine evaluation (Answer C is incorrect). Newly published or updated guidelines should be considered in the development of the library content; however, dosing assessment should occur more often than such guidelines would be updated, and such guidelines might not be the only source used in the development of dosing guardrails (Answer D is incorrect). |
|
|
Term
A joint task force created by the American College of Clinical Pharmacy (ACCP) and the Pediatric Pharmacy Advocacy Group (PPAG) developed strategies to expand the quality and capacity of clinical pharmacy services provided to pediatric patients. Which strategy would best be used to enhance clinical pharmacy services?
A. Developing minimum expectations for the training of those entering pediatric practice.
B. Substituting on-the-job training for PGY2 residency experience.
C. Expanding the service coverage of the currently available clinical pharmacy specialist.
D. Developing expectations for the participation of clinical pharmacists in pediatric research. |
|
Definition
Answer: A
Developing minimum expectations for pharmacists entering pediatric practice to include PGY1 training for operations pharmacists and PGY2 training for clinical specialists should be part of the plan to expand clinical pharmacy services (Answer A is correct). On-the-job training or experience is not likely to meet the learning experiences obtained during residency training and is not a suitable substitute (Answer B is incorrect). Adding responsibilities to those the current clinical pharmacy specialist already has without redistributing services or protecting time may diminish the clinical services (Answer C is incorrect). Participating in research certainly may be a service of clinical pharmacy, though this is more likely to be a result of implementing expectations for training to enter practice versus the best strategy to enhance service (Answer D is incorrect). |
|
|
Term
In the pediatric population, a unilateral approach to quality assessment in pediatric health care is likely to be unsuccessful. Which is most likely to complicate a unilateral approach in pediatric patients?
A. Communication barriers.
B. Heterogeneity of the population.
C. Patient independence.
D. Availability of health insurance |
|
Definition
Answer: B
A unilateral approach to quality assessment may be complicated in pediatric patients because of the heterogeneity of the population in development and pathophysiology (Answer B is correct). Although communication barriers and lack of independence result in the need to involve caregivers in quality enhancement, this does not necessarily complicate the unilateral approach to quality (Answers A and C are incorrect). Availability of health insurance is arguably better for the pediatric population, and availability of such insurance may not affect the approach to quality assessments (Answer D is incorrect). |
|
|
Term
When possible, which national strategy for health care improvement would best be integrated in pediatric health care quality?
A. Engaging caregivers to seek care for patients.
B. Improving safety through reduction of harm.
C. Encouraging healthy eating.
D. Engaging caregivers to coordinate care. |
|
Definition
Answer: B
National strategies for improving health care include reducing harm through improved safety (Answer B is correct). Caregivers and patients should be in engaged as partners in care (Answer A is incorrect), and health care providers engage in effective communication to improve transition of care (Answer D is incorrect). Encouraging healthy eating is not currently a national strategy for health care improvement (Answer C is incorrect). |
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|
Term
Which best describes cytochrome P450 (CYP)enzyme activity in term neonates?
A. Higher activity than in adulthood.
B. Absent until 9–12 months of age.
C. Not applicable because these are phase II enzymes.
D. Low initial activity with a gradual increase in activity. |
|
Definition
Answer: D
The maturation of drug-metabolizing enzyme activity is delayed, which results in toxicity with certain drugs (Answer D is correct). Answer A is incorrect because most enzymes increase their activity as the neonate matures. Answer B is incorrect because even though all the enzymes are in evidence, they have reduced activity. Answer C is incorrect because the CYP enzymes are not phase II elimination enzymes. |
|
|
Term
Which is most likely to cause an altered pharmacodynamic
(PD) drug response in infants?
A. Skin surface area.
B. Pulmonary surface area.
C. Reduced receptor number.
D. Impermeable blood-brain barrier |
|
Definition
Answer: C
Receptor number, density,distribution, and function differ in children compared with adults. Answers A and B are related to drug absorption and are therefore incorrect; similarly Answer D, impermeable blood-brain barrier, is incorrect. Answer C, reduced receptor number, is related to drug distribution and is therefore correct. |
|
|
Term
Which most likely complicates intramuscular drug delivery in neonates?
A. Total body water content.
B. Variable local skin perfusion.
C. Altered local area blood perfusion to muscles.
D. Increased muscle tone from neuromuscular pathways. |
|
Definition
Answer: C
Local blood perfusion will affect how quickly and completely an intramuscularly administered drug is effective (Answer C is correct). Answer A (total body water content) and Answer B (skin perfusion) may affect drug concentration, and neither are related to intramuscular drug delivery (Answers A and B are incorrect). Muscle tone is decreased in neonates, and it will not affect delivery (Answer D is incorrect). |
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|
Term
Which factor best describes increases in percutaneous absorption in neonates?
A. Insensible water loss.
B. Underdeveloped epidermis.
C. Subcutaneous adipose tissue.
D. Reduced muscle mass and tone. |
|
Definition
Answer: B
Answer B is correct because the underdeveloped epidermis allows more drug to cross the physical barrier of the skin. Answer A is incorrect because insensible water loss through the skin is a result of the underdeveloped epidermis, not a cause of increased absorption. Answers C and D are incorrect because subcutaneous adipose tissue and reduced muscle mass and tone do not substantially affect the absorption of drugs through the skin. |
|
|
Term
You are caring for a pediatric patient with cystic
fibrosis, and the patient is experiencing diarrhea.
Which mechanism best describes altered drug effects secondary to diarrhea in in this patient?
A. Altering bile salt binding.
B. Reducing drug absorption.
C. Malabsorption of nutrients.
D. Enhancing renal drug clearance. |
|
Definition
Answer: B
Answer B is correct; diarrhea increases the gastro-enteral
transit time, so drugs have less time to be absorbed
while in the body. Neither Answer A nor Answer D is a
mechanism that will alter drug absorption in diarrhea.
Diarrhea will reduce nutrient absorption (Answer C), but this is unrelated to drug absorption. |
|
|
Term
Which best describes when acid secretion from the stomach reaches adult levels?
A. 3 months.
B. 1 year.
C. 3 years.
D. 12 years. |
|
Definition
Answer: C
The pH of the stomach is neutral at birth and drops to a pH of 2–3 within hours but does not consistently attain an adult pH until the patient is at least 3 years of age,rendering Answer C correct and Answers A, B, and D incorrect. |
|
|
Term
Which best describes total body water at birth in term newborns?
A. 92%.
B. 75%.
C. 60%.
D. 50%. |
|
Definition
Answer: B
A term infant’s total body water is about 75% of his or her weight, making Answer B correct and Answers A, B, and D incorrect. |
|
|
Term
You are caring for a neonate in the neonatal intensive
care unit. Which is the most important consideration
for neonates regarding drug absorption?
A. Gastric emptying time is decreased during the
first week of life.
B. Transdermal absorption is greater in neonates
because hydration is decreased and skin thickness
is increased.
C. Rectal administration of medications gives the
most predictable absorption in neonates.
D. Intramuscular absorption is variable in
neonates |
|
Definition
Answer: D
Answer A is incorrect because gastric emptying is increased (not decreased) during the first week of life. Answer B is incorrect because hydration is increased and skin thickness is decreased in neonates, not increased. Answer C is incorrect because rectal absorption may be increased, given the immaturity of hepatic metabolism for neonates and very young infants. However, the absorption of rectally administered drugs in neonates and infants is decreased because of the greater number of high-amplitude pulsatile contractions in the rectum, making Answer D correct. Intramuscular absorption is variable due to the decrease in muscle mass, therefore should be used on a limited basis in neonates. |
|
|
Term
When determining the correct dose for aminoglycosides,
which change are you most likely to see in
pediatric patients compared with adults?
A. Volume of distribution is proportionately less in neonates than in adults.
B. Volume of distribution does not change in neonates compared with adults.
C. Volume of distribution is proportionately greater in neonates than in adults.
D. Volume of distribution varies from patient to patient; therefore, no comparison between adults and neonates can be made. |
|
Definition
Answer: C
Volume of distribution is larger (0.52 L/kg) in neonates compared with adults (0.2 L/kg), making Answer C correct and Answers A, B, and D incorrect. |
|
|
Term
You are working in a neonatal intensive care satellite pharmacy, and a new medical intern asks for the dose of ceftriaxone for a full-term neonate, day of life 3. Which is the most appropriate response?
A. Ceftriaxone should not be used in neonates because of the risk of kernicterus.
B. Ceftriaxone is highly protein bound; therefore,a free drug level must be checked after the third dose.
C. Ceftriaxone should not be used in neonates because of the risk of “gray baby syndrome.”
D. Ceftriaxone has increased elimination in neonates; therefore, higher doses must be used. |
|
Definition
Answer: A
Ceftriaxone causes kernicterus secondary to displacement of bilirubin (Answer A is correct). In addition, biliary sludging reduces bilirubin clearance. Ceftriaxone should be used with extreme caution in neonates, especially if they have hyperbilirubinemia or were born prematurely and is typically not used in a 3-day-old patient (Answer D is incorrect). Chloramphenicol, not ceftriaxone, causes gray baby syndrome (Answer C is incorrect). Even though ceftriaxone is protein bound, its free drug levels are not routinely evaluated in this population (Answer B is incorrect). |
|
|
Term
| Epidemiology Medulloblastoma |
|
Definition
Most common of all malignant brain tumors in children (20%)
2. Bimodal distribution: Peaks between 3 to 4 years of age and again between 8 and 10 years of age. About 80% of patients with meduloblastoma are diagnosed within the first 15 years of life.
3. Primitive neuroectodermal tumor (PNET): tumors that appear identical under microscope to medulloblastoma, but occur primarily in the cerebrum. Mostly occur in younger children and are fairly rare (0.62 per million) |
|
|
Term
| Treatment medulloblastoma |
|
Definition
Lomustine (CCNU) + vincristine + cisplatin
ii. Continues over about 8 cycles over 1 year
iii. Current 3-year event-free survival (EFS) rate is about 80%
high risk --cisplatin, carboplatin, cyclophosphamide and vincristine after radiation |
|
|
Term
| Infants with medulloblastoma |
|
Definition
Infants (< 3 years of age)
a. Radiotherapy is controversial secondary to the known long-term severe effects on intellectual development.
b. Most clinical trials have evaluated chemotherapy alone
i. Poor outcomes with EFS of 29%
c. Current trials focus on using high-dose chemotherapy with carboplatin and thiotepa, followed by autologous stem cell rescue (no radiation)
i. Overall survival about 30-40%
d. Methotrexate (intrathecally and intravenously) has been added to conventional chemotherapy in some studies, but has resulted in leukoencephalopathy in high numbers of patients, which may lead to long-term neurocognitive defects |
|
|
Term
| most common agents used in the treatment of pediatric hematologic malignancies and solid tumors Alkylating Agents |
|
Definition
Anthracyclines – daunorubicin, doxorubicin and idarubicin
2. Oxazophosphorines – cyclophosphamide and ifosfamide
3. Platinum analogues – cisplatin and carboplatin
4. Nitrosoureas – lomustine
5. Non-classic alkylators – procarbazine, dacarbazine and temozolomide |
|
|
Term
| most common agents used in the treatment of pediatric hematologic malignancies and solid tumors Antimetabolites |
|
Definition
Folate antagonists – methotrexate
2. Pyrimidine analogues – cytarabine
3. Purine analogues – mercaptopurine and thioguanine |
|
|
Term
| most common agents used in the treatment of pediatric hematologic malignancies and solid tumors Camptothecins |
|
Definition
|
|
Term
| most common agents used in the treatment of pediatric hematologic malignancies and solid tumors Vinca alkaloids |
|
Definition
| vincristine and vinblastine |
|
|
Term
| most common agents used in the treatment of pediatric hematologic malignancies and solid tumors Epipodophyllotoxins |
|
Definition
|
|
Term
| most common agents used in the treatment of pediatric hematologic malignancies and solid tumors Miscellaneous chemotherapeutics |
|
Definition
| asparaginase, bleomycin and dactinomycin |
|
|
Term
| most common agents used in the treatment of pediatric hematologic malignancies and solid tumors Biological therapies |
|
Definition
Monoclonal antibodies – rituximab, brentuximab vedotin and dinutuximab
2. Differentiating agents – trans-retinoic acid and isotretinoin
3. Tyrosine kinase inhibitors – imatinib and dasatinib |
|
|
Term
|
Definition
Hemorrhagic cystitis (dose-dependent)
SIADH (high dose), Myelosuppression, DDIx’s: P450 2B6 and 3A4 enzyme substrate
Mesna used when doses are ≥ 1 gm/m2 |
|
|
Term
|
Definition
Hemorrhagic cystitis (2° acrolein)
Neurotoxicity (2° chloracetylaldehyde)
Nephrotoxicity, Myelosuppression, prevention of hemorrhagic cystitis: IV hydration and oral fluids, empty bladder frequently, use mesna
DDIx’s: P450 2B6 and 3A4 enzyme substrate
Cumulative doses (≥ 60 gm/m2) are associated with Fanconi syndrome (renal proximal tubule dysfunction requiring electrolyte supplementation) |
|
|
Term
|
Definition
Nausea & vomiting, Mucositis (CIVI, Facial flushing, Red-Orange urine, Radiation recall, Myelosuppression
Cardiac (450-550 mg/m2 lifetime cumulative dose in adults; threshold in children is lower – around 300 mg/m2), Associated with secondary malignancies
To decrease cardiac toxicity: give as continuous infusion, use dexrazoxane, use liposomal product |
|
|
Term
|
Definition
| Nausea & vomiting, Mucositis (CIVI), alopecia, Red-Orange urine, Myelosuppression, Associated with secondary malignancies |
|
|
Term
|
Definition
Has metal-chelating activity (chelates free iron and iron bound in anthracycline therefore preventing the formation of cardiotoxic reactive oxygen radicals
2. Dose is 10x the doxorubicin dose given as a bolus infusion 30 minutes before the doxorubicin
3. Side effects: nausea & vomiting, increase in LFT’s, increase in iron, increase in amylase, increase in
triglycerides, decrease in zinc, pain at injection site (myelosuppression is thought to be the dose liimiting side effect)
4. May protect tumor cells (?) |
|
|
Term
| Sodium-2-mercaptoethanesulfonate (MESNA, Mesnex) |
|
Definition
Dosing and administration (60-120% w/w of cyclophosphamide or ifosfamide)
1. Can be given as a continuous IV infusion over 24 hours
2. Can be given in small boluses (usually 20% w/w dose) before, during and every 3-4 hours after cyclophosphamide or ifosfamide has been given
3. Oral mesna dose is twice the IV dose |
|
|
Term
|
Definition
Mild-moderate myelosuppression (anemia)
Severe nausea & vomiting
Ototoxicity
Nephrotoxicity (dose-related), Peripheral neuropathies
Nephrotoxicity if preventative measures not utilized, IV hydration, mannitol/furosemide, hypertonic saline solutions, sodium thiosulfate and amifostine have been used to decrease nephrotoxicity
Hearing loss a concern in long-term survivors |
|
|
Term
|
Definition
Moderate-severe nausea & vomiting
Some peripheral neuropathies
Some nephrotoxicity
Ototoxicity
Mild increases in LFT’s
Myelosuppression (platelets)
Dosing can be calculated by a variety of formulas specific for use in pediatric patients
Hearing loss a concern in long-term survivors |
|
|
Term
|
Definition
Brand name - CeeNU Nausea & vomiting
Orally administered – absorption is rapid Take on empty stomach
Nausea & vomiting
2. Anorexia
3. Stomatitis
4. Alopecia
5. Increased LFT’s
6. Neurologic
7. Nephrotoxicity (dose dependent)
8. Infertility
Dose-limiting toxicity
1. Myelosuppression
a. Often delayed – nadir is later (about 3-4 weeks after therapy) |
|
|
Term
|
Definition
Prodrug of dacarbazine
Well absorbed orally
Take on an empty stomach (increases extent and rate of absorption and decreases N/V)
Does not require liver for activation
Degraded to active form (MTIC) at physiological pH
Good CNS penetration-- used for brain tumors
Do not crush or chew capsules
Give at bedtime
Valproic acid my decrease clearance of temozolomide |
|
|
Term
|
Definition
Rapidly and completely absorbed orally
First pass metabolism
CNS penetration- Used for Hodgkins
Hepatic
Nausea & vomiting
Diarrhea
Mild stomatitis
Neurotoxicity (high doses)
Rash
Pulmonary infiltrates (need to D/C drug)
Infertility
Avoid alcohol (disulfiram-like reaction)
Avoid MAO inhibitors, tricyclic antidepressants
Avoid foods rich in tyramine |
|
|
Term
|
Definition
Slow and incomplete PO absorption
IV preferred route
Used for Hodgkins and solid tumors
Poor CNS penetration, dose limiting N/V, |
|
|
Term
| Common Drug Interactions methotrexate |
|
Definition
Amoxicillin- Decreased renal elimination of methotrexate
Cotrimoxazole-Synergistic anti-folate effects; protein binding displacement of methotrexate; decreased renal elimination of methotrexate
NSAIDs-Reduced clearance of methotrexate
Increased methotrexate toxicity
Withhold NSAIDs for at least 7-10 days prior to methotrexate therapy and through the adequate clearance of methotrexate
PPIs-PPIs can block renal elimination of methotrexate, Temporarily hold omeprazole during methotrexate therapy from several days before methotrexate is given until drug is adequately cleared (consider use of H2 antagonist – e.g., famotidine)
Entity
Interaction
Effect
Management Considerations
Reference
Amoxicillin
Decreased renal elimination of methotrexate
Increased methotrexate toxicity
If possible, avoid concurrent use during methotrexate therapy until drug has been adequately cleared
Ronchera CL, et al. Ther Drug Monitor. 1993;15:375.
Methotrexate product information (April 2005)
Cotrimoxazole
Synergistic anti-folate effects; protein binding displacement of methotrexate; decreased renal elimination of methotrexate
Increased methotrexate toxicity
If possible, avoid concurrent use during methotrexate therapy until drug has been adequately cleared
Ferrazzini G, et al. J Pediatr. 1990;117:823.
Methotrexate product information (April 2005)
Non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen)
Reduced clearance of methotrexate
Increased methotrexate toxicity
Withhold NSAIDs for at least 7-10 days prior to methotrexate therapy and through the adequate clearance of methotrexate
Cassano WF. Am J Pediatr Hematol Oncol. 1989;11:481.
Proton pump inhibitors (PPIs) (e.g., omeprazole)
PPIs can block renal elimination of methotrexate
Increased methotrexate toxicity
Temporarily hold omeprazole during methotrexate therapy from several days before methotrexate is given until drug is adequately cleared (consider use of H2 antagonist – e.g., famotidine)
Folic acid-Reverses the effects of methotrexate |
|
|
Term
| Monitoring pearls methotrexate |
|
Definition
serial methotrexate serum concentrations w/ leucovorin rescue
a. Frequency may vary depending upon which protocol is used, but at least once daily
b. Methotrexate concentration used to determine leucovorin dose
c. Leucovorin cannot prevent toxic effects of methotrexate in all cases, particularly when patient is experiencing delayed clearance |
|
|
Term
|
Definition
Absorption is saturable and is good at low doses (has a short half-life and relies on renal excretion)
b. Usually given IV (must be given IV for doses > 25 mg due to saturable absorption) unless MTX levels are low, then can be given orally
c. Replenishes reduced pools of folate
d. Selectively rescues healthy cells since they have less polyglutamated form of methotrexate
e. Leucovorin competes with methotrexate for transport into cells (more uptake in healthy cells)
f. Leucovorin dosing is per protocols/nomograms |
|
|
Term
| Urine pH for methotrexate |
|
Definition
Alkalinize to maintain ≥ 7 during methotrexate and leucovorin therapy (MTX is a weak acid)
b. 50 – 150 mEq sodium bicarbonate / sodium acetate in intravenous fluids
c. Oral sodium bicarbonate can be given, but often hard to tolerate the large doses that are necessary
d. Acetazolamide has been used to maintain urinary pH
e. Monitor urine pH at least every 6-8 hours |
|
|
Term
| Urine output for methotrexate |
|
Definition
Keep urine output > 100 mL/hr (adults) or 2 – 3 mL/kg/hr (peds)
b. Monitor with each void
c. Maintain with vigorous hydration with intravenous fluids
d. Sometimes administer 1000 mL/m2 of IVF over 6 hours prior to initiation of methotrexate infusion
e. Continue hydration at 125 mL/m2/hr (3 liters/m2/day) during methotrexate infusion, and for 1-3 days after the infusion has been completed during high dose therapy |
|
|
Term
|
Definition
| Limit use in patients with third-spacing (e.g., ascites, pleural effusions) as this can slow clearance of methotrexate employ adequate mouth care regimens to decrease mucositis |
|
|
Term
|
Definition
Utilized in delayed methotrexate clearance, Does not decrease intracellular concentrations of methotrexate, so leucovorin needs to be continued
c. Given as a 1-time dose of 50 units/kg as an IV push over 5 minutes
d. Leucovorin doses should be held at least 2 hours before and at least 2 hours after glucarpidase administration
e. Toxicities – paresthesias, flushing, nausea/vomiting, headache, hypotension; rare to see rash, hypersensitivity, hypertension, diarrhea, throat irritation/tightness and tremor
f. When patients have received glucarpidase, methotrexate levels can only reliably be measured using chromatographic methods for 48 hours after administration VERY EXPENSIVE |
|
|
Term
| cytarabine (ara-c) pearls |
|
Definition
| Cytarabine syndrome: fever, myalgia, bone pain, rash, malaise, conjunctivitis, chest pain that can occur 6-12 hours after administration (treat with steroids), use steroid eye due 2/2 conjunctivitis, susceptible to strep viridans sepsis--use vancomycin, however fever common side effect during infusion |
|
|
Term
|
Definition
Assoc with liver toxocity, bonemarrow supression and mucocytis;Dose reduce by 75% when given with allopurinol,
Counsel patients to take doses in the evening on an empty stomach (relapse assoc with am admin) and to avoid taking with dairy products
Thiopurine methyltransferase (TPMT) polymorphisms affect toxicity profile (myelosuppression) and drug dosing |
|
|
Term
| etoposide (VePesid, VP-16) pearls |
|
Definition
Drug is a weak irritant/weak vesicant
Administration issues, Due to poor solubility, doses are dispensed in large volumes, Infusion-related hypotension is a concern, Etoposide phosphate is given in smaller volumes and not associated with hypotension effects to a great extent, Secondary leukemias are a concern; polysorbate 80 and Tween 80 diluents- infusion reactions-- switch to etopaphos |
|
|
Term
|
Definition
Used for ALL and solid tumors/lymphomas;Mild bone marrow suppression, Muscle weakness
Foot drop syndrome Jaw pain
Myalgias Alopecia SIADH Peripheral neuropathies Constipation (ileus) – treat aggressively; To decrease incidence of toxicities, doses are often capped at 2 mg
Liposomal form associated with less neurotoxicity, thus higher doses are able to be administered Vesicant
Jaw pain is more common in children
Use docusate prophylaxis to prevent constipation
Vesicant |
|
|
Term
|
Definition
| Raynaud’s phenomenon Nausea & vomiting Some constipation Jaw pain Myalgias Some alopecia, Bone marrow suppression |
|
|
Term
| Treatment of topotecan and irinotecan diarrhea? |
|
Definition
| atropine/diphenoxylate and immediate use of loperamide, also Oral cephalosporins (e.g., cefixime, cefpodoxime, etc.) often used to minimize diarrhea and maximize irinotecan effectiveness |
|
|
Term
| Hydroxurea (Hydrea) used for? |
|
Definition
|
|
Term
| Monoclonal antibodies – rituximab, brentuximab vedotin and dinutuximab pearls |
|
Definition
| More targeted treatment, less general toxicities, infusion reactions and targeted cell reactions i.e. rituximab-- T and B cells- bone marrow effects |
|
|
Term
| Rituximab (Rituxan) pearls |
|
Definition
| Infusion related SE, headache, infection, Reactivation of hepatitis B |
|
|
Term
|
Definition
| For neuroblastoma binds to the disialoganglioside GD2, which is highly expressed in neuroblastoma cells; infusion reactions, Pain, peripheral neuropathy (use PCA) Capillary leak syndrome Neutropenia, thrombocytopenia, lymphopenia, anemia, Hypokalemia, hypoalbuminemia, hypocalcemia |
|
|
Term
| All-trans retinoic acid (ATRA, tretinoin, Vesanoid) |
|
Definition
Used for APML Retinoic-Acid Syndrome” (occurs in about 25% of patients) Hyperleukocytosis (WBC > 20,000/mm3) Fever, Respiratory problems – shortness of breath, pulmonary infiltrates, Weight gain, Edema, Hypotension; Treatment: high dose steroids
Also liver toxicities |
|
|
Term
| Isotretinoin (CRA, 13-cis-retinoic acid, Amnesteem®, Claravis®, Sotret®, Myorisan™, Absorica™, Zenatane™) used for? |
|
Definition
| Used for neuroblastoma Acts as a differentiation agent (causes neuroblastoma cells to mature to a less benign form) |
|
|
Term
| Isotretinoin side effects |
|
Definition
Dry skin, nosebleeds, photosensitivities, Carries a black box warning of contraindication in females who are pregnant or may become pregnant
i. Use is associated with teratogencity/birth defects- As part of the REMS program, access to isotretinoin is restricted and available through the iPLEDGE™ risk management program |
|
|
Term
|
Definition
| Tyrosine kinase inhibitors (TKIs), Inhibits BCR-ABL tyrosine kinase, the genetic aberration associated with Philadelphia chromosome positive CML and ALL; Give in one or two daily doses with food. Daily doses above 600 mg should be divided. Tablets may be dispersed in water or apple juice |
|
|
Term
| Dasatinib (Sprycel®) used for |
|
Definition
| PharmacologyInhibits BCR-ABL tyrosine kinase, the genetic aberration associated with Philadelphia chromosome positive CML and ALL |
|
|
Term
|
Definition
| Myelosuppression Headache pleural/pericardial effusions, Pulmonary arterial hypertension, QT prolongation; Give in one daily dose with or without food |
|
|
Term
| Drug interactions with tyrosine kinase inhibitors (Imatinib or Dasatanib) |
|
Definition
ReferenceInhibitors of CYP3A4- Increased effects or toxicity of TKI (e.g., nausea, vomiting, edema, neutropenia, cardiac effects, etc.)
Inducers of CYP3A4- Decreased efficacy of TKI
Grapefruit juice - Increased effects or toxicity of TKI (e.g., nausea, vomiting, edema, neutropenia, etc.)
Acid lowering agents (e.g., antacids, H2 blockers, PPIs- Decreased absorption of dasatinib |
|
|
Term
|
Definition
Specific organisms have a greater propensity to penetrate the CNS
Damage to the CNS and blood brain barrier (e.g. asphyxia) also may increase the risk of meningitis. Evaluation of CSF values of protein, glucose, and white blood cells (neutrophils) may aid diagnosis (high protein, low glucose, high WBC/neutrophil count). However, interpretation of neonatal CSF may be complicated by concurrent pathophysiologies (e.g. IVH results in high protein levels in the CSF). Clinical signs and symptoms may include irritability (60%), seizures (60%), fever or hypothermia (60%), bulging fontanel (25%), nuchal rigidity (15%) |
|
|
Term
| Antibiotics for neonatal meningitis? |
|
Definition
| Drugs must be known to penetrate CSF adequately. Broad spectrum coverage may include a combination of penicillin + aminoglycoside + cefotaxime. Aminoglycosides are included despite poor CSF penetration due to synergy against GBS. In newborns antiviral coverage for HSV using acyclovir may be added |
|
|
Term
| Length of therapy neonatal meningitis? |
|
Definition
| Treatment duration varies by microorganism. Generally, GBS and Listeria meningitis are treated for 14 days, gram negative meningitis for 21 days, and HSV meningitis for 21 days intravenously followed by 6 months of suppressive therapy. |
|
|
Term
| Onset of NEC for infants? |
|
Definition
| Onset of NEC is usually in the first week of life for infants >34 weeks gestation, and typically week 3 or beyond for preterm infants below 30 weeks gestation. |
|
|
Term
|
Definition
| The pathogenesis of NEC likely results from multiple factors that result in mucosal injury in a susceptible host. Factors implicated in the pathogenesis of NEC include prematurity, alterations in mesentery perfusion, medications that cause intestinal mucosal injury (hyperosmolar oral medications) or enhance microbial overgrowth (broad spectrum antibiotics and H2-antagonists/proton pump inhibitors). Enteral feeding generally precedes NEC. Maternal breast milk decreases the risk of NEC compared to formula. Controversy exists regarding the optimal timing of initial feeding and rate of advancement. |
|
|
Term
|
Definition
| The pathogenesis of NEC likely involves circulatory instability. Circulatory events implicated in the development of NEC include perinatal asphyxia, recurrent apnea, severe RDS, congenital heart disease, PDA, umbilical artery catheterization, anemia, polycythemia, and red blood cell transfusions. These associations are generally controversial. Use of NSAIDS such as indomethacin to treat PDA does not increase NEC risk, and in several trials actually reduces NEC risk by closing the PDA. |
|
|
Term
|
Definition
| Initial symptoms typically include abdominal distention, bilious vomiting, and/or bloody stools. |
|
|
Term
|
Definition
| NEC prevention strategies include: establishing standardized feeding guidelines, exclusive use of breast milk, reduction in antibiotic use, reduction in acid blockade, and use of probiotics alone or combined with prebiotics. The use of probiotics in the NICU is highly controversial given the benefits demonstrated in numerous, heterogeneous RCTs, but the lack of an FDA approved product in the U.S. |
|
|
Term
| Duration of antibiotic therapy for NEC |
|
Definition
| The duration of therapy is 48-72 hours for suspected NEC (Bell’s stage 1), 7-10 days for definite NEC with mild illness (Bell’s stage 2A), and 14 days for definite NEC with moderate-severe illness (Bell’s stage 2B and 3). |
|
|
Term
|
Definition
ON (Ophthamalia Neonatorum) is conjunctivitis (conjunctival erythema, swelling, and discharge) that occurs in the first 28 days of life. It may be caused by infectious (septic) or non-infectious (aseptic) sources.
ON was the leading cause of neonatal blindness before the 1880’s. When prophylaxis with silver nitrate became common, gonococcal conjunctivitis was reduced from 10% to 0.3%. |
|
|
Term
|
Definition
Infectious ON is acquired during childbirth when the newborn travels through an infected birth canal. The most common organisms are Chlamydia trachomatis, Neisseria gonnorhea, and other bacteria. Gonococcus has the earliest onset at 2-7 days, while other organisms typically become symptomatic at 6-14 days. ON was reported in 8.5 per 100,000 births of newborns in the USA in 2007. Comparable rates are also seen in more developed countries in Europe and Canada. Chlamydia causes ~40% of ON cases, Neisseria gonorrheae accounts for 1%, Herpes simplex < 1%, and other non-sexually transmitted infecting agents causing ~50% of infectious ON cases.
Chemical ON is much less common as erythromycin as largely replaced silver nitrate as primary prophylactic therapy. |
|
|
Term
| Drugs used for prophylaxis of ON |
|
Definition
| erythromycin ointment 0.5%, tetracycline ointment 1%, silver nitrate 1%, and povidone iodine solution 2.5%. All prophylactic treatments appear to be equally effective. Prophylaxis fails in 7-19% of cases treated for gonococcal prophylaxis and 23-32% of cases treated for Chlamydia prophylaxis. |
|
|
Term
|
Definition
| During a recent shortage of erythromycin ophthalmic ointment, gentamicin ophthalmic ointment was selected by many centers as an alternative, rather than one of the proven alternatives. The use of this untested product resulted in ulcerative periocular dermatitis on day 1 of life in about 6% of cases. |
|
|
Term
|
Definition
| ON was reported in 8.5 per 100,000 births of newborns in the USA in 2007. Comparable rates are also seen in more developed countries in Europe and Canada. Chlamydia causes ~40% of ON cases, Neisseria gonorrheae accounts for 1%, Herpes simplex < 1%, and other non-sexually transmitted infecting agents causing ~50% of infectious ON cases. |
|
|
Term
| Treatment non-sexually transmitted bacteria responsible for ON ? |
|
Definition
| Common non-sexually transmitted bacteria responsible for ON include Haemophilus species, Staphylococcus species, Streptococcus species, and Escherichia coli. These etiologies are treated with topical antibiotics (aminoglycosides, polymyxin B sulfate-trimethoprim solution, macrolides, or fluoroquinolone). Pseudomonas ON is rare, but severe. Treatment includes systemic and topical aminoglycosides and occasionally subconjunctival injections. |
|
|
Term
| Chlamydia trachomatis treatment for ON ? |
|
Definition
| Chlamydia trachomatis should be treated with systemic erythromycin 50 mg/kg/day divided in 4 doses x 14 days. Topical therapy is not indicated. Systemic erythromycin may cause pyloric stenosis in neonates. Oral azithromycin represents an alternative therapy (20 mg/kg once daily x 3 days); however, further studies are needed. |
|
|
Term
| Neisseria gonorrhea treatment for ON ? |
|
Definition
| Neisseria gonorrhea should be treated with a single parenteral dose of cefotaxime (100 mg/kg) or ceftriaxone (25-50 mg/kg). Ceftriaxone is generally listed as contraindicated in newborns due the concern for kernicterus from bilirubin displacement. Frequent eye irrigations with saline solution should be performed until resolution of discharge. |
|
|
Term
|
Definition
| HSV should be treated with intravenous acyclovir (20 mg/kg/dose IV q8h x 14 days) and topical trifluridine 1%, iododeoxyuridine 0.1%, or vidarabine 3%. The initial treatment should be followed by oral suppressive therapy (300 mg/m2/dose PO q8h x 6 months). |
|
|
Term
|
Definition
Ampicillin or penicillin + gentamicin,
tobramycin, or amikacin
Ampicillin or penicillin + cefotaxime
Avoidance of cephalosporins
preferred to limit resistance. |
|
|
Term
|
Definition
Ampicillin + gentamicin
Nafcillin + gentamicin
Vancomycin + gentamicin
Ampicillin + cefotaxime
Nafcillin + cefotaxime
Vancomycin + cefotaxime |
|
|
Term
| Treatment neonatal meningitis? |
|
Definition
Ampicillin or penicillin + cefotaxime
Vancomycin + meropenem
Vancomycin + cefotaxime
Vancomycin + cefepime |
|
|
Term
|
Definition
Piperacillin/tazobactam + gentamicin
Ampicillin + gentamicin + metronidazole
Ampicillin + cefotaxime + metronidazole
Vancomycin + piperacillin/tazobactam + gentamicin
Meropenem
Inclusion of anaerobic coverage controversial. |
|
|
Term
| Treatment of Neonatal fungus |
|
Definition
| Amphotericin B, fluconazole, or micafungin |
|
|
Term
| Treatment neonatal toxoplasmosis ? |
|
Definition
| Pyrimethamine, sulfadiazine, and leucovorin |
|
|
Term
| Treatment neonatal Syphillis ? |
|
Definition
|
|
Term
| Treatment neonatal Rubella ? |
|
Definition
|
|
Term
| TORCH is an acronym for ? |
|
Definition
TORCH is an acronym for a group of congenitally acquired organisms. The specific organisms represented are Toxoplasmosis, Other (specifically, Treponema palladium AKA Syphillis, but may include Varicella-zoster virus and Parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes simplex virus (HSV). Several important viruses are missing from this group, including enteroviruses, Borrelia burgdorferi (Lyme disease), and human immunodeficiency virus (HIV).
All may cause fetal loss, intrauterine growth retardation, and/or newborn infection. |
|
|
Term
| Source of infant exposure to Toxoplasmosis ? |
|
Definition
| Pregnant woman eating raw meat or exposure to cat feces |
|
|
Term
| Maternal and infant treatment of toxoplasmosis |
|
Definition
| Toxoplasmosis: If seroconversion is identified (as done in Europe, but not USA), treatment of mother with Spiramycin can prevent fetal infection. If fetus is infected, treatment of mother with pyrimethamine + sulfadiazine + folinic acid is advised. Toxoplasmosis is treated with pyrimethamine and sulfadiazine supplemented with leucovorin x 1 year. CBC including platelet counts should be monitored periodically throughout therapy. |
|
|
Term
| Maternal and infant treatment of Syphilis ? |
|
Definition
| Syphilis: Proper treatment of maternal syphilis according to CDC guidelines using penicillin or acceptable alternative if penicillin allergy is present. Infants- Syphilis is treated with intravenous penicillin G x 10 days. |
|
|
Term
| Maternal exposure to Rubella treatment? |
|
Definition
| Rubella: Administer rubella vaccine to all children according to CDC guidelines. Use of immune globulin for infected pregnant women is controversial. |
|
|
Term
| Maternal prophylaxis for CMV ? |
|
Definition
| CMV: Routine screening for maternal CMV is not recommended at this time because there is no effective prophylaxis or treatment measure. |
|
|
Term
| Maternal HSV considerations |
|
Definition
| HSV: If mother is high risk for infecting newborn, encourage cesarean section delivery and maternal antiviral therapy. If mother has active HSV, observe contact precautions after birth. |
|
|
Term
|
Definition
| HSV is treated with intravenous acyclovir x 14 days for SEM disease and x 21 days for CNS or disseminated infection. Guidelines recommend 20 mg/kg IV q8h for all infants, although new literature suggests interval adjustment based on maturity. Following intravenous therapy, oral suppressive therapy is initiated x 6 months. Infants with ocular involvement should receive a topical ophthalmic drug (1% trifluridine, 0.1% iododeoxyuridine, or 3% vidarabine) as well as parenteral therapy. Urine output and SCr should be monitored during intravenous therapy and CBC including platelets should be monitored periodically throughout IV/PO therapy. |
|
|
Term
|
Definition
| CMV is treated with intravenous ganciclovir or oral valgancyclovir x 6 weeks. A minimum of 2-4 weeks of parenteral therapy is recommended in preterm infants with symptomatic, end-organ disease. CBC including platelets counts should be monitored periodically throughout therapy. |
|
|
Term
| Risk factors for neonatal encephalopathy ? |
|
Definition
| maternal thyroid disease, severe preeclampsia, post-term delivery, and intrauterine growth restriction. |
|
|
Term
| Criteria for therapeutic hypothermia in addition to moderate or severe encephalopathy |
|
Definition
| pH ≤ 7.0 or a base deficit of ≥ 16 mmol/L from umbilical cord blood or during the first hour after birth, APGAR score ≤ 5 at 10 minutes after birth, or abnormal background activity for at least 30 minutes or seizures on amplitude integrated electroencephalogram. |
|
|
Term
| Therapeutic hypothermia criteria for infants? |
|
Definition
Therapeutic hypothermia should be considered for neonates born at ≥36 weeks gestation with moderate or severe encephalopathy at ≤ 6 hours of age. Whole body or head cooling occurs to a core temperature of 33-35° C for a duration of 72 hours.
Therapeutic hypothermia improves survival and neurodevelopmental outcome at 18 months of age. |
|
|
Term
| Pharmacokinetic parameters are altered during therapeutic hypothermia |
|
Definition
The function of CYP450 declines during hypothermia resulting in decreased clearance of some medications. Reduced cardiac output and increased systemic vascular resistance may reduce blood flow to the liver and kidneys, further impacting clearance. Peripheral vasoconstriction may also lead to decreased volume of distribution. Morphine, utilized for sedation during cooling, substantially accumulates and the rate of continuous infusion should be reduced to prevent toxicity.
Phenobarbital, phenytoin, topiramate, and midazolam, indicated for seizures, also accumulate. Special attention should be paid to therapeutic drug monitoring and/or appropriate dosage adjustment. Gentamicin levels do not appear to be affected independently by hypothermia. However, renal injury is common in the setting of hypoxia-ischemia. Judicious monitoring is essential, along with consideration of alternative antibiotics. |
|
|
Term
| Numerous pharmacologic strategies have been examined for neuroprotection in the setting of hypoxia-ischemia. All have demonstrated promise in preclinical studies and are currently being examined in Phase 1-3 clinical trials. |
|
Definition
| 1. Xenon gas - NMDA antagonist to decrease excitotoxic cell death 2. Magnesium sulfate - NMDA antagonist to decrease excitotoxic cell death 3. Allopurinol – antioxidant to reduce oxidative stress 4. Melatonin – antioxidant and anti-inflammatory 5. Erythropoietin or darbepoetin – anti-apoptotic growth factor 6. Topiramate – AMPA antagonist protective of developing neurons |
|
|
Term
| T or F In the absence of complication, isolated IVH appears to have minimal impact on long-term outcome. |
|
Definition
|
|
Term
| T or F Complicated IVH is not associated with a higher incidence of spastic motor deficits and major cognitive deficits. |
|
Definition
|
|
Term
| T or F Nearly all IVH occurs in the first 5 days of life with 50% occurring on the first day of life. |
|
Definition
|
|
Term
| Risk factors IVH in infants |
|
Definition
| decreased gestational age and birth weight, gender (males > females), maternal chorioamnionitis, prenatal asphyxia, lack of antenatal steroid therapy, prolonged neonatal resuscitation, hypotension, hypoxia, acidemia, and hypercarbia. |
|
|
Term
| Guidelines for antenatal steroids |
|
Definition
Current guidelines recommend a single course of antenatal glucocorticoids be administered to all mothers at risk for preterm delivery between 24 and 34 weeks gestation. The optimal window for glucocorticoid administration is 24 hours to 7 days before birth.
The optimal corticosteroid (betamethasone or dexamethasone) has not been elucidated.
Repeat courses are not currently recommended due to concerns regarding adverse impact on neurodevelopmental outcome. However, recent studies show no neurodevelopmental detriment and suggest reduced severity of respiratory distress syndrome (see section on the prevention of Respiratory Distress Syndrome).
The mechanism of action of antenatal corticosteroids with regard to IVH has not been fully elucidated. Potential mechanisms include improved cardiovascular stability in the infant after birth and/or stimulation of maturation of the germinal matrix. |
|
|
Term
| IVH prophylactic treatment for neonates |
|
Definition
Indomethacin administered before 12 hours of age for the prophylaxis of patent ductus arteriosus significantly reduces the incidence of severe IVH in infants born at < 1250 grams.
Use in clinical practice is variable due to the lack of impact on long term neurodevelopmental outcome (see section on the treatment of Patent Ductus Arterioles). The mechanism of action of prophylactic indomethacin with regard to IVH has not been fully elucidated. Potential mechanisms include decreases in cerebral blood flow, inhibition of the formation of free radicals generated by the cyclooxygenase portion of the prostaglandin biosynthesis pathway, and/or acceleration of the maturation of microvessels in the germinal matrix.A similar effect is not observed with prophylactic ibuprofen. |
|
|
Term
|
Definition
| Posthemorrhagic ventricular dilatation (PHVD) occurs in the setting of obstructed CSF absorption and outflow due to blood clot formation after IVH. This complication of IVH is associated with significant impairment in neurodevelopmental outcome. |
|
|
Term
| Pharmacologic management of PVHD ? |
|
Definition
| Pharmacologic management of PHVD targets cerebrospinal fluid production. Clinical trials have utilized acetazolamide (a carbonic anhydrase inhibitor) in combination with furosemide without success and with a high incidence of acute nephrocalcinosis and long-term neuromotor impairment. Osmotic agents (i.e., glycerol or isosorbide) also decrease CSF formation. This approach is not recommended due to lack of controlled trials and concerns regarding significant adverse effects in preterm infants. |
|
|
Term
| Clinical factors and risk factors associated with NAS ? |
|
Definition
| Clinical factors associated with maternal substance abuse include lack of prenatal care, premature delivery, sexually transmitted infections, cigarette smoking, fetal intrauterine growth restriction, and poor maternal nutritional status. Risk factors for increased severity of NAS include term gestation, male gender, polysubstance abuse, and cigarette smoking. |
|
|
Term
|
Definition
| Clinical suspicion of intrauterine exposure may be corroborated by toxicology screening, most commonly neonatal urine and meconium toxicology. Meconium testing is more sensitive than urine testing and has a longer window of detection (from 20 weeks of gestation). |
|
|
Term
|
Definition
| Infants with NAS exhibit a combination of neurologic excitability (tremors, irritability, increase muscle tone, seizures), gastrointestinal dysfunction (uncoordinated sucking, vomiting, diarrhea), and autonomic signs (diaphoresis, nasal stuffiness, mottling, temperature instability). |
|
|
Term
| Scoring systems for NAS are ? |
|
Definition
| Standardized scoring systems have been developed to assist clinicians with identification, quantification, and assessment of response to therapy. Common tools include the Finnegan Neonatal Abstinence Severity Score, Lipsitz tool, Neonatal Narcotic Withdrawal Index, and Neonatal Withdrawal Inventory. Scoring mechanisms are highly subjective; however, careful training of staff can increase interrater reliability. Importantly, preterm infants may demonstrate fewer signs of withdrawal due to neurologic immaturity and scales have not been validated in this population. |
|
|
Term
| Advantages of Buprenorphine over methadone for opioid dependency during pregnancy / |
|
Definition
| Buprenorphine, a partial µ-opioid receptor agonist and complete κ-opioid receptor antagonist, has been found to be equally safe and efficacious alternative to methadone for opioid dependency during pregnancy. Buprenorphine and methadone produce a similar incidence of NAS; however, buprenorphine exposed neonates require a lower dose and shorter duration of morphine and have decreased length of hospitalization. |
|
|
Term
| Mothers participating in opioid-treatment programs should not be encouraged to breastfeed their infants. T or F ? |
|
Definition
| Mothers participating in opioid-treatment programs should be encouraged to breastfeed their infants; active or recent illicit drug use is considered a contraindication to breastfeeding. Frequent, small-volume feeds may be used. |
|
|
Term
| Preferred opiates for NAS ? |
|
Definition
| Opioids should be utilized as first-line therapy for NAS secondary to opioid exposure. Morphine is preferred over methadone due to its short half-life and the ease of titrating the dose to clinical response. Additionally, methadone has black box warning for potentially fatal QTC prolongation and QTC prolongation has been described in neonates after in utero methadone exposure. Paregoric and tincture of opium are not used due to high alcohol content and toxic ingredients. Morphine dose 0.04-0.2 mg/kg/dose PO q3-4 hours, titrate to effect, Methadone 0.05-0.2 mg/kg/dose PO q12-24 hours, titrate to effect |
|
|
Term
| Phenobarbital use for NAS ? |
|
Definition
| Phenobarbital is inferior to morphine as first-line therapy for patients exposed to opioids (greater incidence of seizures and longer treatment duration). Commonly used as second line therapy to decrease inpatient hospital stay. Concerns persist regarding the impact of this strategy on long-term neurodevelopment. Phenobarbital is the preferred adjunctive therapy in the setting of concomitant barbiturate or benzodiazepine exposure. 8 mg/kg PO x 2 followed by 2.5 mg/kg/dose PO q12h |
|
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Term
|
Definition
| Clonidine has been examined as first-line and adjunctive therapy for NAS secondary to opioid exposure. Advantages include minimized exposure to opioids postnatally and preclinical data suggesting neuroprotective properties. Infants treated with adjunctive clonidine have a longer duration of hospitalization compared to infants treated with adjunctive phenobarbital. However, the overall duration of therapy is significantly shorter with clonidine. The primary monitoring parameter is blood pressure during initiation, titration, and discontinuation. 0.5-3 mcg/kg/dose PO q6h, titrate to effect |
|
|
Term
| Neonatal seizures background |
|
Definition
| In the developing cerebral cortex, excitatory activity predominates and inhibitory systems are relatively underdeveloped. Additionally, the threshold for seizure generation is lower in the developing brain. he neurologic prognosis of neonates with seizures is determined heavily by the underlying neurologic disease. However, seizures can disrupt the cascade of biochemical and molecular pathways responsible for plasticity and development of the maturing nervous system. Neonatal seizures increase the risk of childhood epilepsy and may impair learning and social adjustment. Seizures occur more often in the first week of life than at any other time of life. |
|
|
Term
| Common etiologies of seizures in neonates |
|
Definition
| Common etiologies of seizures in neonates include hypoxic-ischemic encephalopathy (most common etiology), intracranial hemorrhage, intracranial infection, metabolic disturbances, and developmental defects. The most common etiology of neonatal seizures (>50%) is hypoxic-ischemic encphalopathy, followed by intracranial hemorrhage (~10%, predominantly preterm neonates), intracranial infection (~10%), and developmental defects (~10%). |
|
|
Term
| Treatment of neonate with seizures and low blood glucose, low mag or calcium? |
|
Definition
| bolus 2 mL/kg of 10% dextrose. Hypocalcemia should be treated with calcium gluconate 100-200 mg/kg IV. Hypomagnesemia should be treated with magnesium sulfate 25-50 mg/kg IV/IM. |
|
|
Term
| Treatment of recurrent seizures that are not accompanied by any obvious associated findings |
|
Definition
| 50-100 mg of IV pyridoxine with simultaneous EEG monitoring. Successful therapy results in cessation of seizures within minutes. |
|
|
Term
| First line anticonvulsant therapy in neonates? |
|
Definition
| phenobarbital 20 mg/kg IV bolus The initial bolus reliably produces a serum concentration of approximately 20 mcg/mL and controls clinical seizures in approximately 40% of cases. For persistent seizures, bolus dosing may continue in increments of 5-20 mg/kg IV to a total dose of 40 mg/kg, or a phenobarbital concentration of approximately 40 mcg/mL. This concentration of phenobarbital controls clinical seizures in approximately 70% of cases. A deleterious effect of phenobarbital on the developing brain has been demonstrated in preclinical models and confirmed in human neonates. |
|
|
Term
| Second line anticonvulsant therapy in neonates ? |
|
Definition
| fosphenytoin 20 mg PE/kg IV. A loading dose of 20 mg PE/kg reliably produces a serum concentration of approximately 20 mcg/mL. In preclinical models, phenytoin produces similar apoptotic neurodegeneration to phenobarbital and this effect is greater when used in combination with phenobarbital. |
|
|
Term
| Third line anticonvulsant therapy in neonates ? |
|
Definition
lorazepam or midazolam. Midazolam dose 0.05-0.15 mg/kg IV
followed by 0.05-0.4 mg/kg/hr |
|
|
Term
| Levetiracetam use for neonatal seizures ? |
|
Definition
Levetiracetam has been examined due to concerns regarding the long-term neurodevelopmental impact of traditional agents. Clinical trials are ongoing and place in therapy is inconsistent between units. Studies suggest efficacy when utilized as first-line therapy (~80% of infants experience prolonged cessation of seizures). Levetiracetam also decreases seizure burden in a high percentage of infants refractory to conventional agents. Preclinical data suggests a lack of neurotoxicity, contrasting the effects of traditional agents. Somnolence and irritability are the most common adverse effects in clinical trials in infants. 10 mg/kg/dose IV/PO
q12-24h, up to 60 mg/kg/day |
|
|
Term
| Alternative agents for neonatal seizure? |
|
Definition
| Lidocaine as a continuous infusion has been utilized extensively in European centers with a high rate of therapeutic success and minimal adverse effects. 2 mg/kg IV followed by 1-7 mg/kg/hr. Bumetanide has been hypothesized to increase sensitivity to GABA agonists (phenobarbital and benzodiazepines) by inhibiting NKCC1, decreasing neuronal Cl- levels and restoring the inhibitory nature of GABAA channels. |
|
|
Term
| Dexamethasone dose for status asthmatics |
|
Definition
| Dexamethasone 0.6 mg/kg/dose PO q24h x 2 doses (maximum 16 mg) Most of the data supporting the use of dexamethasone is emergency room data not pediatric critical care data. |
|
|
Term
| Methylprednisolone dose for status asthmaticus |
|
Definition
| Methylprednisolone 2 mg/kg load then 0.5-1 mg/kg/dose IV q6h. |
|
|
Term
| Albuterol dosing for status asthmaticus |
|
Definition
Intermittent dosing: 0.15 mg/kg/dose; however most clinicians would use 2.5 mg, 5 mg or 10 mg per inhalation.
Continuous dosing: 0.5 mg/kg/hour; however most clinicians would use 5 mg/hr, 10 mg/hr, 15 mg/hr, 20 mg/hr (up to 40 mg/hr) |
|
|
Term
| T or F Inhaled steroids have no role in changing the course of status asthmaticus. |
|
Definition
|
|
Term
| Use of ipratroprium with status asthmaticus |
|
Definition
Has been shown to reduce hospital admissions from the emergency room in patients with a less than optimal response to beta-2-agonists alone.Has not been shown to change the course of status asthmaticus once the patient is admitted to the hospital.
Dosing: 0.5mg inhaled (with albuterol) q20 minutes X 3 doses. |
|
|
Term
| Mag sulfate for status asthmaticus |
|
Definition
Intravenous magnesium is less effective than inhaled albuterol alone. Maximum efficacy if serum magnesium is increased to approximately 4 to 6 mg/dL.
Dosing: 25-75 mg/kg/dose IV over 20 minutes (maximum 2000 mg) |
|
|
Term
| Ketamine for status asthmaticus |
|
Definition
Sedative that may cause bronchodilation. Bronchodilation may be due to endogenous catecholamine release.
It has minimal negative cardiovascular effects.
It is unclear if it is beneficial or not in status asthmaticus.
Dosing: 1-2 mg/kg/dose IV. |
|
|
Term
| Terbutaline for status asthmaticus |
|
Definition
| May be used if a patient is failing inhaled albuterol therapy. May be helpful if patient is unable to take a deep enough breath for inhaled therapy. May be administered subcutaneously or by continuous intravenous administration. Subcutaneous dosing: 0.01 mg/kg/dose (maximum: 0.4 mg/dose) every 15-20 minutes for 3 doses. Continuous infusion dosing: 0.2-2 mcg/kg/min. |
|
|
Term
| Aspirin overdose mild toxicity |
|
Definition
| Mild toxicity (dose up to 150 mg/kg; serum: 30 mg/dL) Gastrointestinal: Nausea, vomiting, abdominal pain, Tinnitus, dizziness, lethargy |
|
|
Term
| Aspirin overdose moderate toxicity |
|
Definition
| Moderate toxicity (dose up to 150-300 mg/kg; serum: 50 mg/dL) tachypnea, respiratory alkalosis, hyperpyrexia, dehydration, tachycardia |
|
|
Term
| Aspirin overdose severe toxicity |
|
Definition
Severe toxicity (dose up to 300-500 mg/kg; serum: 70 mg/dL),
Hypoglycemia, cyanosis, oliguria, hallucinations, seizures, coma, |
|
|
Term
| Aspirin overdose potentially fatal |
|
Definition
Potentially fatal (>500 mg/kg; serum: > 80 mg/dL)
Renal failure, Pulmonary edema, Cerebral edema
Myocardial depression, hypotension, cardiac arrest |
|
|
Term
| Treatment aspirin overdose |
|
Definition
| Dextrose for hypoglycemia, Mild toxic ingestion: normal saline infusion at 10-20 mL/kg/hr x 1-2 hours, Moderate-to-severe ingestions: hydrate with urinary alkalization fluids, Sodium bicarbonate (150 mEq/L) + potassium chloride (20-40 mEq/L) in D5W; infuse 10-20 mL/kg as a bolus and then infuse at 2-3 mL/kg/hr continuously; Start this early, prior to the return of the first salicylate level, if salicylate overdose is strongly suspected, Activated charcoal without sorbitol if the patient presents within 2 hours of acute ingestion and is mentally alert or within 4 hours of significant ingestions or with delayed release formulations. Hemodialysis is usually reserved for cases of significant neurological symptoms, severe acidosis or hypotension and renal failure. Not recommended-- Ipecac, Whole bowel irrigation |
|
|
Term
|
Definition
| level > 2 ng/mL Ventricular arrhythmias and other symptoms of digoxin toxicity are the result of excessive accumulation of intracellular calcium and extracellular potassium. Bradycardia and heart block from digoxin toxicity are caused by vagal, parasympathetic stimulation, slowing the pace at the sinoatrial and atrioventricular nodes. |
|
|
Term
| Treatment digoxin toxicity |
|
Definition
| treat Hyperkalemia (K > 6 mEq/L) with sodium bicarbonate or insulin-dextrose to shift potassium intracellularly if patient is also experiencing arrhythmia. Do not give calcium-->cardiac arrest, Do not use sodium polystyrene sulfonate for digoxin-induced hyperkalemia because the drug causes depletion of potassium from the body and may result in hypokalemia once the digoxin toxicity is corrected. Cardiac pacing for severe, symptomatic heart block; Digoxin-Fab only if symptomatic, Each 40 mg vial of digoxin-Fab neutralizes about 0.5 mg of digoxin. Assume an 80% oral bioavailability for digoxin in acute overdoses.resolves in 30-90 min |
|
|
Term
|
Definition
| risk greatest in the first 6 months after the birth of a sibling when iron-containing prenatal vitamins are in the house, Almost two-thirds of iron exposures occur in children younger than 6 years. Abdominal symptoms = 10 mg/kg elemental iron, Minimum toxic dose = 20 mg/kg elemental iron, Observation at a medical facility recommended = 40 mg/kg elemental iron, Severe toxicity = 60 mg/kg elemental iron, Lethal dose = >180 mg/kg elemental iron, generally takes 4-6 hours to be absorbed from the gastrointestinal tract, |
|
|
Term
|
Definition
| generally takes 4-6 hours to be absorbed from the gastrointestinal tract, Generally nontoxic: < 300 mcg/dL, Mild symptoms: 300-500 mcg/dL, Moderate symptoms: 500-1,000 mcg/dL, Severe symptoms/death: > 1,000 mcg/dL |
|
|
Term
|
Definition
| No treatment recommended for ingestions < 20 mg/kg elemental iron and those who have been symptom free for 6 hours, Whole bowel irrigation (PEG), fluids, blood,bicarb, Parenteral chelation for Serum iron > 500 mcg/dL -Deferoxamine 100 mg deferoxamine chelates 8.5-9.5 mg free iron |
|
|
Term
| Treatments that are not recommended for iron poisoning |
|
Definition
| Activated charcoal; does not adsorb iron, Sodium polystyrene sulfonate, Oral complexing agents, Calcium EDTA, Oral sodium bicarbonate, Oral phosphate salts, Oral magnesium hydroxide, Hemodialysis or hemofiltration, Gastric lavage (must consider risk vs. benefit) |
|
|
Term
| No measurable blood lead concentration is considered safe T or F? |
|
Definition
|
|
Term
|
Definition
| Most children with elevated (>5 mcg/dL) blood lead levels (BLL) do not exhibit any clinical signs or symptoms, behavior disorders, non-linear reduction in Intelligence Quotient (IQ), hearing loss, seizures, encephalopathy, abdominal pain, constipation, renal dysfunction, microcytic hypo chromic anemia, growth suppression; osteopenia (lead inhibits activation of vitamin D), Death, |
|
|
Term
|
Definition
| BLL 5-44 mcg/dL (Risk levels I-III)-- environmental cleanup and Correct dietary deficiencies in iron, zinc, protein, calcium and vitamin, BLL 45-69 mcg/dL (Risk level IV),follow recommendations for Risk levels I-III succorer for 19 days, BLL 70 mcg/dL or more (Risk level V)--Hospitalization, Follow recommendations for Risk levels I-III + dimercaprol + edetate calcium disodium |
|
|
Term
| Dimercaprol for lead poisoning |
|
Definition
| Administered every 4 hours by deep intramuscular injection x 3 days, Alkalinize urine during therapy to prevent the breakdown of the chelate-lead complex in the kidneys, Dimercaprol is dissolved in peanut oil. Avoid in peanut allergic patients, May cause hemolysis in patients with glucose-6-phosphatase deficiency |
|
|
Term
| Edetate calcium disodium (calcium EDTA) for lead poisoning |
|
Definition
| Given once daily x 5 days Start dosing 4 hours after initiating dimercaprol to prevent redistribution of lead into the central nervous system. Adverse events: nephrotoxicity (reduced by adequate hydration) Do not confuse this drug with sodium EDTA which is used for hypercalcemia. |
|
|
Term
| Crotaline snakebites symptoms |
|
Definition
| necrotic wound hematologic toxicity, manifested as coagulopathy, hemolysis and thrombocytopenia with signs of bleeding. Other systemic signs may include nausea, vomiting, oral paresthesia or unusual tastes, hypotension, tachycardia, tachypnea and altered mental status. |
|
|
Term
| Crotalidae Polyvalent Immune Fab, Ovine - FabAV |
|
Definition
| FabAV is usually used for cases of moderate to severe bites where swelling and pain are more significant and systemic symptoms, coagulopathy (e.g., INR > 3; aPTT > 50 seconds; fibrinogen < 75 mg/dL; platelets < 50,000 cells/mm3) or severe bleeding are present. The dose of FabAV is determined by the severity of the bite, not by the weight of the patient. Children receive the same venom load from a bite as an adult. Therefore, the mg/kg dose of FabAV will be higher in a pediatric than adult patient. repeat in 1 hr if needed, The half-life of FabAV is shorter than the venom components, requiring repeated dosing every 6 hours to sustain control of the venom’s toxicity. |
|
|
Term
| Tricyclic antidepressants (TCAs) toxicity |
|
Definition
| Dose where hospitalization is recommended, >1 mg/kg for protriptyline, >2.5 mg/kg for desipramine, nortriptyline and trimipramine, >5 mg/kg for amitriptyline, clomipramine and doxepin, symptoms within 2-6 hrs, Serum tricyclic levels poorly correlate with toxicity. TCAs cause widening of the QRS and ventricular arrhythmias in overdose, hypotension,seizures, coma, ileus |
|
|
Term
| Tricyclic antidepressants (TCAs) overdose treatment |
|
Definition
| Intravenous isotonic crystalloids or colloids are first line for hypotension, Consider norepinephrine for fluid non-responsive hypotension in TCA toxicity because TCAs have alpha agonist properties, Dopamine may be less effective at correcting hypotension because TCAs deplete presynaptic norepinephrine stores during toxicity, Refractory hypotension may respond to glucagon. sodium bicarb 1-2 mEq/kg/dose administered over 1-2 minutes. Repeat as necessary to narrow the QRS interval. Goal pH of 7.45-7.5, .5 mL/kg of 20% lipid emulsion over 2-3 minutes, then a 0.25 mL/kg/min continuous infusion dc after 30-60 min, bentos for seizures, Activated charcoal without sorbitol, Gastric lavage |
|
|
Term
| Treatments that are not routinely recommended for TCA overdose |
|
Definition
| Ipecac, Phenytoin, Beta-blockers, Hemodialysis, Physostigmine (contraindicated), Flumazenil (contraindicated) |
|
|
Term
| What year was the IRB formed |
|
Definition
| Institutional Review Board began in 1966 |
|
|
Term
| What is the Belmont report? |
|
Definition
| 1979, the Belmont Report states that research must meet three tests: it must have respect for person, provide beneficence, and have a strong principle of justice. |
|
|
Term
| projects are exempt from IRB review |
|
Definition
| 1. Typical educational practices 2. Educational tests, surveys, interviews, or observation of public behavior 3. Research with elected public officials, appointed public officials, candidate for public office 4. Existing data, documents, pathological specimens, if publicly available or unidentifiable 5. Evaluation of public benefit service programs, and 6. Taste and food quality evaluation and consumer acceptance studies. |
|
|
Term
|
Definition
| This type of review does not mean that there is a less rigorous review, just that there are fewer reviewers than the full committee. The proposed research has minimal risk and falls into one of the following categories: Clinical studies, Blood sample collection, Prospective collection of biological samples via noninvasive means, Data collected through noninvasive means that are routinely practiced in clinical settings, Materials (data, documents, specimens, etc.) have been collected or will be collected for non-research purposes, Collection of voice, video, or digital data for research purposes, Individual or group behavior through surveys, interviews, or oral histories, Continuing review of research previously approved by the convened IRB with no further direct subject participation, and Continuing review of research (not under IND or IDE) where the IRB has determined and documented at a convened meeting that the research involves no greater than minimal risk and no additional risks have been identified. |
|
|
Term
| types of projects reviewed by the full IRB committee include |
|
Definition
| 1. FDA regulated projects such as IND and IDE), 2. Projects posing greater than minimal risk to subjects, 3. Research involving vulnerable populations Research regarding sensitive topics, including Sexual practices, . Substance use or abuse, Religion, Economic status of subject or family member, Perceived sanction for participation or non-participation. |
|
|
Term
| Research involving vulnerable populations, include |
|
Definition
a. Those who speak a language different from the researchers,
b. Representatives of a minority culture, c. Those who might be at risk because of prejudices based on current events (e.g. the AIDS epidemic in the 1980s) d. Elderly persons, e. Adolescents, f. Those with cognitive impairment, g. Those participating in illegal or stigmatizing activities, h. Those subjects who might be vulnerable to coercion because of health status, i. Students, j. Employees of the research institution, and k. Members of the military. |
|
|
Term
|
Definition
| The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) provides medication error categorization and indexing standards. |
|
|
Term
|
Definition
| Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) scores- Measure of patient satisfaction |
|
|
Term
|
Definition
| National Committee for Quality Assurance (NCQA) |
|
|
Term
|
Definition
| Health Plan Employer Data and Information Set (HEDIS): 81 measures across 5 domains of care. These measurements are used by health plans to compare patient care and service. |
|
|
Term
| What are the core measures for the Joint Commission ? |
|
Definition
Joint commission and Centers for Medicare and Medicaid Services (CMS) have worked together to align common measures so that they are identical for acute myocardial infarction, heart failure, pneumonia, and perinatal care measures ii. Children’s Asthma Care Core Measure Set
1. Joint commission only measurement, required for free-standing children’s hospitals 2. Includes: Use of Relievers for Inpatient Asthma, Use of Systemic Corticosteroids for Inpatient Asthma, and Home Management Plan of Care Given to Patient/Caregiver |
|
|
Term
|
Definition
| Hospital Quality Alliance (HQA) |
|
|
Term
|
Definition
| PPMI is sponsored by the ASHP and the ASHP Research and Education Foundation. The goal of the PPMI is to advance the health of patients by developing and disseminating optimal pharmacy practice models that are based on the effective use of pharmacists as direct patient care providers. |
|
|
Term
| Types of performance measures of PPMI ? |
|
Definition
| Structure- quantifies the resources available to provide care, Process measures- how care is delivered or a system works, Outcome measures- measures the results of health care |
|
|
Term
| PDSA cycle or PDCA cycle for Quality Improvement |
|
Definition
| Plan, Do, Study (Check), Act |
|
|
Term
|
Definition
| Define, Measure, Analyze, Improve, Control (incorporate the beneficial solutions into standard operating procedures) |
|
|
Term
| Hazardous Drug definition |
|
Definition
| a. Carcinogenicity, b. Teratogenicity or developmental toxicity, c. Reproductive toxicity in humans, d. Organ toxicity at low doses in humans or animals, e. Genotoxicity, and f. New drugs that mimic existing hazardous drugs in structure or toxicity [for examples see current National Institute for Occupational Safety and Health (NIOSH) publications]. |
|
|
Term
|
Definition
| a major revision to the USP takes the hazardous drug compounding from USP 797 and creates a new chapter, USP 800 (to be published). |
|
|
Term
|
Definition
| Clinical data related to patient care indicating a reasonable probability that an adverse event has occurred or is occurring. An example of a trigger tool for an adverse event is a physician order for an antidote, a medication stop, or a dose decrease. |
|
|
Term
| Clinical Decision support basic requirements |
|
Definition
| 1. Drug dose based on the patient’s weight 2. Single and cumulative dose limits, including lifetime dosing 3. Dose limits for combination products (e.g., acetaminophen as an ingredient of multiple products taken by the same patient) 4. Therapeutic duplication, including combination products 5. Cross-allergies 6. Contraindications to routes of administration 7. Food-drug and herbal-drug interaction 8. Contraindications based on diagnosis, laboratory studies, or radiology studies 9. IV compatibilities |
|
|
Term
| Two Types of Random Variables |
|
Definition
| 1 Discrete variables, including dichotomous and categorical 2. Continuous variables |
|
|
Term
|
Definition
1.Only a limited number of values within a given range
2. Nominal: Classified into groups but no order or rank. The investigator is naming variables in an
unordered manner with no indication of relative severity (e.g., sex, mortality, disease presence, race,
marital status).
3. Ordinal: Ranked in a specific order but with no consistent size or magnitude of difference between
ranks (e.g., NYHA [New York Heart Association] functional classification describes the functional status of patients with heart failure in which subjects are classified in increasing order of disease severity [I, II, III, and IV])
4. COMMON ERROR: When summarizing ordinal data, using the means to measure central tendencies and the SDs to measure distribution is usually inappropriate. |
|
|
Term
|
Definition
1. Continuous variables can take on any value within a given range.
2. Interval: Data are ranked in a specific order with a consistent change in magnitude between units; the
zero point is arbitrary (e.g., degrees Fahrenheit).
3. Ratio: Like “interval” but with an absolute zero (e.g., degrees Kelvin, heart rate, blood pressure, time,
distance) |
|
|
Term
|
Definition
The sum of all values divided by the total number of values
Should generally be used only for continuous and normally distributed data Very sensitive to outliers: Commonly pulled or skewed to the tail that contains them Most commonly used and best understood measure of central tendency Geometric mean: Convert data to their log values and calculate the mean, which commonly results in the conversion of a skewed to a normal distribution. |
|
|
Term
|
Definition
Midpoint of the values when placed in order from highest to lowest: Half of the observations are above, and half are below.
ii. If summarizing data in percentiles, the median is the 50th percentile. Can be used for ordinal or continuous data. Unlike with mean, the investigator does not have
to defend the use of median when describing the center of ordinal data or data that appear to
be skewed. Appropriate for skewed results because the median is insensitive to outliers |
|
|
Term
|
Definition
Most common value in a distribution
ii. Can be used for nominal, ordinal, or continuous data
iii. Sometimes, there may be more than one mode (e.g., bimodal).
iv. Not useful if a large range of values and each value occurs infrequently |
|
|
Term
|
Definition
Measure of the variability about the mean: Most common measure used to describe the spread of data, Square root of the variance (average squared difference of each observation from the mean); returns variance back to original units (non-squared), Appropriately applied only to continuous data that are normally or near-normally distributed or that can be transformed to be normally distributed (e.g., the geometric mean), Appropriately applied only to continuous data that are normally or near-normally distributed or that can be transformed to be normally distributed (e.g., the geometric mean), By the empirical rule, 68% of the sample values are within ±1 SD, 95% are within ±2 SD, and 99% are within ±3 SD.
The coefficient of variation gives the reader an idea of the spread of the data; it is the ratio of the SD to the mean and can also be reported as a percentage (SD/mean × 100%). Knowledge of the mean and SD allows the reader to re-create the distribution of data. |
|
|
Term
|
Definition
Difference between the smallest and largest value in a data set, Easy to compute (simple subtraction) but not very informative by itself, Size of range is very sensitive to outliers.
Often reported as the actual values rather than the difference between the two extreme values |
|
|
Term
|
Definition
The point (value) in a distribution below which a certain percentage of values lie, The 50th percentile lies at a point at which 50% of the other values in the group are smaller;
50th percentile also represents the median of the data, Unlike with the mean, normal distribution need not be assumed, The IQR describes the middle 50% of values (IQR = 25th–75th percentile). |
|
|
Term
| Presenting data using only measures of central tendency can be misleading without measures of the distribution or spread of the data; be wary of studies that report only the medians or means. |
|
Definition
|
|
Term
| Probabilities versus proportions versus percentage |
|
Definition
| Probabilities and proportions are calculated the same way, and both can be expressed as a percentage; however, the term proportions refers to preexisting information, and probabilities refers to the future. |
|
|
Term
|
Definition
1. Conclusions or generalizations made about a population (large group) from the study of a sample of
that population
2. Used to test hypothesis and make estimations based on samples of a population
3. Choosing and evaluating statistical methods depend, in part, on the type of data used. |
|
|
Term
|
Definition
The hypothesis an investigator is trying to disprove or reject; when comparing
groups, statement of no difference between groups being compared (treatment A = treatment B) |
|
|
Term
| Alternative hypothesis (Ha): |
|
Definition
Opposite of null hypothesis; when comparing groups, statement of a
difference between groups being compared (treatment A ≠ treatment B) |
|
|
Term
|
Definition
he structure or the manner in which the hypothesis is written dictates which statistical test is used
(e.g., for a two-sample Student t-test, the H0: mean 1 = mean 2). Helps the reader infer if any observed differences between groups can be explained by chance |
|
|
Term
Tests for statistical significance (hypothesis testing) determine whether the data are consistent with the
H0 (no difference) or whether enough “evidence” exists to reject the H0. |
|
Definition
a. If H0 is “rejected,” there is a statistically significant difference between groups (unlikely
attributable to chance).
b. If H0 is “not rejected,” the investigators failed to find a statistically significant difference between
groups (any “apparent” differences may be attributable to chance). Note that we cannot conclude the treatments are equal. |
|
|
Term
| Determining What Is Sufficient Evidence to Reject H0 |
|
Definition
1. Set the a priori significance level (α), and generate the decision rule.
2. Developed after the research question has been stated in hypothesis form
3. Used to determine the level of acceptable error caused by a false positive (also known as level of
significance)
a. Convention: A priori α is most often 0.05.
b. Critical value is calculated, capturing how extreme the sample data must be to reject H0. |
|
|
Term
|
Definition
A p value is the probability of obtaining a test statistic as extreme, or more extreme, than the one
actually obtained; it is the likelihood of getting the results you did, or something more extreme given
that the null hypothesis is true (no difference between groups). n general, the test statistic and critical value are not presented in the literature; instead, a p value is
reported and compared with an a priori α value usually 0.05) to assess statistical significance. |
|
|
Term
| CIs Instead of Hypothesis Testing |
|
Definition
Hypothesis testing, which includes calculation of p values, is used to determine whether a statistically
significant difference exists between groups; however, p values are uninformative concerning the size
or clinical significance of the difference. CIs give us a better idea of the true difference in the population according to the sample groups, which
helps us determine the clinical significance of the results and whether they apply to our practice. CIs are a “range” of data and are often reported with a point estimate. |
|
|
Term
| Interpretation of wide CIs |
|
Definition
Many results are possible, either larger or smaller than the point estimate reported.
b. All values contained in the CI are statistically plausible.
6. If the estimate is the difference between two continuous variables, a CI that includes zero (no
difference between two variables) can be interpreted as not statistically significant (a p value of 0.05 or
greater).
7. If the estimate is an OR or a relative risk, a CI that includes 1 (e.g., no difference in risk between the
two variables) can be interpreted as not statistically significant.
8. There is no need to report both the 95% CI and the p value. |
|
|
Term
| Parametric versus nonparametric tests |
|
Definition
Parametric tests assume that
i. Data are randomly sampled from a parent population with a normal or near-normal
distribution; methods to determine this include looking at the data distribution, comparing the
mean and median, or using statistical tests
ii. Measured (dependent) data are continuous and on either an interval or a ratio scale
iii. Homogeneity of data variance between groups being compared (homoscedasticity)
b. Nonparametric tests are used when data do not meet the parametric test criteria (e.g., data are not normally distributed, the distribution cannot be discerned, or the data measured are nominal or ordinal). |
|
|
Term
|
Definition
| Student t-test, ANOVA, ANCOVA |
|
|
Term
|
Definition
| A statistical hypothesis test for comparing two groups that follow a Student t-test distribution a. One-sample test: Compares the mean of the study sample with the population mean Independent or unpaired samples t-test: Compares the means of two independent samples , can be equal or unequal variance test. if ratio of a larger variance is > 2, then they are unequal, Paired t-test: Compares the means of paired samples or repeated measures within the same group |
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Term
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Definition
A more generalized version of the t-test that can apply to more than two groups
a. One-way ANOVA: Compares the means of three or more independent groups: Sometimes called single-factor ANOVA b. Two-way ANOVA: Compares the means of three or more independent groups for two categorically independent variables Repeated-measures ANOVA: Compares the means of three or more related groups |
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Term
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Definition
| Compares the means of three or more independent groups while statistically controlling for another continuous independent variable (covariate) that may be negatively influencing (confounding) your results |
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Term
| Nonparametric Tests-- Independent samples |
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Definition
a. The Wilcoxon rank sum test and the Mann-Whitney U test are used to compare two independent samples; both are related to the Student t-test.
b. The Kruskal-Wallis test is used to compare three or more independent groups and is related to the one-way ANOVA test. As with other tests that compare more than two groups, post hoc testing is required to determine which specific groups are different. |
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Term
| Nonparametric Tests-- Matched or paired samples |
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Definition
a. Sign test and Wilcoxon signed rank test are used to compare two matched or paired samples and
are related to a paired t-test.
b. Friedman ANOVA by ranks is used to compare three or more matched or paired groups and is
related to the repeated-measures ANOVA test. |
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Term
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Definition
Nonparametric tests are also used to compare groups when the dependent variable is continuous if
other assumptions for the parametric tests are not met. |
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Term
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Definition
| Chi-square (χ2) test, Fisher exact test, McNemar, Mantel-Haenszel |
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Term
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Definition
A nonparametric test used to compare expected and observed proportions between
two or more groups
a. Test of independence: Used to test if there is a significant association between two categorical
variables from a single population
b. Goodness-of-fit test: A single-sample nonparametric test used to determine whether the
distribution of participants follows a known or hypothesized distribution
c. Commonly represented by contingency tables .Chi-square test is useful to answer questions about rates, proportions, or frequencies when the data are nominal |
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Term
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Definition
| Specialized version of the chi-square test for small groups (cells) containing less than five predicted observations |
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Term
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Definition
| Used to compare paired samples such as a before and after study, or when two treatments are given to matched subjects |
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Term
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Definition
| Used to control for the influence of confounders when comparing dichotomous outcomes (e.g., stratifying into age groups or other potential risks factors related to the outcome of interest) |
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Term
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Definition
The probability or likelihood of making this error is defined as the significance level α.
1. Convention is to set α to 0.05, effectively meaning that, 1 in 20 times, a type I error will occur when
the H0 is rejected, or that 5.0% of the time, a researcher will conclude that there is a statistically
significant difference between groups in the sampled population when one does not actually exist. |
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Term
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Definition
The calculated chance that a type I error has occurred is called the “p value.” The p value tells us the likelihood of obtaining a given (or a more extreme) test result if the H0 is true. When the α level is set a priori, H0 is rejected when p is less than α. The p value tells us the probability of
being wrong when we conclude that a true difference exists in the sampled population (false positive).
4. A lower p value does not mean the result is more important or clinically meaningful, but only that it is statistically significant and not likely attributable to chance. CIs are much more informative when applying the results to our clinical practice. |
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Term
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Definition
Type II Error: The probability or likelihood of making this error is termed β.1. Concluding that no difference exists in the sampled population when one truly does exist, or failing to
reject the H0 when it should be rejected
2. It has become a convention to set β between 0.20 and 0.10, which effectively means that an
investigator will fail to conclude that a statistically significant difference exists between sampled groups when one actually does exist 20% and 10% of the time, respectively: We are much more tolerant of a type II versus a type I error. |
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Term
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Definition
| The probability or likelihood of correctly rejecting the H0 when a difference between groups in the sampled population is present |
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Term
| Power is dependent on the following factors: |
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Definition
a. Predetermined α: A smaller α or risk of error you will tolerate when rejecting H0 results in a decrease in power
b. Sample size: An increase in sample size results in an increase in power.
c. The delta or size of the difference between the outcomes you wish to detect: An increase in delta
results in an increase in power, or the larger the difference you have designed your study to detect, the higher the power. Delta is the size of difference you have determined to be clinically significant before the study begins.
d. The variability in the outcomes that are being measured: An increase in variability results in a decrease in power. Variability is estimated from previous data or published results.
e. Poor study design may negatively influence power.
f. Failure to select the most appropriate statistical test may decrease power (e.g., using of a
nonparametric test when a parametric test is appropriate; using a non-paired test when a paired test
is appropriate). |
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Term
| Sample size calculation and statistical power analysis |
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Definition
a. Increase in sample size results in a decrease in type I and type II errors; unfortunately, the budget often restricts the number of subjects we can recruit for a study.
b. Sample size estimates should be performed in all studies a priori (before they begin).
c. Important factors for estimating an appropriate sample size
i. Acceptable β or type II error rate (usually 0.10–0.20)
ii. Selecting an a prior difference (delta) in study outcomes that is clinically relevant iii. The estimated variability in the outcome measured
iv. Acceptable α or type I error rate (usually 0.05)
v. Statistical test used to test the hypothesis for the primary end point |
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Term
| Statistical significance versus clinical significance |
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Definition
a. The size of the p value is not related to the clinical importance of the result. Smaller values mean
only that “chance” is less likely to explain the observed differences.
b. Statistically significant does not necessarily mean clinically significant.
c. Lack of statistical significance does not mean that results are not clinically important: Consider
factors that could have affected the power such as sample size, delta, and observed variability. |
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Term
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Definition
Studies the Time Between Entry in a Study and Some Event (e.g., death, myocardial infarction)
1. The outcome variable of interest is the time until the occurrence of an event.
2. Observations are called censored when the information concerning the survival time is incomplete.
Subjects sometimes leave a study for reasons other than the event of interest (e.g., lost to follow-up) or
do not experience the event before the end of the study.
3. Allows for the reality that not all subjects enter the study at the same time
4. Standard methods of statistical analysis (e.g., t-tests and linear or logistic regression models) cannot be
applied to survival data because of censoring.
5. Survival methods correctly use information from both censored and uncensored observations.
6. Survival and hazard functions are key concepts in survival analysis. The survival function gives the
probability of surviving or not experiencing an event up to that time for each time interval, whereas the hazard function gives the potential that the event will occur per unit of time, considering that the subject has survived up to that time. |
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Term
| Estimating the Survival Function: |
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Definition
1. Kaplan-Meier method
a. Uses survival times (or censored survival times) to estimate the proportion of people who would survive a given length of time under the same circumstances
b. Allows the production of a table (“life table”) and a graph (“survival curve”) (Figure 4)
c. Readers can visually inspect the curves, but they need a test to evaluate them formally.
2. Log-rank test: Compares the survival distributions between (two or more) groups
a. This test precludes an analysis of the effects of several variables or the magnitude of difference between groups or the CI (see below for Cox proportional hazards model).
b. H0: No difference in survival between the two populations
c. Log-rank test uses several assumptions:
i. Random sampling and subjects chosen independentlyii. Consistent criteria for entry or end point
iii. Baseline survival rate does not change as time progresses.
iv. Censored subjects have the same average survival time as uncensored subjects.
3. Cox proportional hazards model
a. Most popular method to evaluate the impact of covariates: Reported (graphically) like Kaplan-
Meier (Figure 3)
b. Allows the investigation of the influence of several independent variables at the same time
c. Actual method of construction and calculation is complex.
d. Compares survival in two or more groups after adjusting for other variables
e. Allows calculation of a hazard ratio and CIs |
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Term
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Definition
| An observational study collects data from an existing situation seeking to evaluate clinical experience questions. Observational studies are important for collecting data in areas where clinical trial cannot be conducted and for identifying possible new treatments. The limitations of observational studies are the less rigid control and the presence of confounding factors that are always present. |
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Term
| Two types of observational studies |
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Definition
| Case-control study, Cross-sectional studies |
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Term
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Definition
| Case-control study (longitudinal, epidemiologic study) is non-randomized observation of two similar groups of subjects that are defined by the presence or absence of an outcome (condition/disease). The case control study is used to detect possible causes or risk factors that may contribute to the outcome. Cases are individuals selected because of the presence of a disease or outcome and controls are individuals without the disease or outcome but otherwise are similar in clinical characteristics to the cases. The cases and controls are compared with respect to various characteristics. Classic example in pediatrics is the association of sudden infant death syndrome (SIDS) and prone sleeping and heavily wrapped bedding. |
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Term
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Definition
| Cross-sectional studies (surveys) analyze data collected on an entire population of subjects or a representative subset at one point in time rather than over a period of time. Cross-sectional studies are often useful for evaluating a new diagnostic procedure. They can be used to determine the prevalence of a disease in a population, the odds ratio for a disease and absolute or relative risk. The cross-sectional study of medication treatment complexity and adherence in children with chronic kidney disease found that poorer adherence was associated with medication dosing frequency, but not the number of medications (Blydt-Hansen 2014). Prospective cohort studies utilize a group of subjects who have something in common. The investigator selects subjects at the beginning of the study and then determines whether they have a risk factor, exposure, or receive a specific therapy. The long-term effectiveness of the varicella vaccine at preventing chicken pox was a 14-year prospective cohort study (Baxter 2013). |
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Term
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Definition
| Phase 0 is first in human testing of small subtherapeutic dose to establish pharmacokinetics and pharmacodynamics. Testing is done in a small number of subjects, 10–20. |
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Term
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Definition
| Phase I is usually the first stage in testing in healthy human subjects to assess safety, pharmacokinetics and pharmacodynamics and may include dose ranging studies, usually in 100 or fewer subjects. Phase 1a is single ascending dose study and Phase 1b is multiple ascending dose studies. |
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Term
| Drug Development Phase II |
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Definition
| Phase II is the second stage to assess biological activity or effect of the selected dose or dose range usually given to subjects with the intended disease. Phase IIA assesses dosing requirements and Phase IIB focuses on efficacy assessing how well the drug works at the selected dose. |
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Term
| Drug Development Phase III |
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Definition
| Phase III is large scale randomized controlled multicenter trials on large numbers of subjects to assess safety and effectiveness. |
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Term
| Drug Development Phase IV |
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Definition
| Phase IV trials are known as post-marketing surveillance focused on safety looking for rare or long-term adverse effects in much larger patient populations. |
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Term
| Experimental Studies (Clinical Trials |
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Definition
| Clinical trials are experimental studies that involve humans and attempts to draw conclusions about a particular procedure or treatment. They are conducted prospectively and lead to stronger scientific inferences than observational studies. Clinical trials are divided into two categories, those with controls and those without controls. |
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Term
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Definition
| Controlled studies (comparative) are clinical trials in which the experimental procedure (e.g., drug therapy) is compared with another, a placebo, or previously accepted therapy (historical controls). Because the purpose of an experiment is to determine whether the treatment makes a difference, studies with controls are much more likely that those without controls to detect whether the difference is due to the treatment or to some other factor. Uncontrolled studies are clinical trials in which the experimental procedure is described, but the treatment is not compare with another. |
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Term
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Definition
| Nominal scale is the simplest level of measurement where data values fit into categories. There is an arbitrary assigning of numerical values to each of the categories. |
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Term
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Definition
| Ordinal scale is a ranking of the data according to some criterion. The ranking is arbitrary, but there is a predetermined order to the observations. |
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Term
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Definition
| Numerical scale can either be discrete or continuous. Discrete data are integers or discontinuous units. |
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Term
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Definition
| Interval scale is data where there is a consistent size between any units of measure but the zero value is arbitrary, e.g. temperature, celsius and Fahrenheit. |
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Term
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Definition
| Ratio scale is also numerical data of consistent size between any units of measure with an absolute zero, e.g. height, weight, and age. |
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Term
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Definition
| Variance is a measure of variability that results by summing the squared deviation of each observation from the mean (sum of squares) divided by the number of observations. |
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Term
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Definition
| Standard deviation is the square root of variance and is the most commonly used measure of variability in the medical literature. |
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Term
| Standard error of the mean |
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Definition
| Standard error of the mean is the standard deviation divided by the square root of the number of observations. It is important to note that standard error of the mean is not a measure of variability of the sample data. |
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Term
|
Definition
| Coefficient of variation is the standard deviation divided by the mean |
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Term
|
Definition
| Confidence interval is the interval estimate constructed that insures that the interval includes the population parameter it estimates. The confidence interval is an interval estimate determined from a sample and is used to estimate a range of values that is likely to include the population value a specified percentage of the time. |
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Term
|
Definition
| Meta Analysis is a systematic statistical method for analyzing results from multiple independent studies that can be used to draw conclusions about therapeutic effectiveness or to plan new studies. Meta-analysis takes the summarizing a set of studies in a review article a step further by using statistical procedures to combine the results from different studies. Often research projects are designed to answer similar questions but do not always come to the same conclusion. For meta-analysis it is important that there be a common endpoint. The problem is to determine which study to believe. Meta-analysis borrows from both expert review and the methodology of multi-center studies. The purpose of meta-analysis is: 1) increase statistical power by increasing the sample size, 2) to resolve uncertainty when reports do not agree, 3) to improve estimates of effect size - degree to which a phenomenon is present in the population, an index of how much difference there is between two groups, and 4) to answer questions not posed at the beginning of the study. |
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Term
| Absolute Risk Reduction (ARR) = |
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Definition
| Absolute Risk Reduction (ARR) = Control Event Rate (CER) – Experimental Event Rate (EER) |
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Term
| Number Needed to Treat (NNT) = |
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Definition
| Number Needed to Treat (NNT) = 1/ARR |
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Term
| Absolute Harm Increase (AHI) = |
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Definition
| Absolute Harm Increase (AHI) = EER - CER |
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Term
| Number Needed to Harm (NNH) = |
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Definition
| Number Needed to Harm (NNH) = 1/AHI |
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Term
| Health Care communication for 7-12 year old |
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Definition
| Education regarding medications changes in this stage. A pharmacist is able to provide the child more details about how a drug works in the body. It is also important to start giving the child more autonomy by asking the child to work with their parents/caregivers in taking their medications. For example, a child with asthma in this stage is able to learn why they need their albuterol inhaler, when they need puffs of the inhaler, how their medication works, and what is going on in their body requiring albuterol. They also are able to understand inhaler techniques. In this stage, it is recommended that the child work with the parent to assure understanding and proper use. |
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Term
| Health Care communication for Ages 13 to adulthood |
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Definition
| Educational materials or messages in this stage can be similar to what is given to an adult. |
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Term
| Tips for counseling toddlers and preschool children |
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Definition
a. This age group may not be actively involved in learning about their medications; however, it is important to include them in the discussion.
b. Begin the interaction with a friendly discussion about a cartoon character on their t-shirt or a toy they have in their hands. This will help the health care provider gain their attention and confidence.
c. Educate the child in simple terms as to what the medication is for and why it is important to take the medication.
d. Example educational message (medication for headache): The medicine will make your head feel better. Your mom or dad will help you know when and how to take the medicine. |
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Term
| Tips for counseling school-aged children |
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Definition
a. School-aged children can become involved in learning about their medications.
b. In this age group, asking about a favorite hobby is a good way to build rapport and confidence of the child.
c. Due to the large range of developmental stages and experiences with medications in the age group, simple open-ended questions (e.g., Why do you need this medication) will help you assess if the child is starting to understand cause-and-effect. As the child moves up along Piaget’s developmental stages, more details can be provided in education.
d. Example educational message (medication for headache): This medication will go into your body to help with the pain in your head. You only need to take this medication when you feel the pain. If the pain does not go away, you can take another dose in four hours. Work with your mom and dad, so that you all know how much medication to take. |
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Term
| Tips for counseling adolescents |
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Definition
a. Adolescents can receive education messages similar to what would be provided to an adult.
b. Promoting control and responsibility for their own healthcare is important in this age group.
c. Often adolescents feel more comfortable talking about certain medications or medical conditions separate from their parents. Offering private communication opportunities are important.
d. Example educational message (medication for headache): This medication will help stop the swelling and pain in your head causing a headache. The medication is an anti-inflammatory agent that is used only when needed. If the first dose does not work, another dose can be given in 4 hours. However, if you feel like you need 5 or more doses in one day or multiple doses for several days, please talk to your health care provider. |
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Term
| General principles of counseling children |
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Definition
1. Education sessions with children should generally be active and be broken into segments lasting no longer than 15 minutes
2. Incorporating pictures and hands-on activities is especially important prior to adolescence |
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Term
| REALM Rapid Estimate of Adult Literacy in Medicine |
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Definition
a. Medical-word recognition and pronunciation test for screening adult reading ability in the healthcare setting
b. Administered and scored in less than 3 minutes
c. Adults read from a list of 66 common medical terms that patients are expected to read to effectively participate in their own healthcare
d. Scores can be converted into four reading grade levels
e. Example:
i. Instructions: “I want to hear you read as many words as you can for the list. Begin with the first work and read along…”
ii. Word examples: Menopause, Antibiotics, Exercise |
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Term
| Test of Functional Health Literacy in Adults (TOFHLA). |
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Definition
a. 17-item test of numerical ability and a 50-item test of reading comprehension
b. Draws on materials commonly used in the healthcare setting
c. Numeracy items test ability to understand monitoring blood glucose, keep a clinic appointment, obtain financial assistance, and understand directions on pill bottles
d. Total scores are divided into 3 categories (inadequate, marginal, adequate)
e. S-TOFHLA (Short-TOFHLA) also has been created and is commonly utilized |
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Term
| Parental Health Literacy Activities Test (PHLAT) |
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Definition
a. 20-item assessment scale designed to investigate health literacy and numeracy skills of a caregiver to an infant (birth to 1 year)
b. Items assessed included mixing infant formula, understanding breastfeeding recommendations, drawing up doses of medications, and understanding nutrition labels |
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Term
| T or F Studies have not shown that infants and children of parents whose primary language is not English have lower rates of preventative care, higher rates of hospitalization and emergency department visits, and adverse medical events. |
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Definition
|
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Term
| Five components of cultural competency |
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Definition
a. Language
b. Normative cultural values: Beliefs, ideas, and behaviors that are generally expected by a cultural group during interactions with others.
1. These may affect the expectations of child’s independence and expectations to communicate during a visit.
2. These may also affect what information families are willing to share
c. Folk illnesses: Diagnoses recognized by a cultural/ethnic group. Folk remedies may put patients at risk for harmful therapies or avoidance of use of recommended therapies.
d. Patient/parent beliefs
e. Provider practices |
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Term
| Methods for providing culturally effective care |
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Definition
a. Inquire about treatment beliefs and attitudes
b. Explore possible barriers to care
c. Include the family’s decision maker in visits. This may actually be a grandparent rather than a parent.
d. Integrate specific health beliefs into the overall treatment plan when possible. |
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Term
|
Definition
a. Listen to the patient/parents perception of the problem
b. Explain your perception of the problem
c. Acknowledge and discuss differences and similarities
d. Recommend treatment
e. Negotiate agreement |
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Term
| Selecting and Effective Use of Interpreters |
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Definition
a. Trained interpreters should be used
b. Adult relatives or friends brought for purposes of interpretation are acceptable only if trained interpreters are not available
c. Children should only be used as interpreters as a last resort
d. Position patient, interpreter, and clinician in a triangular pattern
e. Maintain eye contact with and speak to the patient/parent rather than the interpreter
f. Use visual aids whenever possible
g. To ensure understanding, have the patient/parent repeat information back through the interpreter
h. Interpreter should provide written instructions for the patient/parent at the conclusion of the visit |
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Term
|
Definition
1. Adherence: The extent to which someone follows an agreed upon plan. Non-adherence can be intentional or unintentional.
2. Compliance: The extent to which someone follows through with instructions given. This term is less desirable because an approach that involves the patient in decision making is preferred. |
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Term
|
Definition
| Orphan Drug Act enacted in 1983 created an opportunity for manufacturers of drugs that were only useful in rare conditions to apply for the designation of “orphan drug”. This is defined as an incidence of disease in less than 200,000 in the US population, or if the manufacturer can demonstrate that it will not be possible to recoup enough money in sales to cover the costs of manufacturing the drug. This allows manufacturers to apply for federal grant funds to conduct R&D, to apply for a tax credit and hold exclusive marketing rights for 7 years. |
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Term
| National Childhood Vaccine Injury Act (NCVIA) |
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Definition
| National Childhood Vaccine Injury Act (NCVIA) authorized in 1986 limits legal liability of vaccine manufacturers while providing a source of compensation for victims of adverse events incurred secondary to vaccination. Additional goals of this act included creation of a reporting database (see VAERS below), stabilization of vaccine costs and ensuring adequate supply of vaccine. The NCVIA document can be found here: |
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Term
| Best Pharmaceuticals for Children Act (BPCA) |
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Definition
| Best Pharmaceuticals for Children Act (BPCA) originally authorized in 1994 under the Pediatric Rule, established incentives for manufacturers to ensure adequate safety and efficacy testing be completed in children. There have been several iterations of BPCA, including FDAMA described below, with the most recent published as BPCA 2007 requiring the NIH to publish a prioritized list every 3 years of medications that still require substantial pediatric testing. |
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Term
| The FDA Modernization Act (FDAMA) |
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Definition
| The FDA Modernization Act (FDAMA) authorized in 1997 provided manufacturers with an extra 6 months of exclusivity if pediatric studies were completed. |
|
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Term
| The Pediatric Research Equity Act (PREA) |
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Definition
| Pediatric Research Equity Act (PREA) was enacted in 2003 and provided a way to fill the gap in requiring pediatrics studies when the Pediatric Rule was enjoined in 2002. This act authorized the FDA to require studies in children on all new NDAs if the drug had potential to be used in the pediatric population. The act was reauthorized in 2012 under FDASIA |
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Term
| Food and Drug Administration Safety and Innovation Act (FDASIA) |
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Definition
| Food and Drug Administration Safety and Innovation Act (FDASIA) was enacted in 2012. FDASIA authorized the FDA to collect fees from manufacturers to support safety initiatives but, more importantly for children, authorized Section 907 that requires inclusion of subgroups in clinical trials. |
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Term
|
Definition
| the Vaccine Adverse Events Reporting System co-sponsored by the CDC and FDA. VAERS was created under the National Childhood Vaccine Injury Act (NCVIA) in 1990 to ensure a reporting mechanism for patients, providers and manufacturers. Important post-marketing surveillance data has been discovered secondary to VAERS, including the link between intussusception and the first generation rotavirus vaccine. All pharmacy providers should actively use VAERS to report adverse events in patients. |
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Term
|
Definition
| ACIP - the Advisory Committee on Immunization Practices was established to provide guidance on vaccine usage in children and adults. The panel consists of experts in medicine, public health and one community advisory member. |
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Term
|
Definition
| VFC – Vaccines for Children program run by the ACIP is designed to provide federal funding for approved vaccines for at risk pediatric populations. It is extremely important for pharmacists to understand the VFC limitations, not only for billing but also for advocacy and outreach |
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Term
| . Disease mitigation with vaccines |
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Definition
| ignificant progress has been made in preventing many diseases through immunization such as measles, diphtheria and pertussis. Some diseases have even been eradicated through vaccine use, such as smallpox and endemic polio in certain areas of the world. However, there is still significant under-utilization of some vaccines, such as HPV, partially due to the limited amount of time they have been on the market. Other barriers include the anti-vaccine movement sparked in part by falsified publications and celebrity endorsement. Pharmacists have a significant responsibility in educating the public about the facts regarding childhood vaccinations |
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Term
| Poison Prevention Packaging Act |
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Definition
| Poison Prevention Packaging Act was passed in 1970 and most recently revised in 2014. Thousands of children have been protected under this law, requiring manufacturers to ensure the closures to containers of regulated household substances and prescription medications were sufficiently difficult to impede a child under the age of 5 years from opening the container. There were exceptions, including non-safety cap authorization for elderly patients, and interestingly the number of poisonings in unregulated substances (e.g. nail polish remover) increased following the implementation of the act. |
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Term
| NPDS or National Poison Database System |
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Definition
| The poison centers are funded primarily via the state and federal government and provide not only immediate instructions for care to callers from the community but also to pre-hospital providers, hospital emergency departments and intensive care units. The centers use a shared database, the NPDS or National Poison Database System, to document all requests and as much outcome data as possible, creating a valuable tool for assessing public health issues related to poisonings and exposures. |
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Term
| Poison Control Center phone # is |
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Definition
| In the early 2000’s a universal number was created that will route to the nearest regional Poison Control Center automatically: 1-800-222-1222. All pharmacists should be familiar with this number. |
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Term
|
Definition
| children under the age of 6 years still account for 48.4% of all human exposures, While males accounted for the majority of cases under the age of 13 years, this is actually reversed in the teenage years, with females becoming involved in the majority of cases. |
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Term
| Drug abuse/misuse- Opioids |
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Definition
| determined to be a full-scale epidemic, opioid abuse has surpassed motor vehicle crashes as the leading cause of accidental death in 15 states. According to the CDC there were 6000 deaths in 1990 from unintentional overdose, which increased to 27,658 in 2007 and subsequently to 38,329 in 2010. In 2013, primary care physicians wrote over 92 million prescriptions for opioids. One in 4 teenagers report experimenting with prescription drugs not prescribed for them and more than 70,000 children are seen in Emergency Departments for overdoses related to the ingestion of a prescription pain medication, usually prescribed for someone in their household |
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Term
| Drug abuse/misuse - Designer Drugs |
|
Definition
| synthetic marijuana, “bath salts”, the 2C drugs (phenylethylamines), MDMA (“ecstasy”) are often drugs of choice of adolescents, available at gas stations and via the internet. Several states have attempted to pass regulations making the substances illegal with little success in stemming the tide, as the manufacturers continually find ways around the laws. |
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Term
| Prescription Drug Monitoring Programs (PDMP) |
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Definition
| State based databases that provide prescribers and pharmacies patient level information on all opioid prescriptions that have been written. In many states, it is now mandated that the PDMP is consulted prior to writing a prescription for an opioid. There are age and location exclusions that vary by state. As of the current date, most of the state based PDMPs are unable to share data across state lines, although the NABP PDP Interconnect system currently has 27 states sharing data. |
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Term
| The Overdose Prevention Act |
|
Definition
| The Overdose Prevention Act introduced to Congress in July 2014 (if passed) will make naloxone available by prescription to family members and caregivers of opiate addicts in every state as part of the national effort to control the opioid epidemic. Currently naloxone is available for caregiver administration in both an intranasal device and autoinjector (Evzio®). Some states, such as California, have made intransal naloxone available without a prescription. |
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Term
| The Medical Reserve Corps (MRC) |
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Definition
| e Medical Reserve Corps (MRC) is an excellent opportunity to become involved at a regional level for disaster preparedness. Volunteers are recruited from all medical disciplines and are trained as a group |
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Term
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Definition
| institutional readiness to respond to CBRNe (Chemical, Biological, Radiological, Nuclear, explosives), blast and burn, mass casualty incidents, biological epidemics and natural disasters affecting your physical structure. Pharmaceuticals and pharmaceutical care are key components in these response efforts and pharmacy should be involve as a core partner in planning, response and mitigation activities. |
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Term
| CDTM (Collaborative Drug Therapy Management) |
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Definition
| DTM (Collaborative Drug Therapy Management) is the collaboration between pharmacists and physicians that allow for pharmacist-guided care under an agreement and is now permitted in most states by law. Each state has significantly different levels of CDTM ranging from very protocol-driven limited practice to recognized provider status |
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Term
| Alliance for Pharmaceutical Care |
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Definition
| Alliance for Pharmaceutical Care is comprised of six large professional pharmacy organizations and works towards improving patient outcomes through advocating for the role of the pharmacist in patient care |
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Term
| Rome III criteria was developed in 2006, standardizing the definition of what? |
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Definition
Constipation 1. Infants and Children < 4 years of age. Must have at least 2 of the following for at least 1 months a. ≤ 2 stools per week b. ≥ 1 episode of fecal incontinence per week (once toilet trained) c. History of excessive stool retention d. History of painful or hard bowel movements e. Presence of large fecal mass in rectum f. History of large-diameter stools that may obstruct toilet
2. Children ≥ 4 years (without irritable bowel syndrome). Must have at least 2 of the following for at least 2 months a. ≤2 stools per week b. ≥ 1 episode of fecal incontinence per week (once toilet trained) c. History retentive posturing or excessive volitional stool retention d. History of painful or hard bowel movements e. Presence of large fecal mass in rectum f. History of large-diameter stools that may obstruct toilet |
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Term
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Definition
| Oral: Polyethylene glycol Rectal: a. Bisacodyl b. Docusate c. Sodium phosphate d. Mineral oil e. Glycerin |
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Term
| Maintenance therapy (in combination with diet/behavioral treatment) for constipation |
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Definition
| Osmotic laxatives : PEG, lactulose, Magnesium hydroxide, sorbitol, magnesium citrate; Stimulants: Senna, bisacodyl; Stool softeners: docusate, mineral oil; fiber and probiotics both lack data |
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Term
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Definition
| 1. Infants: 75% (Higher in premature infants) 2. Children: 60% 3. Adolescents and Adults: 50% in women, 60% in men |
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Term
| Maintenance fluids < 10kg |
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Definition
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Term
| Maintenance fluids 11 – 20 kg |
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Definition
| 1000 mL + 50 mL/kg for each kg > 10 kg |
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Term
| Maintenance fluids > 20 kg |
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Definition
| 1500 mL + 20 mL/kg for each kg > 20 kg |
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Term
| Isonatremic dehydration: Classic dehydration |
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Definition
| a. Proportionate loss of sodium, chloride, and water b. Can cause ischemic organ damage due to loss of extracellular fluid (ECF) in later stages--acute renal failure, Ischemic necrosis of GI tract, Multiple organ failure |
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Term
| Hyponatremic dehydration: Hypotonic: |
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Definition
| Excess loss of electrolytes (Na and Cl) compared to water loss, Low ECF osmolality causes shift of water into cells (worsening ECF fluid loss) Risk of brain swelling, Rehydration must occur slowly to allow brain cells to adapt |
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Term
| Hypernatremic dehydration: Hypertonic: |
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Definition
| Uncommon after infancy, 1. Normally, antidiuretic hormone is secreted and patient feels thirsty, which helps combat effects, 2. Infants have limited ability to convey thirst, 3. Also risky in patients with poor ADH activity or those without access to fluids --Most severe type has Greater loss of water relative to solute, Hyperosmolality in ECF causes fluid shift from cells to ECF, Brain cells shrink (due to depletion of fluid), and cerebral blood vessels are distended, which may lead to hemorrhage. |
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Term
| Risk factors for dehydration |
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Definition
| Gastroenteritis/diarrhea, Febrile illness, Stomatitis, Diabetic ketoacidosis, Burns, Underlying metabolic or renal disorders, Prematurity, Recent surgery |
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Term
| Treatment Severe dehydration |
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Definition
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Term
| Treatment Minimal or no dehydration: |
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Definition
| No rehydration therapy required, Replace losses: < 10 kg: 60-120mL oral rehydration solution (ORS), > 10 kg: 120-140 mL ORS with each diarrheal or vomiting episode |
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Term
| Treatment Mild to moderate dehydration: |
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Definition
| Rehydration therapy: 50-100 mL/kg ORS over 3-4 hours, Replace losses-- < 10 kg: 60-120mL oral rehydration solution (ORS), > 10 kg: 120-140 mL ORS with each diarrheal or vomiting episode |
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Term
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Definition
| WHO recommends that ORS contain: 75mEq sodium, 75 mmol/L glucose, and total osmolarity of 245 mOsm/L, same as Pedialyte; Cola and juices are generally not recommended |
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Term
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Definition
| Higher in neonates and young infants than adults due to reduced HCl secretion and frequent feeds |
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Term
| Gastric pH effect of drug absorption |
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Definition
| Acid labile drugs (β lactams, macrolides) are not broken down in stomach, making more available for absorption in the intestines |
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Term
| Gastric emptying of infants |
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Definition
| Neonates and young infants have slower gastric emptying time, affecting rate and potentially extent of absorption, Normal gastric emptying rates reached by 6-8 months in healthy children |
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Term
| Topical therapy in infants and children |
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Definition
| Systemic absorption of topical therapy greater in infants and children |
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Term
| Higher total body water in pediatric patients results in a larger volume of distribution (Vd) of drugs T or F |
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Definition
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Term
| Body fat stores reach adult values at what age? |
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Definition
| Body fat stores reach adult values at ~2-3 years of age, Effects of the body fat distribution on drug disposition is not fully understood |
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Term
| Circulating protein changes with infants |
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Definition
| 1. Neonates and young infants have lower circulating plasma proteins such as α 1-acid glycoprotein and lipoproteins 2. Newborns have higher circulating bilirubin and free fatty acids 3. Reduced protein binding and more free, unbound drug |
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Term
| sk factNeonates have poor biliary clearance, forcing renal elimination of drugs that rely on biliary elimination (eg Ceftriaxone) T or F |
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Definition
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Term
| Induction of labor percentages? |
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Definition
| Induction of labor is undergone by more than 22% of all gravid women, The incidence of induction is 225 per 1000 live births (data from 2006) |
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Term
| ACOG defines upper limit of duration of stage 2 with a normal fetal heart tracing and some labor progress as ? |
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Definition
| 1. Nulliparous--3 hours with regional anesthesia, 2 hours with no regional anesthesia 3. Multiparous--2 hours with regional anesthesia, 1 hour with no regional anesthesia There is evidence to support that stage 2 labor extending past 2 hours may increase maternal morbidities including perineal trauma, chorioamnionitis, need for instrumental delivery, and postpartum hemorrhage. The same study also showed that stage 2 labor lasting more than 3 hours for nulliparous women increased risk of low Apgar scores at 5 min, birth depression, and NICU admission. |
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Term
| Third stage disorders of labor |
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Definition
| Increased risk of hemorrhage after 30 min, Active management includes Early cord clamping, Controlled cord traction, Administration of uterotonic agent, usually oxytocin, Retained placenta may be removed manually |
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Term
| Analgesic administration for stage one labor |
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Definition
| Analgesic administration such as morphine (15-20 mg SC or IM as a single dose) may allow mother to rest and provides pain relief. |
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Term
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Definition
| Misoprostol – synthetic PGE1 analog, For cervical ripening; May be administered orally or intravaginally, Dose – 25 mcg (1/4 of 100 mcg tablet) q3-6 h |
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Term
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Definition
| Dinoprostone - PGE2 for cervical ripening; Vaginal insert; 10 mg; releases rate of 0.3mg/hr; Gel; 0.5 mg intracervically, Manufacturer of dinoprostone recommends a 6-12 hr delay for the start of oxytocin after dinoprostone administration |
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Term
| Pharmacological induction of labor |
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Definition
| Oxytocin 0.5-1 milliunits/min; increase every 30-60 min by 1-2 milliunits/min-- range 6-10 milliunits/min |
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Term
| Pre-eclampsia and eclampsia |
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Definition
| Pre-eclampsia and eclampsia account for 10-15% of maternal deaths worldwide (lower in Western countries), Third leading cause of maternal death in the US, Major cause of maternal morbidity, preterm birth, perinatal death, and intrauterine growth restriction; Pre-eclampsia seems to result from an abnormal vascular response to placentation with unclear etiology, Eclampsia also has unclear etiology, Findings include, but are not limited to, cerebral vasoconstriction, cerebral edema, cerebral infarction, and cerebral hemorrhage and may be causes or effects of eclamptic convulsions. |
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Term
| Risk factors pre-eclampsia, eclampsia |
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Definition
| Pre-eclampsia in a first degree relative (2-5 fold risk increase), Age ≥ 35 years, History of chronic hypertension, kidney disease, diabetes, and/or obesity, Twin or molar pregnancy, Previous pre-eclampsia, Fetal congenital abnormality, Reside at high altitude |
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Term
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Definition
| Gestational hypertension: hypertension that develops at ≥ 20 weeks gestation |
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Term
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Definition
| Systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg AND 24 hour proteinuria ≥ 0.3 g/24 hr or ≥ 1 on dipstick from 2 urine samples collected 4-6 hours apart or at least within 7 days |
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Term
| Severe pre-eclampsia diagnosis |
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Definition
Severe pre-eclampsia (at least 1 of the following criteria):
a. Systolic BP ≥ 160 mmHg or diastolic BP ≥ 110 mmHg at 2 different times at least 6 hours apart b. 24 hour proteinuria ≥ 5 g/24 hr or ≥ 3 g protein from 2 urine samples collected 4 hours apart c. Urine output < 500 mL in 24 hours d. Cerebral or visual symptoms e. Pulmonary edema or cyanosis f. Epigastric or RUQ pain g. Impaired liver function h. Thrombocytopenia
i. Fetal growth restriction |
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Term
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Definition
| HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) has different criteria but in general includes: Platelets < 100,000 – 150,000, AST or ALT > 40 IU/L (an alternative criteria is AST > 70 IU/L), LDH > 600 IU/L alone or with hemolysis on peripheral smear and TBili > 1.2 mg/dL |
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Term
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Definition
| Eclampsia: development of convulsions and/or unexplained coma during pregnancy or postpartum in patients with signs and symptoms of pre-eclampsia (usually symptoms align with those for severe pre-eclampsia) |
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Term
| Cure for pre-eclampsia and eclampsia |
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Definition
| The only curative treatment is delivery of fetus. Timing should consider both maternal and fetal risks and benefits--Immediate delivery if onset at 36-37 weeks or greater, Delivery at 24-36 weeks depends on severity of pre-eclampsia, Administer antenatal corticosteroids if indicated |
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Term
| Medications for pre-eclampsia |
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Definition
| Maternal BP goal should be 140-150 SBP/90-100 DBP, ACOG 1st line agents are hydralazine, labetalol, and nifedipine. Initial drug selection should consider maternal factors (i.e. avoid labetalol in patient with history of asthma), Magnesium sulfate may be used for seizure prophylaxis in severe preeclampsia and seizure treatment in eclampsia, Use caution with concomitant use of nifedipine and magnesium sulfate due to concern for neuromuscular blockade and severe hypotension, Second line therapies are labetalol and nicardipine infusions, Sodium nitroprusside should be reserved for the most extreme and refractory cases due to concern for cyanide and thiocyanate toxicity, Prophylactic/preventative aspirin may be used in patients with prior history of pre-eclampsia |
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Term
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Definition
| Magnesium sulfate 4-6 g over 15-20 min followed by 1-2 g/h continuous infusion. Continue for 24 hours post-delivery and/or 24 hours after last convulsion, Recurrent seizure may be treated with an additional 2 g magnesium sulfate over 3-5 min, Additional seizures may be treated with amobarbital 250 mg over 3-5 min, BP control with hydralazine, labetalol, or nifedipine, Sodium nitroprusside or nitroglycerin are rarely needed, Diuretics should only be used if pulmonary edema is present |
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Term
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Definition
| Rho(D) immune globulin at 28 weeks for all nonsensitized Rh-negative women and within 72 hours after delivery of Rh-positive infant |
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Term
| Genetic screening for neural tube defects and trisomies 21 and 18 at ? weeks? |
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Definition
| Genetic screening for neural tube defects and trisomies 21 and 18 at 15-20 weeks |
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Term
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Definition
| At 10-14 weeks---Provides a more accurate gestational age which reduces need for induction of labor, Allows for detection of multiple pregnancies At 18-20 weeks---Evaluates structural abnormalities |
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Term
| Nutrition and food safety for pregnant women |
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Definition
| Avoid unpasteurized milk, raw eggs, and undercooked meats and seafood, Fish type should be varied to minimize mercury consumption |
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Term
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Definition
| Should be taken prior to conception and through the 1st 4 weeks of gestation to be effective, Recommended for all women of child-bearing age since around half of all pregnancies are unplanned, Dose = 400 mpg daily, Contained in most prenatal vitamins |
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Term
| Omega-3 Fatty Acids for pregnant women |
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Definition
| Recommended that pregnant women consume 200 mg of docosahexaenoic acid (DHA) per day, May be obtained from 1-2 servings of seafood per week or oral supplementation |
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Term
| Supplemental iron for pregnant women |
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Definition
| Not routinely recommended, If anemia is identified, dose = 120 mg of elemental iron per day for 3 months |
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Term
| Influenza vaccine for pregnant women |
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Definition
| One dose of inactivated vaccine at any gestational age during the active influenza season |
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Term
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Definition
| One dose regardless of prior administration; around 28 weeks gestation preferred, but at least after 20 weeks |
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Term
| Pathophysiology of morning sickness |
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Definition
Not fully understood, but thought to be related to the placenta, not the fetus, Clinical course follows levels of human chorionic gonadotropin (may stimulate estrogen production from ovary), Onset is usually within 4 weeks after last menstrual period; peaks around 9 weeks gestation, Continue
Pathophysiology
A. Not fully understood, but thought to be related to the placenta, not the fetus.
B. Clinical course follows levels of human chorionic gonadotropin (may stimulate estrogen production from ovary), Onset is usually within 4 weeks after last menstrual period; peaks around 9 weeks gestation, 60% resolves by the end of first trimester; 91% resolves by 20 weeks gestation, can happen any time of day |
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Term
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Definition
| Hyperemesis gravidarum occurs is 0.3-1%, ersistent vomiting, more than 5% weight loss, ketonuria, electrolyte abnormalities, and dehydration, Complications may include peripheral neuropathy and Wernicke’s encephalopathy, Less common in older women, multiparous women, and smokers which is contributed to smaller placental volumes in these mothers |
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Term
| Nausea and vomiting occurs in 50% of pregnancies, Nausea alone occurs in an additional 25% |
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Definition
| Women with twins and hydatidiform moles with higher levels of HCG, Vitamin B6 deficiency (theoretical risk determined from use of Vitamin B6 to treat symptoms) |
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Term
| Pharmacological treatments for N/V in pregnancy include |
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Definition
| Pyridoxine/doxylamine, Antihistamines, Phenothiazines, Dopamine antagonists, 5-HT receptor antagonists (Recent studies show conflicting data regarding the incidence of birth defects associated with the use of ondansetron during pregnancy), |
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Term
| CAM treatment (alternative therapy) for N/V of pregnancy |
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Definition
| Ginger extract, acupuncture |
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Term
| Corticosteroid maternal use in 1st trimester |
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Definition
| (Do NOT use in first trimester due increased incidence of cleft palate) |
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Term
| Preterm birth is defined as |
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Definition
| Preterm birth is defined as birth between 20 and 37 weeks, Preterm birth is the leading cause of neonatal death and antenatal hospitalization |
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Term
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Definition
| Preterm labor may be caused by ascending infection, hypoxic-ischemic damage to the uteroplacental unit, chronic stress, and fetal and uterine developmental malformations, 50% of hospitalizations for preterm labor result in term delivery |
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Term
| Risk Factors preterm labor |
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Definition
| History of obstetrical problems including prior preterm labor or miscarriages, Lower socioeconomic status, Single mother, Unhealthy lifestyle, Multiple pregnancy, Maternal age < 18 years old |
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Term
| Pharmacologic management of preterm labor |
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Definition
| Antenatal corticosteroids for fetal lung maturation for preterm labor between 24 and 34 weeks gestation. Lowers risk of respiratory distress syndrome, NEC, and intracranial hemorrhage.--dexamethasone, betamethasone; Magnesium sulfate for fetal neuroprotection when anticipated birth is before 32 weeks gestation, |
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Term
| Tocolytics for preterm labor |
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Definition
| Tocolytics – do not increase favorable neonatal outcomes, but may allow time for administration of corticosteroids and magnesium when indicated. May be used for up to 48 hours--Beta adrenergic agents (terbutaline), Calcium channel blockers, NSAIDS |
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Term
| PROM only occurs with preterm labor T or F |
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Definition
| PROM may occur both as a preterm and term condition. |
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Term
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Definition
| PROM which is defined as spontaneous rupture of membranes before 37 weeks gestation. |
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Term
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Definition
| Prolonged PROM is PROM > 24 hr and has increased risk of ascending infection. 50-75% of women deliver within a week of PROM. |
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Term
| Potential fetal complications of PROM include: |
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Definition
| Potential fetal complications include: umbilical cord compression, cord prolapse, sepsis, and stillbirth. |
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Term
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Definition
| Inflammatory process is usually present. Thought to be due to cytokines., Infection -Microbes are present in 30-50% of amniotic fluid samples, Endotoxins or hydrolytic enzymes may lead to cascade that causes the rupture of membranes, Membrane strength and stretch, genetic component |
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Term
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Definition
Administer antenatal corticosteroids and GBS prophylaxis if indicated to mother, Broad spectrum antibiotics are considered standard of care for the short-term benefits. A common regimen is ampicillin and erythromycin x 7days
Amoxicillin/clavulanate is NOT recommended due to a statistically significant increase in the incidence of NE, Tocolytics are not recommended and only used to allow for the 1st course of corticosteroids and/or transfer to a higher level of care |
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Term
| 3 types Diabetes in pregnancy |
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Definition
| Diabetes in pregnancy can occur as part of a history of type I diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM), or as a new onset of gestational diabetes mellitus (GDM) |
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Term
| Maternal complications of diabetes in pregnancy |
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Definition
| Hypertension and pre-eclampsia, Cesarean section, Excessive weight gain, Risk for future T2DM |
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Term
| Fetal complications of diabetes in pregnancy |
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Definition
| Macrosomia, Neonatal hypoglycemia, Hyperbilirubinemia, Shoulder dystocia |
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Term
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Definition
| Administer 50 g oral glucose solution, If the screening threshold exceeds 135-140 mg/dL at 1 hour, a 3 hour oral glucose tolerance test (100 g) |
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Term
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Definition
| Insulin lispro and aspart may be provide better control than regular insulin, ypical starting dose is 0.7-1 units/kg/day, Glyburide and metformin are being utilized with increasing frequency, ACOG (2013) states oral therapy may be considered first-line therapy, recent meta-analysis showed that glyburide treatment was inferior to both metformin and insulin and that metformin plus insulin, when needed, may result in better control, |
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Term
|
Definition
| Glyburide dose = 2.5-20 mg per day in divided doses. Doses up to 30 mg/day have been required. Avoid in patients with sulfa allergy. |
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Term
|
Definition
| Metformin dose = 250 mg once daily. Titrate weekly to maximum daily dose of 2,500 mg divided two to three times daily |
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Term
| T1DM and T2DM and pregnancy |
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Definition
| Patients with pre-pregnancy requirements of 75-100 units/day may require high doses and/or more frequent administration during the 2nd and 3rd trimesters, Insulin requirements may increase up to 3 fold during the 3rd trimester |
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Term
| Postpartum management of diabetes in pregnancy |
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Definition
| Pregnancy-induced insulin resistance ends with delivery of the placenta, Sliding scale insulin may be used until a consistent maternal diet is resumed, Patients with T1DM and T2DM may resume their insulin regimens at one-half of the pre-delivery dose, Patients with GDM should be tested for T2DM 6 weeks post delivery |
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Term
| Congenital heart disease (CHD) |
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Definition
| 5T’s account for the majority of lesions = transposition, TAPVR, tet, tricuspid atresia, truncus |
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Term
| Central cyanosis and shock results from CCHD in several scenarios: |
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Definition
| Significant right-to-left shunting across the ductus arteriosus alters pulmonary blood flow or contributes to heart failure. Closure of the ductus arteriosus prevents systemic blood flow (HLHS, TAPVR, TA, etc.) or pulmonary to systemic mixing of oxygenated blood (transposition). |
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Term
| the most common form of CCHD in the United States is |
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Definition
| Tetralogy of fallot is the most common form of CCHD in the United States (~40%), ransposition of the great arteries (~20%), total anomalous pulmonary venous return (~6%), truncus arteriosus (~5%), and tricuspid atresia (~5%) account for a large percentage of cases. |
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Term
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Definition
| Opening between right and left ventricle, Results in shunting of oxygenated blood primarily from the left to the right side, Pre-operative management--Diuretics to reduce fluid overload, digoxin to increase inotropy, ACE inhibitors for afterload reduction. |
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Term
| Post-operative management urgical repair: Ventricular septal defect closure |
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Definition
| Management of low cardiac output syndrome, Hypertension occurs commonly after septal defect closure, Arrhythmias can occur (ventricular), Diuretics to reduce fluid overload, vasodilators for hypertension, Many patients will not need long-term pharmacotherapy, Aspirin may be required if foreign material used to close septal defect. |
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Term
| A positive screen for CCHD includes |
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Definition
| A positive screen includes: SpO2 < 90% OR SpO2 < 95% in both upper and lower extremities on three measurements each one hour apart OR SpO2 difference > 3% between upper and lower extremities. 76.5 % sensitive and 99.9% specific for CCHD, Positive screens should be followed by echocardiography. |
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Term
| PGE1 dosing for ductal dependent lesions |
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Definition
| If the ductus is known to be large, the initial dose is 0.01 mcg/kg/min. f the ductus is restrictive or the status of the ductus is unknown, the initial dose is 0.05 mcg/kg/min, max 0.1; . |
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Term
| The major complications of prostaglandin E1 infusion |
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Definition
| he major complications of prostaglandin E1 infusion include apnea, hypotension, and tachycardia (all dose-dependent). Decomposition after initiation of prostaglandin E1 may indicate the presence of CHD with pulmonary venous or left atrial obstruction (obstructive TAPVR, D-type transposition). |
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Term
| Normal MAP of preterm neonates |
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Definition
| Mean arterial blood pressure (MAP) equal to gestational age in weeks has been used commonly in practice and trials, despite a lack of published evidence evaluating this threshold |
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Term
| First line treatment for hypotension in neonates |
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Definition
| Volume replacement with normal saline 10 mL/kg is a common first line therapy. Appropriate intervention in the setting of hypovolemia or distributive shock (i.e., sepsis). Inappropriate intervention in the setting of cariogenic shock, Normal saline preferred over albumin in neonates due to equivalent efficacy and fewer pulmonary complications. |
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Term
| Second line treatment for hypotension in neonates |
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Definition
| Dopamine commonly utilized as second line therapy, Appropriate in the setting of distributive shock with decreased vascular tone.uperior to dobutamine with regard to increasing MAP. Equivalent to epinephrine with regard to increasing MAP. Epinephrine adverse effects include increases in heart rate, plasma lactate, and blood glucose. |
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Term
| First line treatment for cariogenic shock in neonates |
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Definition
| Dobutamine should be considered as first line therapy in the setting of caridogenic shock, Superior to dopamine with regard to right ventricular output and cerebral blood flow, Of note, trials of milrinone in preterm infants have failed to show clinical benefits. Further understanding of the PK/PD of this agent in preterm neonates is necessary to define the role of milrinone in the treatment of cardiogenic shock. |
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Term
| Drug used for vasopressor resistant hypotension in neonates |
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Definition
| Hydrocortisone utilized for vasopressor resistant hypotension, Reduces vasopressor requirement (dose and duration). Inferior to dopamine as primary pharmacologic therapy. |
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Term
| The role of the PDA in hypoperfusion |
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Definition
| The role of the PDA in hypoperfusion should be considered (see previous section for treatment guidance). Treatment with indomethacin is discouraged in the setting of active or recent hydrocortisone therapy due to the high risk of spontaneous intestinal perforation (~12%) when indomethacin and corticosteroids are utilized concurrently. |
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Term
|
Definition
| Increased pulmonary blood flow may result in pulmonary edema, increased oxygen and ventilatory requirements, and possibly chronic lung disease (CLD, Decreased systemic blood flow (systemic steal) may result in brain injury (intraventricular hemorrhage [IVH] and/or periventricular leukomalacia), gastrointestinal injury (necrotizing enterocolotis and/or spontaneous intestinal perforation [SIP]), and renal dysfunction. Chronic compensation for decreased systemic blood flow and increased preload from pulmonary over circulation may lead to heart failure. |
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Term
| T or F The incidence of persistent PDA decreases with increasing gestational age. |
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Definition
| F The incidence of persistent PDA increases with decreasing gestational age. |
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Term
| Mechanism of ibuprofen and indomethacin for PDA closure |
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Definition
| ndomethacin and ibuprofen constrict the ductus arteriosus through inhibition of prostaglandin synthesis via COX inhibition. COX facilitates conversion of arachidonic acid to PGG2. PGG2 is subsequently converted to PGH2 which is converted to PGF2α, PGE2, PGI2, or TXA2. |
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Term
| Mechanism of acetaminophen for PDA closure |
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Definition
| Acetaminophen may constrict the ductus arteriosus through inhibition of prostaglandin synthesis via POX inhibition. POX facilitates conversion of PGG2 to PGH2. |
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Term
| Prophylactic therapy used to target premature infants at a high risk for persistent PDA and to prevent early complications associated with the PDA (specifically, IVH). |
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Definition
| Indomethacin Regimens utilized for prophylaxis range from 0.1-0.2 mg/kg IV q12-24hrs x 3-6 doses initiated at < 6-24 hours of life. The most common regimen is 0.1 mg/kg IV q24h x 3 doses initiated at < 6 hours of life. Prophylactic indomethacin significantly reduces the frequency of PDA ligation (5% vs. 11%) and severe IVH (9% vs. 14%) in neonates born at < 1250 grams. Prophylactic indomethacin does not impact the incidence of chronic lung disease or alter long-term neurodevelopmental outcome. |
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Term
| Prophylactic ibuprofen lysine for PDA |
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Definition
| Prophylactic ibuprofen significantly reduces the frequency of PDA ligation (2% vs. 4%). Prophylactic ibuprofen does not significantly impact the frequency of severe IVH (8% vs. 10%). |
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Term
| Efficacy of indomethacin and ibuprofen for early symptomatic therapy in the first 24-96 hours of life |
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Definition
| ndomethacin and ibuprofen have equal efficacy during this time period (~75% closure rates). Of note, ibuprofen appears to increase the risk of CLD compared to indomethacin or placebo. |
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|
Term
| Late symptomatic PDA therapy occurs after 96 hours of life |
|
Definition
| The efficacy and optimal doses of indomethacin and ibuprofen in this time period have not been well described. Dose escalation of indomethacin guided by serum concentrations increases efficacy compared to standard therapy, Pharmacokinetic analysis of the maturation of ibuprofen elimination in older neonates suggests a similar approach. |
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|
Term
| Adverse effects indomethacin for PDA |
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Definition
| ndomethacin decreases blood flow to the brain, kidneys, and gastrointestinal tract during rapid infusion. Decreased urine output and increased serum creatinine are common adverse effects. An increased risk of SIP occurs when indomethacin is given concomitantly with corticosteroids (~12% rate of SIP compared to 1-2% with either therapy alone). Decreased platelet aggregation raises concerns for bleeding, although this adverse effect has not been demonstrated in clinical trials. |
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Term
| Adverse effects ibuprofen for PDA |
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Definition
| Ibuprofen has less impact on end organ blood flow during infusion. In randomized trials, ibuprofen has less impact on urine output and serum creatinine compared to indomethacin. The incidences of other adverse effects are not well defined. |
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|
Term
| Adverse effects acetaminophen for PDA |
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Definition
| he most concerning adverse effect of acetaminophen is liver toxicity. CYP2E1 metabolizes acetaminophen to the toxic NAPQI. The activity of CYP2E1 has not yet been quantified in preterm neonates, nor has the capacity for glutathione conjugation should NAPQI generation occur. |
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Term
| Adverse effects of surgical ligation for PDA |
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Definition
| Surgical ligation should be avoided in early management due to increased rate of CLD in a clinical trial of prophylactic ligation. A higher incidence of neurosensory impairment has also been reported after PDA ligation in observational trials (reflecting a higher degree of illness/immaturity or a direct toxicity of ligation). The risk of post-operative cardiorespiratory decompensation decreases with late ligation (> 4 weeks of age). However, chylothorax, pneumothorax, and recurrent laryngeal nerve injury are relatively common adverse effects (up to 67%). |
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Term
| Persistent pulmonary hypertension (PPHN) in newborns |
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Definition
| Persistent pulmonary hypertension (PPHN) describes failure of normal pulmonary vascular adaptation after birth characterized by elevated pulmonary vascular resistance. Affected neonates fail to establish adequate oxygenation and may develop multiorgan dysfunction. Advances in postnatal management have decreased mortality from approximately 34% to < 10%. Advances in postnatal management have decreased mortality from approximately 34% to < 10%. The most common underlying diagnosis is MAS, followed by idiopathic disease. |
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Term
|
Definition
| he mortality rate for neonates with PPHN is < 10%. However, survivors of PPHN are at increased risk of developmental delay (2%), motor disability (6%), and hearing deficits (11%). |
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Term
| Risk factors for PPHN in newborns |
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Definition
| MAS primarily occurs in the setting of postterm delivery (> 41 weeks gestation). However, any intrauterine stress may lead to passage of meconium in utero; therefore, chronic asphyxia and infection are common comorbidities. Idiopathic PPHN may coincide with antenatal medication exposures including NSAIDs and SSRIs. |
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Term
| Supportive therapies for PPHN |
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Definition
| Antibiotics vital for pneumonia. Surfactant therapy is useful in the setting of RDS or MAS. Sedation supports ventilator synchrony and decreases oxygen consumption. Vasopressor therapy may be utilized to increase systemic vascular resistance in an effort to reduce ductal shunting (dopamine, norepi), After administration of 100% oxygen, inhaled nitric oxide (iNO) represents the primary pulmonary vasodilator therapy for neonates with PPHN. |
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Term
| potential adjunctive therapy for PPHN |
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Definition
| sildenafil, a PDE5 inhibitor. Improves oxygenation and survival in patients refractory to iNO. Recently approved in intravenous form. Most common adverse effect is systemic hypotension, which can be avoided by slow infusion (3 hours) of the IV loading dose. AND milrinone, a PDE3 inhibitor. Improves oxygenation in patients refractory to iNO. Particularly useful in the setting of impaired left ventricular function. Most common adverse effect is systemic hypotension. Loading doses not commonly used in neonates, which delays the onset of action. |
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Term
| less common adjunctive therapy for PPHN |
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Definition
epoprostenol (PGI2). Intravenous therapy is generally avoided in neonates due to profound systemic hypotension. The intravenous dosage form may be nebulized and given via conventional mechanical ventilation. However, the alkaline solution may irritate the airway and delivery of a precise dose is impossible. ALSO bosentan, an endothelin receptor antagonist.
1. Oral only. Not commercially available as a liquid preparation. Most commonly utilized in settings without access to iNO. RCT ongoing examining bosentan as adjunctive therapy. |
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|
Term
| Most common pathogens EONS |
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Definition
| Group B streptococcus (GBS) and E. coli are the predominant organisms. The rate of EONS is inversely related to the birth weight of the newborn |
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Term
| Urine and surface cultures are recommended for EONS T or F |
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Definition
| F Urine and surface cultures are not recommended for EONS |
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Term
|
Definition
| CRP must be drawn at least 12 hours after birth to allow the inflammatory response to occur and increase values (>10 mg/L). PCT samples must be collected before 4 hours of life and exceed 2 ng/mL to indicate the presence of EONS. Both tests are especially useful in recognizing non-septic newborns, although PCT is more specific for bacterial sepsis and in some reports has a positive predictive value over 90% when appropriate cutoff values are used. |
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Term
|
Definition
| Prevention of colonization or infection of maternal genitourinary tract reduces the incidence of EONS. Penicillin, ampicillin, or cefazolin for > 4 hours before delivery is recommended for all pregnant women colonized with GBS. Vancomycin should be utilized in the presence of a serious penicillin allergy. |
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Term
|
Definition
| Initial drugs of choice should be ampicillin or penicillin and an aminoglycoside such as gentamicin. Routine use of broad spectrum agents (e.g. cefotaxime) is associated with development of resistant gram-negative bacteria and increased risk of invasive candidiasis. When available, positive blood culture results may allow targeted therapy. Empiric antibiotic therapy can be stopped in 2-3 days if cultures are negative and clinical and laboratory markers of sepsis remain normal. The length of antibiotic treatment is somewhat controversial. While traditionally treatment course has been for 7-10 days, treatment for > 5 days has been associated with death and necrotizing enterocolitis. Treatment strategies using < 5 days of antibiotics have not undergone rigorous clinical trials; however, one small trial utilized procalcitonin as a marker of sepsis resolution allowing early discontinuation of antibiotics without adverse consequences. |
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Term
| Late Onset Neonatal Sepsis (LONS) |
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Definition
| Late Onset Neonatal Sepsis (LONS) involves infection occurring at greater than 72 hours to 7 days (definition varies by publication). |
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Term
| Most common organism LONS |
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Definition
| The most common organism is coagulase negative staphylococcus, typically accounting for over 50% of LONS episodes, Other common pathogens are Staphylococcus aureus, gram-negative bacteria, and fungal infections. Common pathogens and resistance patterns vary widely by unit. |
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Term
|
Definition
| Factors that compromise skin integrity such as extreme prematurity, skin wounds (e.g. surgery), or intravenous lines predispose neonates to LONS, especially with coagulase negative staph aureus (CONS). Delayed enteral feedings promotes colonization of the GI tract with pathogenic gram-negative bacteria and fungi. Prolonged and/or broad spectrum antibiotic use predisposes neonates to LONS with gram-negative organisms, often having problematic resistance patterns. Invasive fungal infections should be suspected in patients with multiorgan failure, persistent hyperglycemia, and/or thrombocytopenia. These symptoms will not resolve despite appropriate, broad spectrum antibacterial therapy. |
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Term
| Fungal prophylaxis for neonates on antibiotics |
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Definition
| Fungal prophylaxis with fluconazole 6 mg/kg IV or PO twice weekly has been examined extensively in premature neonates. Fluconazole prophylaxis reduces the risk of invasive fungal infection, but effect size depends on baseline rate. Fluconazole prophylaxis should be reserved for units with a high baseline rate of invasive fungal infections. |
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Term
| Probiotics role with LONS/nosacomial infections |
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Definition
| Probiotics may alter gut flora but have not successfully reduced the incidence of nosocomial infection or LONS. On the other hand, early enteral feeding, especially when breast milk is used, has significantly decreased nosocomial infection rate. |
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Term
| Immune replacement therapy role with LONS/nosacomial infections |
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Definition
| Immune replacement therapy, including IVIG and GCSF, has not reduced the rate or impacted the outcome of nosocomial infection in the general premature population or those with neutropenia. |
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Term
|
Definition
| Empiric treatment should focus on the antibiotic approach that best addresses the organisms common to a particular NICU. This often involves a penicillin and an aminoglycoside. Use of cefotaxime empirically seems ill-advised because of increased resistance to this antibiotic when used frequently and inferior sensitivity pattern to aminoglycosides for organisms causing nosocomial infection. Widespread use of vancomycin has been generally discouraged; however, concerns for impaired neurodevelopment with infections due to CONS has led many to continue empiric use, Antibiotics should reach the site of infection in adequate concentrations to eradicate the offending organism (e.g. cefotaxime penetrates the CSF well so may be preferred in cases with meningitis). |
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Term
| Fungal therapy in neonates |
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Definition
| Intravenous amphotericin B and fluconazole are appropriate antifungal agents for patients with suspected or proven invasive fungal infections. For proven infection from any site, 21 days of therapy is required due to the common involvement of multiple organs including the CNS. Liposomal amphotericin B products should be avoided in neonates due to the low rate of renal toxicity with conventional products in this population and the common involvement of the kidneys in neonatal invasive fungal infection. Echinocandins – although not recommended as first line over traditional anti-fungals, evidence and PK data is emerging regarding the role of micafungin in neonates. Advantages may include improved CNS penetration, renal effects, and penetration of biofilm. |
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Term
| Bacterial meningitis is more common in the first month of life than at any other age. T or F |
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Definition
| T Neonates are at high risk for meningitis due to common exposure to pathogenic microorganisms with predilection for CNS penetration and immature host defense systems. Mortality from neonatal meningitis has decreased over the past several decades (from 50% to 10-20%). Substantial neurologic morbidity is common (~30% of survivors will have mild deficits, ~25% of survivors will have severe deficits). |
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Term
| Which common neonatal pathogens are specially equipped to penetrate the blood brain barrier. |
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Definition
| E. coli express fimbrial components that bind to glycoproteins on cerebral endothelial cells. Additionally, Citrobacter koseri evades host defenses and traverse the blood brain barrier by replicating in macrophages. Plus more. |
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Term
| T or F Blood cultures can be negative in up to 38% of infants with meningitis. |
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Definition
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Term
| T or F Damage to the CNS and blood brain barrier (e.g. asphyxia) also may increase the risk of meningitis |
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Definition
|
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Term
| Diagnosis neonatal meningitis |
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Definition
| Indicators of neonatal meningitis are similar to other populations (high protein, low glucose, high WBC/neutrophil count). However, interpretation of neonatal CSF may be complicated by concurrent pathophysiologies (e.g. IVH results in high protein levels in the CSF). Clinical signs and symptoms may include irritability (60%), seizures (60%), fever or hypothermia (60%), bulging fontanel (25%), nuchal rigidity (15%) |
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Term
| Neonatal meningitis treatment |
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Definition
| Appropriate antibiotic therapy initially requires a broad-spectrum approach until the organism is known. Drugs must be known to penetrate CSF adequately. Broad spectrum coverage may include a combination of penicillin + aminoglycoside + cefotaxime. Aminoglycosides are included despite poor CSF penetration due to synergy against GBS, In newborns antiviral coverage for HSV using acyclovir may be added to the antibacterial if there is an index of suspicion. Treatment duration varies by microorganism. Generally, GBS and Listeria meningitis are treated for 14 days, gram negative meningitis for 21 days, and HSV meningitis for 21 days intravenously followed by 6 months of suppressive therapy. |
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|
Term
|
Definition
| Initial symptoms typically include abdominal distention, bilious vomiting, and/or bloody stools. |
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|
Term
|
Definition
| Clinical signs are typical of sepsis, including apnea, bradycardia, and temperature instability (noted in Bell’s stage 1); additional acidosis and thrombocytopenia (Bell’s stage 2); and metabolic and respiratory acidosis, neutropenia, and DIC (Bell’s stage 3). |
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Term
| NEC prevention strategies |
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Definition
| NEC prevention strategies include: establishing standardized feeding guidelines, exclusive use of breast milk, reduction in antibiotic use, reduction in acid blockade, and use of probiotics alone or combined with prebiotics. The use of probiotics in the NICU is highly controversial given the benefits demonstrated in numerous, heterogeneous RCTs, but the lack of an FDA approved product in the U.S. |
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|
Term
|
Definition
| Make NPO, NEC prevention strategies include: establishing standardized feeding guidelines, exclusive use of breast milk, reduction in antibiotic use, reduction in acid blockade, and use of probiotics alone or combined with prebiotics. The use of probiotics in the NICU is highly controversial given the benefits demonstrated in numerous, heterogeneous RCTs, but the lack of an FDA approved product in the U.S. |
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|
Term
|
Definition
| The duration of therapy is 48-72 hours for suspected NEC (Bell’s stage 1), 7-10 days for definite NEC with mild illness (Bell’s stage 2A), and 14 days for definite NEC with moderate-severe illness (Bell’s stage 2B and 3). |
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|
Term
| TORCH is an acronym for a group of congenitally acquired organisms. Which are they? |
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Definition
| Toxoplasmosis, Other (specifically, Treponema pallidum, but may include Varicella-zoster virus and Parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes simplex virus (HSV). Several important viruses are missing from this group, including enteroviruses, Borrelia burgdorferi (Lyme disease), and human immunodeficiency virus (HIV). All may cause fetal loss, intrauterine growth retardation, and/or newborn infection. |
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Term
| TORCH viruses are spread from ? |
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Definition
| Transplacental spread is the most common way the traditional TORCH viruses are spread from an infected mother’s blood. |
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Term
| Classic symptoms of specific congenital infections should lead to testing for one or more TORCH organism |
|
Definition
| Toxoplasmosis = diffuse intracranial calcifications, hydrocephalus, chorioretinits, mononuclear CSF pleocytosis, Syphilis = skeletal abnormalities, pseudoparalysis, rhinits, maculopapular rash, Rubella = cataracts, glaucoma, pigmentary retinopathy, radiolucent bone disease, sensorineural hearing loss, CMV = periventricular intracranial calcifications, microcephaly, thrombocytopenia, HSV = mucocutaneous vesicles, CSF pleocytosis, thrombocytopenia, elevated liver transaminases, conjunctivitis |
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Term
| Toxoplasmosis treatment neonates |
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Definition
| Toxoplasmosis is treated with pyrimethamine and sulfadiazine supplemented with leucovorin x 1 year. CBC including platelet counts should be monitored periodically throughout therapy. |
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|
Term
| Syphilis treatment neonates |
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Definition
| Syphilis is treated with intravenous penicillin G x 10 days. |
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|
Term
| Rubella treatment neonates |
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Definition
| Rubella is treated with supportive care. |
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|
Term
|
Definition
| CMV is treated with intravenous ganciclovir or oral valgancyclovir x 6 weeks. A minimum of 2-4 weeks of parenteral therapy is recommended in preterm infants with symptomatic, end-organ disease. CBC including platelets counts should be monitored periodically throughout therapy. |
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Term
|
Definition
| HSV is treated with intravenous acyclovir x 14 days for SEM disease and x 21 days for CNS or disseminated infection. Guidelines recommend 20 mg/kg IV q8h for all infants, although new literature suggests interval adjustment based on maturity. Following intravenous therapy, oral suppressive therapy is initiated x 6 months. Infants with ocular involvement should receive a topical ophthalmic drug (1% trifluridine, 0.1% iododeoxyuridine, or 3% vidarabine) as well as parenteral therapy. Urine output and SCr should be monitored during intravenous therapy and CBC including platelets should be monitored periodically throughout IV/PO therapy. |
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Term
| neuroprotection in the setting of hypoxia-ischemia |
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Definition
| Numerous pharmacologic strategies have been examined for neuroprotection in the setting of hypoxia-ischemia. All have demonstrated promise in preclinical studies and are currently being examined in Phase 1-3 clinical trials. Xenon gas, Magnesium sulfate, Allopurinol, Melatonin, Erythropoietin or darbepoetin, Topiramate |
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|
Term
| What adverse effects have been associated with greater exposure to pain and stress in the NICU. |
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Definition
| . Decreased brain growth and development at term equivalent age, poorer cognitive and motor function at 18 months of age and altered spontaneous brain activity at school age have been associated with greater exposure to pain and stress in the NICU. |
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Term
| Pain meds for neonatal intubation |
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Definition
| Fentanyl and remifentanil are both acceptable agents for analgesia during endotracheal intubation. Remifentanil produces superior intubation conditions and fewer circulatory changes compared to morphine. |
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Term
| Sedatives for ET intubation in neonates? |
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Definition
| No sedatives have data supporting use for endotracheal intubation in the preterm population. Midazolam produces hypotension with bolus dosing leading to desaturations and cardiopulmonary resuscitation in randomized controlled trials. Propofol has highly variable pharmacokinetic parameters in neonates and produces profound arterial hypotension in preterm neonates. Ketamine is a promising option with efficacy compared to placebo in a small randomized controlled trial. Further studies are required. Vagolytic agents (generally, atropine) and muscle relaxants (generally, rocuronium) should be considered as adjunctive therapies to further optimize conditions during intubation. |
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Term
| T or F The routine use of continuous sedatives or analgesics for ventilated preterm infants is not recommended. |
|
Definition
|
|
Term
| Midazolam for ventilated neonates? |
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Definition
| A pilot randomized controlled trial of midazolam versus morphine versus placebo demonstrated a high incidence of severe IVH, PVL, or death in midazolam treated neonates. |
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Term
| Dexmedetomidine for ventilated neonates? |
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Definition
| Dexmedetomidine has promising preliminary data suggesting efficacy with limited adverse effects. Additionally, dexmedetomidine holds promise as a neuroprotective agent in the neonatal population. Further investigation is warranted. |
|
|
Term
| morphine vs fentanyl for ventilated neonates |
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Definition
| Currently, morphine is a most widely accepted approach for preterm neonates who demonstrate clinical signs of pain or agitation during mechanical ventilation. Fentanyl has not been adequately examined in clinical trials to justify widespread use in preterm neonates. Concerns exist regarding the impact of early exposure to opioids on the developing brain. |
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Term
| Postoperative pain in neonates |
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Definition
| Postoperative analgesia should be provided as long as pain assessment tools document ongoing pain. Continuous infusion and intermittent morphine have both been used successfully in this setting. Intravenous acetaminophen reduces the required dose of morphine in infants after non-cardiac surgery. The impact of this reduction on outcome requires further investigation. |
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Term
|
Definition
| Meconium plug syndrome occurs when meconium passage is delayed causing bowel obstruction in neonates. This syndrome is relatively benign and generally improves with the water-soluble contrast enema used to diagnose it. In rare cases, refractory meconium plug syndrome requires consideration of further pharmacologic or surgical management. Meconium plug syndrome occurs when the infant fails to pass meconium within 24 hours after birth. |
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Term
|
Definition
| Meconium is black, tarry stool that accumulates in utero composed of intestinal epithelial cells, mucus, amniotic fluid, bile, and water. |
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Term
| Risk factors meconium plug? |
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Definition
| preterm birth and maternal diabetes. Additionally, maternal magnesium treatment may further increase risk (decreasing release of acetylcholine resulting in myoneural depression). Cystic fibrosis and Hirschsprung’s disease may initially present as meconium plug syndrome. |
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Term
| Oral or rectal acetylcysteine for meconium plug syndrome |
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Definition
| Acetylcysteine reduces the viscosity of mucoproteins in meconium by cleaving disulfide bonds. Concentration is generally 10% although dilution to 1-6% has been utilized for PR administration. Dosing regimens range from 1-5 mL every 6-8 hours. |
|
|
Term
| erythropoietin (EPO) and darbepoetin for anemia of prematurity ? |
|
Definition
| Hematopoetic agents, erythropoietin (EPO) and darbepoetin, may reduce the need for late blood transfusions, but have no impact on early transfusion rates (when the majority of transfusions are needed.) Routine use of erythropoietin is NOT recommended and its use is restricted to limited indications to prevent late anemia.Concerns regarding the increased risk of retinopathy of prematurity (ROP) after EPO, particularly with early EPO use, has led many practitioners to restrict its use to isolated cases. |
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Term
| Iron supplementation is recommended by the AAP for what age infants? |
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Definition
| Iron supplementation is recommended by the AAP at 1 month of age in preterm infants who are fed human milk. Supplemental iron improves the iron status in preterm infants, but the effect on the need for RBC transfusion is unknown. The exact timing and optimal dose of iron supplementation is controversial; however, many suggest even earlier initiation than recommended by the AAP |
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Term
| The optimal thresholds and criteria for RBC transfusion in neonates? |
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Definition
| The optimal thresholds and criteria for RBC transfusion remain controversial. Recently, a temporal association between RBC transfusion and development of NEC has been observed. Also IVH. Some have theorized this may be more common with low Hgb thresholds. The ideal transfusion volume has not been elucidated. Some studies suggest larger volumes (20 ml/kg) may have greater benefits and reduce need for subsequent transfusions relative to lower volumes (5-10 ml/kg) |
|
|
Term
| extrauterine growth restriction (EUGR). |
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Definition
| Infants born prematurely, especially very low birth weight (VLBW) and extremely low birth weight (ELBW) infants, are at high risk for extrauterine growth restriction (EUGR). |
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|
Term
| Risk factors for extrauterine growth restriction (EUGR) include: |
|
Definition
| male gender, need for mechanical ventilation on day 1 of life, chronic lung disease, history of necrotizing enterocolitis, postnatal steroid use, delayed initiation of feeding, delayed time to full feeds, and delayed return to birth weight. |
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Term
|
Definition
| Postnatal weight loss has been reported at 10-15% of birthweight, although VLBW infants (<1500 gm) may lose up to 15-20% of their birth weight and may require 2-3 weeks to regain birth weight. Goal is to achieve weight gain of at least 15 gm/kg/day once birth weight is regained. |
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|
Term
|
Definition
| Fluid amounts should be increased by 10-20 ml/kg/day as tolerated up to 120-150 ml/kg/day within the first week of life. (start 60-100, depending) |
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|
Term
|
Definition
| Lipid emulsions should be infused over 24 hours (or max 0.2 gm/kg/hr) to avoid overwhelming the premature infant’s clearance ability. |
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|
Term
| Carnitine supplementation for neonates |
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Definition
| Carnitine supplementation (10-20 mg/kg/day) to facilitate transport and subsequent oxidation of fatty acids may be considered; however, evidence to support this practice is limited. Carnitine supplementation is recommended for premature infants requiring parenteral nutrition for > 4 weeks. |
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Term
| Glucose for neonatal nutrition |
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Definition
| Serum glucoses should be measured 2-4 times daily until stabilized, then subsequently with changes in glucose infusion rates (GIRs), Hyperglycemia is defined as a serum glucose > 150 mg/dL. Insulin infusions to maximize GIRs should be avoided. If hyperglycemia occurs, GIRs should be lowered to ~4 mg/kg/min before insulin should be considered. Early initiation of protein has been shown to enhance endogenous insulin production and stabilize serum glucoses. |
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Term
| Glucose in fluids neonates |
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Definition
| Preterm infants lack glycogen stores (glycogen produced only in 3rd trimester), therefore adequate exogenous provision is critical for maintaining glucose supplies. nitiation of glucose infusions should target normal endogenous production. Term infant: 6-8 mg/kg/min, Preterm infant: 4-6 mg/kg/min, Excessive GIRs (>12 mg/kg/min) are to be avoided. Excessive glucose provision leads to lipogenesis which can actually increase energy expenditure and result in carbon dioxide production and retention. This is particularly concerning in infants requiring ventilator support. |
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Term
| Calcium/phosphorus/Vitamin D AAP guidelines for neonates |
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Definition
| Calcium: 150-220 mg/kg/day, Phosphorus: 75-140 mg/kg/day, Vitamin D: 200-400 IU/day |
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|
Term
| Calcium/phosphorus ideal ratio for neonates |
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Definition
| Maintain a ratio of 1.7:1 (~2:1) of calcium:phosphorus for ideal bone mineralization. |
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Term
| Preterm infant formulas and human milk fortifiers |
|
Definition
| Preterm infant formulas are designed to provide additional calcium and phosphorus. Human milk fortifiers should be considered for additional calcium and phosphorus supplementation in breastfed infants |
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|
Term
| If evidences of osteopenia exists despite fortification start... |
|
Definition
| calcium (20 mg/kg/day) and phosphorus (10-20 mg/kg/day) should be provided. No evidence exists to support monitoring vitamin D levels, although monitoring may be considered in special circumstances (e.g., malabsorption, cholestasis). |
|
|
Term
| Iron AAP recommendations (breastfed infants or low iron formulas) |
|
Definition
| Preterm infants: elemental iron 2 mg/kg/day beginning at 1 month of age, Term infants: elemental iron 1 mg/kg/day beginning at 4 months of age |
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|
Term
| Starter “Vanilla” TPNs for preemies |
|
Definition
| Starter TPNs are pre-made stock solutions available for early initiation of fluids with protein within hours of birth for very low birth weight infants (VLBW). Goal is to provide ~ 3-4 gm/kg/day protein when initiated at normal fluid rates 80-100 ml/kg/day of a VLBW infant. Typical starter TPNs contain: 2-5% amino acids, 5-10% dextrose, calcium gluconate 2-4 gm/L in a total fluid volume of 200-250 ml. tended for use for 24-48 hours until custom parenteral nutrition can be initiated. |
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|
Term
| Enteral nutrition for neonates |
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Definition
| Enteral nutrition should be initiated within 5 days of life, sooner preferable, at 10-20 ml/kg/day and advanced by 10-20 ml/kg/day as tolerated until 150-160 ml/kg/day achieved. |
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|
Term
| Maternal vs donor breastmilk. |
|
Definition
| Exclusive feeding with breastmilk is the preferred enteral nutrition for the preterm infant. AAP recommends that donor human milk be used in preference to bovine milk (formulas) for premature infants < 1500gm when maternal milk is not available. There is no consensus on the duration of use of donor breast milk, however most transition over to formula at 1250-1500 gm |
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|
Term
|
Definition
| Donor breast milk is typically “term” milk and has been pasteurized to reduce infection risk. Pasteurization decreases the activity of many factors which may provide protection from infection and assist in gastrointestinal maturation. Processing of donor milk also reduces fat and protein content. |
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|
Term
| Premature infant formulas |
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Definition
| Premature infant formulas contain higher amounts of energy, protein, calcium and phosphorus relative to standard milk based formulas designed for term infants. |
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|
Term
| High protein infant formulas |
|
Definition
| provide enteral nutrition with a high protein:energy ratio. Designed for VLBW infants to provide 4 gm/kg/day of protein when fed at 120 kcal/kg/day. |
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|
Term
| Transitional formulas or “post-discharge”infant formulas |
|
Definition
| Transitional formulas or “post-discharge” formulas are nutritionally enriched formulas intended to transition a premature infant from preterm formula to a term infant formula. They may also be used to supplement breast feedings to provide extra nutrients. Transitional formulas are enriched with protein, minerals, vitamins and trace elements to support “catch up” growth. AAP supports use of transitional formula or multi-nutrient supplemented breastmilk post-discharge for up to 12 months. |
|
|
Term
|
Definition
| Most human milk fed to the VLBW infant is either maternal milk produced after day 14 of lactation (lower in protein) or is donor milk provided by mothers of term infants (low in protein). The protein content is always insufficient for VLBW infants. Human milk fortifier added to enhance the caloric, protein, and mineral content of human milk to meet nutritional goals. iming of fortification varies within practice. Some centers fortify as soon as a total of 25 mL/day is tolerated, others wait until tolerance of 100 mL/kg/day enteral feeds, while others wait for full volume feeding |
|
|
Term
| Energy requirements of preterm infants |
|
Definition
| Parenteral: 80-100 kCal/kg/day Enteral: 120-140 kCal/kg/day |
|
|
Term
|
Definition
| Apnea is believed to occur as the result of physiologic immaturity of the respiratory control center as well as immature airway structures which are easily collapsible. Severe apnea resulting in bradycardia or desaturation is believed to result in altered cerebral perfusion leading to long term complications including periventricular leukomalacia (PVL) and cerebral palsy (CP), and neurodevelopmental impairments (NDI) and BPD. Apnea may have a genetic link, theorized to be related to adenosine receptor differences. |
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|
Term
| Resolution of apnea of prematurity |
|
Definition
| Severe apnea resulting in bradycardia or desaturation is believed to result in altered cerebral perfusion leading to long term complications including periventricular leukomalacia (PVL) and cerebral palsy (CP), and neurodevelopmental impairments (NDI) and BPD. |
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|
Term
| Caffeine citrate for apnea |
|
Definition
| Caffeine citrate has been shown to be effective for the prevention of apnea in at risk infants before symptoms of apnea present. Although the latest Cochrane review did not find evidence to support caffeine prophylaxis, several recent trials of early caffeine therapy support this role in the prevention of apnea. |
|
|
Term
| Advantages of caffeine citrate |
|
Definition
| Caffeine citrate is the preferred agent for management of apnea. It has fewer adverse effects and a higher therapeutic index than theophylline or aminophylline. An additional advantage of caffeine is its long half-life (~ 100 hrs) which allows for once-daily dosing. The Caffeine for Apnea of Prematurity (CAP) trial showed that in addition to effectively managing apnea, caffeine reduced the incidence of BPD and long term neurodevelopmental impairments (NDI). The effect on NDI is theorized to be the result of a protective effect on hypoxic induced white matter injury. |
|
|
Term
| Doxapram for apnea of prematurity |
|
Definition
| Doxapram is a non-specific stimulant of the central nervous system and is indicated for apnea refractory to methyxanthine therapy. Its use is generally limited due to its numerous adverse effects as well as the need for a continuous infusion. The parenteral formulation also contains benzyl alcohol which further limits its use. |
|
|
Term
| Despite advances in the management of premature infants, the prevalence of BPD has remained unchanged. T or F |
|
Definition
|
|
Term
|
Definition
| Defines BPD in all premature infants with oxygen requirement > 28 days of life, but assigns a severity of BPD based upon duration and amount of oxygen required at 36 weeks PMA or 56 days of life if born > 32 weeks GA. Mild BPD (FIO2 < 0.21) Moderate BPD (FIO2 0.22-0.29) Severe BPD (FIO2 > 30% or CPAP/mechanical ventilation) |
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Term
| Caffeine therapy for ventilated premature infants |
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Definition
| Although controversial at this time, there is growing evidence that early use of caffeine (< 3 DOL) in ventilated preterm infants < 29 weeks may be more effective in reducing the incidence of death or BPD compared to late initiation. Further large, RCT are needed to confirm this. |
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Term
| Vitamin A vitamin A for BPD |
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Definition
| itamin A is essential for organized growth and differentiation of epithelial cells. It is theorized to be beneficial in cell regeneration after injury in infants at risk for BPD (<1000–1250 gm) and has resulted in small but significant reductions in oxygen requirements at 1 month or 36 weeks PMA in randomized controlled trials. |
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Term
| The anti-inflammatory and antimicrobial effects of macrolides (azithromycin, clarithromycin, and erythromycin) have been evaluated for prophylaxis in the prevention of BPD |
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Definition
| Azithromycin - Despite lack of efficacy in the prevention of BPD observed in large randomized controlled trials, sub-group analysis and pooled data analysis from azithromycin trials have shown reductions in BPD rates in preterm infants. Further trials to identify the target population, optimal dosing regimen and to assess for toxicity are recommended before adoption into clinical practice. Clarithromycin – A single center, randomized controlled trial observed reduction in BPD rates with clarithromycin treatment of ureaplasma positive infants, however, larger trials are needed to validate these results and control for confounding variables. Erythromycin has not been shown to impact BPD rates, likely due to poorer lung epithelial and macrophage penetration and reduced efficacy against ureaplasma. |
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Term
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Definition
| Postnatal corticosteroids increase surfactant production, reduce inflammation, and enhance lung epithelial differentiation. Despite concerns regarding the risk of early exposure and poor neurodevelopmental outcomes (cerebral palsy), steroids have been shown to be beneficial in reducing BPD in high risk infants. Widespread use of steroids to prevent BPD is contraindicated at this time; however, treatment for ventilator dependent BPD may be warranted (see treatment below). lthough hydrocortisone is theorized to have less of an impact on neurodevelopment than dexamethasone, clinical trials have failed to show a reduction in BPD rates. |
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Term
| Inhaled nitric oxide (iNO) for BPD? |
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Definition
| Evidence does not support the early use of iNO to prevent BPD; however, limited evidence supports its use iNO role after day of life 7. NIH consensus panel reviewed all existing data and recommended against the use of iNO for early or late use as prophylaxis or rescue therapy. |
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Term
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Definition
| Sildenafil has been shown to improve alveolar growth, preserve lung angiogenesis, and decrease pulmonary vascular resistance which may be beneficial in preventing BPD, however, it has only been investigated in the management of established BPD. Concerns exist regarding the increased risk of ROP. |
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Term
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Definition
| Dexamethasone – Infants at high risk of BPD who require prolonged ventilation may benefit from dexamethasone. The AAP Committee on the Fetus and Newborn recommends that high doses of dexamethasone (0.5 mg/kg/day) show no benefit over lower doses (< 0.2 mg/kg/day) and has been associated with significant short and long term adverse effects. When utilized, the duration of therapy should be minimized (<10 days). Hydrocortisone – Limited data , Inhaled corticosteroids have been examined in several small randomized controlled trials which demonstrate no significant effect on BPD, Diuretics (intravenous, enteral, or inhaled) have been shown to transiently improve pulmonary mechanics and oxygenation, however no evidence exists to support prolonged use. bronchodilators no evidence exists to support chronic use in BPD. |
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Term
| Risk factors for RDS include: |
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Definition
| prematurity, white race, male gender, hypothermia, perinatal asphyxia, sepsis. Negative risk factors: prolonged rupture of membranes and antenatal steroids. |
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Term
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Definition
| InSurE strategy is an approach of Intubation, prophylactic surfactant, and rapid Extubation to CPAP. effective in reducing the need for mechanical ventilation and BPD in larger infants (>1250 gas). Both the InSurE strategy and the early CPAP/selective surfactant strategy has been shown to reduce risk of BPD and mortality relative to prophylactic surfactant followed by mechanical ventilation. |
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Term
| Synthetic vs animal surfactant |
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Definition
| Equivalent outcomes were shown in comparison trials of lucinactant to animal derived products (poractant and beractant) with no significant differences in neonatal morbidities. The prospect of surfactant aerosolization in combination with early CPAP holds great promise for the future. Aerosolized surfactant therapy will make the use of animal derived surfactants nearly obsolete. |
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Term
| Retinopathy of prematurity (ROP) |
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Definition
| Retinopathy of prematurity (ROP) is a disorder of the developing retina in preterm infants that can potentially lead to blindness. Retinopathy of prematurity can be viewed as an arrest of normal retinal neuronal and vascular development followed by a pathological compensatory mechanism resulting in aberrant vascularization of the retina. |
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Term
| Risk factors for developing ROP include: |
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Definition
| oxygen, poor growth, prolonged need for parenteral nutrition, hyperglycemia and insulin, fungal infection, late bacteremia, and genetics (Caucasian> black; male > female). |
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Term
| 2 therapies that can increase ROP? |
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Definition
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Term
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Definition
| Caffeine citrate supplementation has been shown in the Caffeine for Apnea of Prematurity (CAP) Trial to reduce the incidence of ROP. |
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Term
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Definition
| Oral propranolol has been shown to be effective in reducing the progression of ROP; however, the risk of serious adverse effects limits its use. Trials are underway to evaluate the benefits of topical therapy. |
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Term
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Definition
| Bevacizumab (Avastin) is an anti-VEGF drug which blocks the effects of VEGF on the retina (neovascularization). Intravitreal injections of bevacizumab have been compared to conventional laser surgery for infants with stage 3+ ROP. Bevacizumab was shown to have a significant benefit in infants with zone 1 and zone II disease. |
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Term
As a member of your institution’s Pharmacy and Therapeutics Committee, you are asked to evaluate the available surfactant products and select one for adding to the institution’s formulary. Which state- ment best justi es your selection?
A. The selected product has the highest content of surfactant protein B (SP-B).
B. The selected product has the most rapid onset of action.
C. The selected product has been shown to reduce the need for mechanical ventilation.
D. The selected product has been shown to reduce the risk of bronchopulmonary dysplasia (BPD). |
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Definition
Answer: D
Although all of the stated properties of a surfactant product would potentially be advantageous, a product that affects long-term outcomes (e.g., reducing the incidence of BPD) would be the most beneficial. Surfactant protein B is known to be a critical component of endogenous surfactant; however, exogenous products with higher SP-B content have not been shown consistently to result in better long-term outcomes (Answer A is incorrect). A rapid onset of action may result in the ability to wean oxygen more rapidly and a shorter duration of mechanical ventilation, but these short-term improvements have not translated into long-term benefit (e.g., decreased length of hospital stay, reduced risk of BPD, reduced mortality) (Answers B and C are incorrect). In fact, a very rapid onset may increase the risk of adverse effects (e.g., pneumothorax) if vigilant adjustments are not made to the patient’s mechanical ventilator settings shortly after surfactant administration. |
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Term
When comparing the literature evaluating the ef - cacy of various treatments for patent ductus arte- riosus (PDA), you nd a case series of 10 patients treated with acetaminophen at an average age of 10 days and a retrospective study of 160 patients treated with indomethacin at an average age of 11 days. The reported closure rates after the rst course of therapy were 100% with acetaminophen and 72% with indomethacin. Which best explains the dispar- ity in closure rates between the two therapies?
A. Heterogeneity between the two study populations.
B. Inadequate statistical power.
C. Publication bias.
D. Superior efficacy of acetaminophen. |
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Definition
Answer: C
Case reports and case series are known to be subject to publication bias because of the desire to report positive results and to be less likely to report inconclusive or negative results—thus, a case series reporting the 100% efficacy of acetaminophen for PDA closure. Heterogeneity between comparator groups can also lead to disparate results; however, in this example, it is not the most likely cause because most neonates treated for PDA are premature, the timing of the treatments was similar in the two publications, and both publications examined the efficacy of a first course of treatment— all major factors that could confound the results if they differed between the groups (Answer A is incorrect). An inadequate statistical power results in the failure to find a difference between treatments when a difference actually exists and often results from an inadequate sample size. This concept applies to a single study comparing two or more treatment groups, but it cannot be applied when comparing results from different studies (Answer B is incorrect). Superiority of one treatment to another can be concluded only from head-to-head comparison studies designed to detect this difference. Superiority cannot be proved in studies designed to find noninferiority, nor can it be concluded from comparing the results of separate publications (Answer D is incorrect). |
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Term
You work in a neonatal intensive care unit (NICU) that is considering implementing a protocol using indomethacin for intraventricular hemorrhage (IVH) prophylaxis. Which outcome is best sup- ported by results of clinical trials and best justi es such a protocol?
A. Improved long-term neurodevelopmental outcomes.
B. Reduced mortality.
C. Reduced incidence of PDA.
D. Reduced incidence of severe IVH. |
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Definition
Answer: D
Clinical trials have shown that indomethacin prophylaxis for IVH reduces the incidence of severe IVH (i.e., grades III and IV). For this reason, some NICUs have implemented an IVH prophylaxis protocol using indomethacin in premature neonates. The trials also showed a reduced incidence of PDA; however, this finding does not justify the use of indomethacin for prophylaxis. Many PDAs will close spontaneously, so the benefit of preventing them by exposing neonates to a drug that ultimately may not have been needed does not justify the risk of adverse effects from this intervention (Answer C is incorrect). The trials have not shown a reduction in mortality or improved neurodevelopmental outcome (Answers A and B are incorrect). Some clinicians would argue that this lack of long-term benefit suggests that indomethacin prophylaxis should not be routinely used. |
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Term
A 750-g girl born at 26 weeks’ gestational age was initiated on caffeine citrate for the prevention of apnea of prematurity. Initially, an intravenous load- ing dose of 20 mg/kg/dose was given, followed by a maintenance dose of 8 mg/kg/dose every 24 hours. One week later, the neonate is having more epi- sodes of apnea. Other causes of apnea (e.g., sepsis) were ruled out, so the caffeine maintenance dose was increased to 10 mg/kg/dose every 24 hours. The physician is concerned about potential toxicity because the dose is at the higher end of the recom- mended range. Which monitoring value would be most indicative of caffeine toxicity?
A. Heart rate.
B. Renal function.
C. Serum concentration.
D. Signs of gastroesophageal re ux. |
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Definition
Answer: A
Tachycardia is a well-known adverse effect of both theophylline and caffeine therapy. Unlike theophylline, caffeine has a wide therapeutic range, and serum concentrations have not been shown to correlate well with efficacy or toxicity. Therefore, routine monitoring of caffeine serum concentrations is not recommended (Answer C is incorrect). Methylxanthine therapy has been associated with decreased lower esophageal sphincter tone, which, some investigators have theorized, increases episodes of gastroesophageal reflux. However, a causative relationship has not been clearly defined, and the more likely cause of reflux episodes in a preterm neonate is immaturity of the lower esophageal sphincter and poor GI motility (Answer D is incorrect). Physiologic gastroesophageal reflux is common in this patient population. Methylxanthine therapy is not known to be nephrotoxic (Answer B is incorrect). |
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Term
A 2500-g boy is born at 35 weeks’ gestational age to a mother whose hepatitis B surface antigen (HBsAg) status is unknown. Which is the best recommendation regarding postexposure prophylaxis for this neonate?
A. Give the hepatitis B vaccine within 12 hours of
birth; administer hepatitis B immune globulin (HBIG) within 7 days if the maternal HBsAg is positive.
B. Give the hepatitis B vaccine and HBIG within 12 hours of life.
C. Give the hepatitis B vaccine birth dose; HBIG is not indicated.
D. Wait for the results of the maternal HBsAg test before giving the hepatitis B vaccine or HBIG |
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Definition
Answer: A
According to the AAP recommendations, a neonate with a birth weight of at least 2000 g who is born to a mother with an unknown HBsAg status should receive the hepatitis B vaccine within 12 hours of birth. Administration of HBIG can be delayed for up to 7 days after birth, awaiting the mother’s test results. If, at that time, the mother’s status is still unknown or is positive, HBIG should be administered (Answers C and D are incorrect). Administration of both agents within 12 hours of birth is recommended if the mother’s HBsAg is positive or for neonates with a birth weight less than 2000 g who are born to mothers whose HBsAg status is unknown (Answer B is incorrect). |
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Term
A 2100-g girl born at 34 weeks’ gestational age devel- ops seizures 2 weeks after birth. Serum electrolytes and glucose are normal. Vesicular lesions are noted on the tongue and buccal mucosa. In addition to anticonvulsant therapy, ampicillin, cefotaxime, and acyclovir are initiated for suspected meningitis. Two days later, the herpes simplex virus (HSV) poly- merase chain reaction (PCR) from the cerebrospinal uid (CSF) is positive and the bacterial cultures are negative, so ampicillin and cefotaxime are discon- tinued. Serum alanine aminotransferase (ALT) has remained normal. Which is the best recommenda- tion regarding this neonate’s antiviral therapy?
A. Continue intravenous acyclovir 20 mg/kg/dose every 8 hours for 7 days.
B. Continue intravenous acyclovir 20 mg/kg/dose every 8 hours for 10 days.
C. Continue intravenous acyclovir 20 mg/kg/dose every 8 hours for 14 days.
D. Continue intravenous acyclovir 20 mg/kg/dose every 8 hours for 21 days. |
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Definition
Answer: D
This neonate’s presentation is consistent with disseminated herpes disease because she has lesions in her mouth and positive herpes PCR from the CSF. According to the AAP treatment algorithm, intravenous acyclovir should be administered for at least 21 days for disseminated or localized CNS disease (Answers A, B, and C are incorrect). Near the end of 21 days of treatment, the CSF PCR should be repeated to confirm the clearance of HSV. If the PCR is negative, acyclovir can be discontinued after 21 days of therapy. If the PCR is positive, acyclovir should be continued for an additional 7 days, after which the CSF PCR should be rechecked; acyclovir should be continued until the PCR is negative. Shorter courses of acyclovir are recommended for preemptive therapy without proven disease (10 days) and for SEM disease (14 days). |
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Term
A 450-g boy who was born at 24 weeks’ gestational age received three doses of surfactant for respiratory distress syndrome (RDS). Because of his very low birth weight and severity of RDS, the medical team would like to initiate therapy to prevent progression to BPD. According to clinical trials, which is most likely to prevent BPD in premature neonates at high- est risk?
A. Azithromycin.
B. Indomethacin.
C. Inhaled nitric oxide. D. Vitamin A. |
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Definition
Answer: D
There are several biologically plausible theories for the prevention of BPD by various drug therapies. Because Ureaplasma spp. have been isolated from the tracheal aspirates of neonates with BPD, it has been theorized that eliminating that organism will decrease the incidence of BPD. Clinical trials have not shown this benefit in all neonates at high risk of BPD (Answer A is incorrect). When examining a specific subset of neonates who were proved to be colonized with Ureaplasma, azithromycin initiated within 3 days of birth did reduce the incidence of BPD. A PDA with a left-to-right shunt increases pulmonary blood flow and is a risk factor for developing BPD; therefore, theoretically preventing a PDA would decrease the risk of BPD. This has not been shown to be true with indomethacin or ibuprofen prophylaxis or with PDA treatment (Answer B is incorrect). In animal models, inhaled nitric oxide has been shown to reduce lung inflammation and promote lung growth that would theoretically decrease the risk of BPD. Clinical trials of human neonates have not shown this benefit (Answer C is incorrect). Vitamin A has been shown to reduce the incidence of BPD in clinical trials. Although used in some NICUs, vitamin A has not become a standard of care within neonatology, given concerns about frequent intramuscular injections in extremely premature neonates as well as a lack of evidence showing a long-term benefit in improving neurodevelopmental outcomes. |
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Term
When benchmarking against similar NICUs, your unit nds a higher than average rate of necrotizing enterocolitis (NEC). The medical team would like to develop a protocol to standardize care of neonates at highest risk of developing NEC. Which interven- tion is most likely to be bene cial in reducing the incidence of NEC in high-risk neonates?
A. Initiate trophic feeding at 7 days of age. B. Administer oral probiotics until 34 weeks’
postmenstrual age is reached.
C. Administer oral antibiotics until full enteral
feeding is achieved.
D. Administer histamine-2 receptor antagonists
until enteral feeds are initiated. |
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Definition
Answer: B
Although oral probiotics are not considered the standard of care for preventing NEC, many studies show their efficacy of doing so. The optimal duration is unknown, but a recent study showed a benefit in neonates receiving oral probiotics until 34 weeks’ postmenstrual age. Other positive studies continued this intervention until the neonate reached term corrected age or until hospital discharge. Delaying enteral feeding has been theorized to reduce the incidence of NEC because it allows for the maturation of the GI tract, and cases of NEC rarely occur in neonates who have not been fed enterally. Overall, clinical studies have not shown this benefit (Answer A is incorrect). Administration of oral antibiotics has been shown to reduce NEC, but the benefit of this intervention is outweighed by the risk of colonization with resistant organisms, which is an outcome that has occurred in clinical trials (Answer C is incorrect). Administration of histamine-2 receptor antagonists has been associated with an increased incidence of NEC. Increasing the pH of the GI tract allows the overgrowth of bacteria, so this intervention should be avoided (Answer D is incorrect). |
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Term
A 39 weeks’ gestational age boy was born to a mother with a history of sickle cell disease treated with chronic hydrocodone plus acetaminophen. He is admitted to the NICU for monitoring for with- drawal symptoms. In the past 12 hours, his Finnegan scores are 10, 8, 9, and 11 (evaluated every 3 hours). Which recommendation would be best for managing this neonate?
A. Initiate clonidine.
B. Initiate morphine.
C. Initiate phenobarbital.
D. Treatment is not indicated because withdrawal
symptoms are not severe enough. |
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Definition
Answer: B
Three consecutive scores using the Finnegan tool of 8 or higher or two consecutive scores of 12 or higher are indicative of the need for pharmacologic management of withdrawal (Answer D is incorrect). An opioid agent (e.g., morphine, methadone) is the treatment of choice for managing withdrawal symptoms from hydrocodone exposure. Clonidine is generally reserved for adjunctive therapy with morphine (Answer A is incorrect). Phenobarbitalmonotherapyisnotaseffectiveasmorphine or methadone for managing opioid withdrawal because it does not treat the GI symptoms or seizures (Answer C is incorrect). Phenobarbital is often used as first-line monotherapy for withdrawal from non-opioid agents. |
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Term
A new drug for the treatment of hypertension was shown to be teratogenic in rat models, but there are no reports of its use in pregnant women. Which characteristic is most likely to allow the drug to cross the placental barrier into the fetal circulation? A. High molecular weight (greater than 500 Da). B. Hydrophilicity.
C. Low protein binding. D. Long half-life. |
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Definition
Answer: C
Drug characteristics associated with transport across the placenta include low molecular weight (less than 500 Da), lipophilicity, and low protein binding (Answers A and B are incorrect). A prolonged half-life may increase the time during which the drug can cross the placenta but, without the other characteristics, does not alone promote drug transport across the placenta (Answer D is incorrect). Although transfer across the placenta does not necessarily predict a drug’s teratogenicity, it is required for the drug to cause fetal harm. |
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Term
You are working with the neonatologists in your unit to develop a treatment protocol for NEC. Which organism is it most important to cover with your rec- ommended empiric antibiotic regimen?
A. Candida albicans.
B. Escherichia coli.
C. Group B Streptococcus. D. Listeria monocytogenes. |
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Definition
| Group B Streptococcus, E. coli, and Listeria are all common pathogens causing early neonatal sepsis (Answers C and D are incorrect). C. albicans can cause late-onset neonatal sepsis, especially in neonates with specific risk factors (e.g., history of abdominal surgery, long-term total parenteral nutrition, Candida colonization of several sites) (Answer A is incorrect). However, because E. coli is most likely to be associated with NEC, it should be covered by an empiric antibiotic regimen— most commonly with an aminoglycoside or a third- or fourth-generation cephalosporin. |
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Term
A breastfeeding mother presents with newly diagnosed hypertension. The medical team asks you to suggest ways to minimize neonatal risks and expo- sure from the treatment while still allowing the mother to breastfeed. Which recommendation is most likely to achieve this goal?
A. Choose a drug with a relatively long half-life. B. Choose a drug that is not highly protein bound. C. Advise the mother to feed when her serum
concentrations of the drug are likely to be low-
est during the day.
D. Select the lowest effective treatment dose. |
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Definition
| Drugs that are not highly protein bound or that have long half-lives are more likely be transferred into and accumulate in breast milk than are those that are highly protein bound or have shorter half-lives, thus increasing the potential for neonatal exposure and adverse effects (Answers A and B are incorrect). In theory, breastfeeding when maternal serum concentrations are likely to be the lowest during the day would minimize exposure to the neonate. However, in reality, this is not very feasible because most neonates feed at least six to eight times a day; thus, maternal serum concentrations would not be low at most of the feeding times (Answer C is incorrect). Maternal serum concentrations do have a significant effect on the concentration of drug in the breast milk, so treating the mother with the lowest effective dose would result in a lower concentration and therefore decrease overall drug exposure to the neonate. |
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Term
A boy born at 42 weeks’ gestational age has pulmo- nary hypertension secondary to meconium aspira- tion syndrome. Sedation, vasopressor therapy, and mechanical ventilation are initiated as supportive therapy. Which is the best initial intervention to lower his pulmonary pressures?
A. Beractant.
B. Epoprostenol.
C. Inhaled nitric oxide. D. Vecuronium. |
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Definition
Answer: C
Inhaled nitric oxide is the treatment of choice for PPHN. Beractant may be a reasonable adjunctive therapy because meconium aspiration can result in endogenous surfactant inactivation, but it is not a pulmonary vasodilator (Answer A is incorrect). Similarly, vecuronium may be added as supportive therapy if the patient does not respond adequately to sedation and pain management, but it will not produce pulmonary vasodilation (Answer D is incorrect). Epoprostenol is a pulmonary vasodilator, but it is considered an additive therapy if the response to nitric oxide is inadequate. Its more invasive route of administration (i.e., intravenous vs. inhaled), risk of systemic hypotension, and relative lack of supporting literature compared with inhaled nitric oxide make epoprostenol a second-line therapy for PPHN (Answer B is incorrect). |
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Term
A 660-g boy born by vaginal delivery at 24 weeks’ gestational age had a poor respiratory effort, grunting, and retractions at birth and required intubation with 100% oxygen in the delivery room. Apgar scores were 4 at 1 minute, 6 at 5 minutes, and 8 at 10 minutes. Maternal obstetric history was signi cant for preterm labor, tobacco smoking, and no prenatal care. Because of the lack of prenatal care and a precipitous delivery, no antenatal steroids were administered. An initial blood gas showed pH 7.1, Pco2 73, Po2 71, and base de cit 10. Ampicillin and gentamicin are ordered for possible early sepsis. A chest radiography is ordered, and the result is pending. After transfer to the NICU at 15 minutes of life, he continues to require 100% oxygen and high peak inspiratory pressures to maintain adequate oxygen saturations. Which is the best recommenda- tion regarding surfactant therapy for this patient?
A. Surfactant therapy should be withheld pending radiographic ndings con rming RDS.
B. Prophylactic surfactant therapy should be administered because this neonate is at high risk of devel-
oping RDS.
C. Early surfactant rescue therapy should be administered because this neonate’s presentation is consis-
tent with RDS.
D. Surfactant rescue therapy should be delayed to avoid overtreatment of this neonate, whose symptoms
of RDS may resolve spontaneously. |
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Definition
Answer: C
This patient is at high risk of RDS because of extreme prematurity, lack of antenatal steroids, and male sex, so surfactant replacement therapy is indicated. Respiratory distress syndrome is usually diagnosed by clinical signs and symptoms. Although radiographic findings may be consistent with RDS, they are not required to make a diagnosis (Answer A is incorrect). Because this patient is at high risk of RDS, prophylactic surfactant administration is a reasonable consideration; however, the time interval for administration (at 10–30 minutes of life, ideally before positive pressure ventilation) has been missed, and the patient already has signs of RDS (Answer B is incorrect). Prophylactic therapy for all high-risk neonates results in overtreatment because not all of these neonates will progress to RDS. Early surfactant rescue therapy has been shown to reduce chronic lung disease and mortality compared with delayed rescue therapy (Answer D is incorrect). Because this patient has risk factors for RDS, has signs consistent with RDS, and early rescue therapy has benefits over delaying surfactant administration, early surfactant rescue therapy (within 2 hours of birth) should be administered. |
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Term
The patient in case 1 had a modest response after two doses of surfactant, but he remains intubated and mechanically ventilated, requiring 30% oxygen 24 hours after birth. Because of his prematurity and con- tinued need for invasive respiratory support, the medical team would like to initiate a therapy to prevent the development of BPD. Which medication would be best to recommend?
A. Azithromycin. B. Caffeine.
C. Dexamethasone. D. Poractant. |
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Definition
Answer: B
Very few interventions, other than preventing preterm birth, have been shown efficacious in preventing BPD. Several pharmacologic interventions theoretically should prevent BPD, but clinical trials have not confirmed this benefit. Macrolide antibiotics (e.g., azithromycin) have been studied for the prevention of BPD because colonization with Ureaplasma in the neonate has been associated with the development of BPD. However, clinical trials did not show a reduced incidence of BPD when all high-risk neonates were given macrolide prophylaxis (Answer A is incorrect). A subset of neonates with a positive PCR result for Ureaplasma who were treated with azithromycin were shown to have lower rates of BPD, but this evidence is limited. Treatment of RDS with surfactant replacement therapy theoretically would prevent BPD; however, clinical trials have not shown this long-term benefit (Answer D is incorrect). Early dexamethasone therapy (within 96 hours of birth) has been shown to significantly decrease the incidence of BPD. Unfortunately, long-term follow-up studies showed an increased risk of cerebral palsy and developmental delay. Until further studies investigating lower doses and optimal timing of dexamethasone are completed, early use of systemic corticosteroids for the prevention of BPD should not be recommended (Answer C is incorrect). Caffeine initiated within 3 days of age has been shown to reduce BPD without negative effects on neurodevelopmental outcomes. |
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Term
The patient from cases 1 and 2 is now 36 weeks’ postmenstrual age. During his NICU stay, he was treated for RDS and Klebsiella sepsis. He has had several failed extubation attempts and remains intubated, requir- ing 30%–40% oxygen to maintain adequate oxygenation and prevent frequent desaturations. His chest radiograph reveals diffuse haziness with lung hyperin ation consistent with chronic lung disease. Which is the best treatment to recommend for his severe BPD?
A. Albuterol 2 puffs by endotracheal tube every 6 hours.
B. Aldactazide 3 mg/kg/day by mouth divided every 12 hours.
C. Fluticasone 2 puffs by endotracheal tube every 12 hours.
D. Furosemide 1 mg/kg/dose intravenously as needed for signs of pulmonary fluid overload. |
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Definition
Answer: D
In clinical practice, long-term therapies for the treatment of BPD are often prescribed. However, there is no evidence to support the use of scheduled bronchodilators, inhaled corticosteroids, or scheduled diuretics in this patient population. None of these therapies has been shown to provide a long-term benefit such as decreased need for mechanical ventilation, length of hospital stay, or mortality in infants with BPD (Answers A, B, and C are incorrect). Symptomatic treatment with as-needed bronchodilators for acute bronchospasm or intermittent doses of diuretic for pulmonary edema provide short- term relief of symptoms without chronically exposing the infant to drugs that have significant potential to cause adverse effects. Trial of a short course of low-dose dexamethasone may be warranted at this time to facilitate extubation, given that extubation has failed on several previous attempts. |
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Term
The patient in cases 1–3 is now 37-3/7 weeks’ postmenstrual age. After prolonged intubation and mechani- cal ventilation, he was extubated 10 days ago to nasal CPAP with 21% oxygen. He has received caffeine since shortly after birth but has had no apneic spells since extubation. Which is the best recommendation regarding his methylxanthine therapy?
A. Discontinue caffeine, and monitor the patient for apnea recurrence.
B. Taper the caffeine dose over the next 2 weeks, and discontinue it if no apnea occurs during the taper. C. Switch to theophylline because its shorter half-life will allow for a faster wean off therapy.
D. Continue caffeine until discharge, and then plan to taper over several weeks as an outpatient. |
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Definition
Answer: A
Apnea of prematurity typically resolves by 34–36 weeks’ postmenstrual age. Most institutions would not discharge an infant home on methylxanthines if he were still having apnea because the risk of sudden infant death is a concern. If apnea has resolved, continuing methylxanthine therapy as an outpatient exposes the infant to possible adverse effects without benefit (Answer D is incorrect). Because this patient has been apnea free since extubation and is older than 36 weeks’ postmenstrual age, methylxanthine therapy can be discontinued. There is no need to taper caffeine (Answer B is incorrect). Because caffeine has a long half-life, the infant should be monitored for 5–7 days to ensure that he remains apnea free after the drug has been sufficiently cleared from the body. Switching to theophylline offers no advantages; rather, it has several disadvantages, most notably a narrower therapeutic index, which increases the risk of adverse effects and necessitates the monitoring of serum drug concentrations (Answer C is incorrect). |
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Term
A 750-g girl was delivered prematurely at 26 weeks’ gestational age secondary to maternal chorioamnion- itis. Soon after birth, she had symptoms of RDS and subsequently received two doses of surfactant. Despite some improvement in her symptoms, she remained intubated and mechanically ventilated. Caffeine was initiated. She also received three doses of indomethacin according to the NICU’s IVH prophylaxis protocol. At 12 days of age, she became tachycardic and had a widened pulse pressure; also, a systolic murmur was heard. She became hypotensive, so a dopamine continuous infusion was initiated, and the dose was titrated to 20 mcg/kg/minute. Her total daily uid intake was 120 mL/kg/day. Her chest radiograph revealed pul- monary edema, and her ventilator support had to be increased. An echocardiogram (ECHO) was ordered and showed a moderate PDA with left-to-right shunting. Which is the best therapy to recommend for the management of this patient’s PDA?
A. Acetaminophen 15 mg/kg/dose intravenously every 6 hours x 3 days because indomethacin failed. B. Furosemide 1 mg/kg/dose intravenously every 12 hours until pulmonary edema is resolved; then
recheck ECHO.
C. Indomethacin 0.2 mg/kg/dose x 1 dose; then 0.25 mg/kg/dose every 12 hours x 2 doses for late symp-
tomatic treatment.
D. Restrict fluid intake to 100 mL/kg/day, and recheck ECHO in 2 days. |
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Definition
Answer: C
The need for and the timing of pharmacologic closure of the PDA are somewhat controversial. Early therapy (within 3 days of life) is likely to result in overtreatment because many PDAs will spontaneously close. Most clinicians would agree that a PDA should be closed when it manifests with symptoms of significant respiratory deterioration or heart failure. This patient’s status has worsened significantly enough to warrant PDA closure with indomethacin. Although indomethacin prophylaxis has been shown to decrease the incidence of symptomatic PDA, it is not 100% effective in doing so, and it is not generally recommended for this indication. Failure of indomethacin prophylaxis to prevent a symptomatic PDA does not indicate the need for a different agent to treat the PDA (Answer A is incorrect). Limited evidence supports the efficacy of acetaminophen for PDA closure, but this agent is not routinely recommended as first-line therapy. Fluid restriction can be adequate to facilitate PDA closure, especially early on; however, it is unlikely to be effective as the sole intervention in an extremely premature neonate. In addition, further fluid restriction in a hypotensive patient whose fluid intake is already limited may worsen hypotension and end-organ perfusion (Answer D is incorrect). Similarly, furosemide administration could worsen hypotension. Furosemide has also been shown to increase renal prostaglandin production; therefore, it is postulated that this agent can contribute to the patency of the ductus arteriosus (Answer B is incorrect). |
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Term
A 3700-g boy was born at 38 weeks’ gestational age by cesarean section for maternal preeclampsia. In the delivery room, he required positive pressure ventilation for a lack of spontaneous respiratory effort. Apgar scores were 2, 5, and 7 at 1, 5, and 10 minutes, respectively. He is intubated and transferred to the NICU, where his initial blood gas shows a severe respiratory acidosis. His oxygen saturation is 87% on an Fio2 of 100%. Despite efforts to optimize his oxygenation and mechanical ventilation, he remains cyanotic with an oxygenation index of 30. An urgent ECHO revealed no structural cardiac defects other than a PDA with a right-to-left shunt, tricuspid valve regurgitation, and an elevated right-sided pressure by Doppler ow. A diagnosis of persistent pulmonary hypertension of the newborn (PPHN) is made. Inhaled nitric oxide at 20 ppm, vasopressors, and sedation are initiated with minimal improvement in oxygenation. Systolic blood pressure remains lower than the estimated pulmonary pressures by ECHO, despite dopamine 20 mcg/kg/ minute and dobutamine 20 mcg/kg/minute. A repeat ECHO con rms that the pulmonary pressures remain high, and there is signi cant right ventricular dysfunction. Which drug is the best therapy to add to this patient’s regimen?
A. Bosentan.
B. Epoprostenol. C. Milrinone.
D. Sildenafil |
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Definition
Answer: A
The bacterial pathogens associated with NEC include Enterobacteriaceae (e.g., E. coli, Klebsiella spp.), Enterococcus spp., Staphylococcus spp., Clostridium, and P. aeruginosa, among others. There is no evidence to support the superiority of one antibiotic regimen to others. Selection of the specific agents should be based on the most likely infecting organisms and the individual NICU’s susceptibilities. Very broad-spectrum agents (e.g., imipenem) should be avoided unless susceptibility patterns warrant their use (Answer D is incorrect). A combination of ampicillin and metronidazole lacks the necessary gram-negative coverage (Answer B is incorrect). Moreover, the addition of anaerobic coverage is often reserved for cases of NEC with intestinal perforation and/or peritonitis. Piperacillin/tazobactam provides anaerobic coverage, so adding metronidazole is unnecessary (Answer C is incorrect). Piperacillin/tazobactam is not generally recommended as a first-line agent because its enterococcal coverage is not as good as that of ampicillin or vancomycin, and its extended gram- negative coverage may not be needed (unless dictated by an individual NICU’s susceptibility patterns). |
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Term
A 4200-g girl is born by cesarean section at 39 weeks’ gestational age to a mother with a history of genital HSV infection and visible genital lesions at delivery. The neonate appears well and begins feeding within a few hours after birth. Surface cultures for HSV are sent at 24 hours of age and are subsequently reported as positive. Intravenous acyclovir is initiated. Cerebrospinal uid for HSV PCR and serum ALT are sent. The neonate remains asymptomatic. The HSV PCR is negative, and the ALT is within normal limits. Which is the best recommendation regarding this patient’s management?
A. Discontinue acyclovir.
B. Continue acyclovir 60 mg/kg/day intravenously in three divided doses to complete 10 days of
treatment.
C. Continue acyclovir 60 mg/kg/day intravenously in three divided doses to complete 14 days of
treatment.
D. Switch to oral acyclovir 300 mg/m2/dose every 8 hours to complete 10 days of treatment. |
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Definition
Answer: C
There is no evidence-based treatment algorithm for PPHN; therefore, the place in therapy for the various available drugs is unclear. Neonates with PPHN who are treated with inhaled nitric oxide have been found to have increased PDE-3 activity. Milrinone is a PDE-3 inhibitor that has been shown to augment the pulmonary vasodilation of inhaled nitric oxide. In addition, milrinone has inotropic and lusitropic effects that would be expected to improve right ventricular function. There is a risk of systemic hypotension with milrinone therapy, but this can be decreased by avoiding a loading dose. Epoprostenol produces pulmonary vasodilation through the prostacyclin pathway; however, it is not a pulmonary- selective vasodilator, and systemic hypotension is likely (Answer B is incorrect). Of the targeted therapies for PPHN, the prostacyclin analogs have the most published data in neonates. The absorption of oral medications (i.e., sildenafil and bosentan) is unlikely to be reliable because of the severity of this patient’s illness and the reduced perfusion to the GI tract (Answer A is incorrect). Sildenafil administered as an intermittent intravenous infusion has been reported in neonates with PPHN, but data are insufficient regarding its optimal dosing to recommend it routinely (Answer D is incorrect). |
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Term
A 4200-g girl is born by cesarean section at 39 weeks’ gestational age to a mother with a history of genital HSV infection and visible genital lesions at delivery. The neonate appears well and begins feeding within a few hours after birth. Surface cultures for HSV are sent at 24 hours of age and are subsequently reported as positive. Intravenous acyclovir is initiated. Cerebrospinal uid for HSV PCR and serum ALT are sent. The neonate remains asymptomatic. The HSV PCR is negative, and the ALT is within normal limits. Which is the best recommendation regarding this patient’s management?
A. Discontinue acyclovir.
B. Continue acyclovir 60 mg/kg/day intravenously in three divided doses to complete 10 days of
treatment.
C. Continue acyclovir 60 mg/kg/day intravenously in three divided doses to complete 14 days of
treatment.
D. Switch to oral acyclovir 300 mg/m2/dose every 8 hours to complete 10 days of treatment. |
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Definition
Answer: B
The AAP has published a treatment algorithm for asymptomatic neonates born to mothers with visible genital HSV lesions. Because this neonate’s surface cultures were positive for HSV, acyclovir cannot be discontinued (Answer A is incorrect). The neonate’s CSF HSV PCR is negative, and her serum ALT is normal, thus ruling out CNS involvement and disseminated disease. Therefore, she should receive therapy with intravenous acyclovir for presumed infection without proven disease. Therecommendeddurationforthisindicationis10days.If shehaddevelopedskinlesions,shewouldbetreatedwith intravenous acyclovir for 14 days (Answer C is incorrect). Oral acyclovir is recommended for suppressive therapy after intravenous acyclovir treatment of SEM, CNS, or disseminated disease, but it is not indicated for the initial treatmentofHSVinfection(AnswerDisincorrect). |
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Term
A 3900-g boy was born at 38 weeks’ gestational age to a mother with a history of syphilis that was adequately treated 3 months before delivery. The mother has shown no signs of relapse or recurrence since treatment. Maternal syphilis rapid plasma reagin (RPR) is 1:16. In the delivery room, the neonate had some grunting and retractions. He was transferred to the NICU and initiated on ampicillin 100 mg/kg/dose intravenously every 8 hours and gentamicin 5 mg/kg/dose intravenously every 24 hours to rule out sepsis/pneumonia. Syphilis RPR was sent for the neonate, and the result was 1:64. The neonate’s symptoms resolved within 6 hours after birth, and blood cultures remained negative at 48 hours. Which is the best recommendation regarding this patient’s management?
A. Discontinue ampicillin and gentamicin. No treatment is indicated for congenital syphilis.
B. Discontinue gentamicin and continue ampicillin to complete 10 days for congenital syphilis.
C. Discontinue ampicillin and gentamicin. Give benzathine penicillin G 50,000 units/kg intramuscularly
x 1 dose for congenital syphilis.
D. Discontinue ampicillin and gentamicin. Give aqueous penicillin G 50,000 units/kg/dose intravenously
every 12 hours x 10 days for congenital syphilis. |
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Definition
Answer: D
The AAP has published a treatment algorithm for neonates born to mothers with reactive serologic tests for syphilis. Because the neonate’s RPR titer is 4-fold higher than the mother’s titer, treatment of the neonate is indicated (Answer A is incorrect). According to the algorithm, aqueous penicillin G is the treatment of choice for neonates born to mothers treated with penicillin more than 4 weeks before delivery but during the pregnancy AND if the neonate has an RPR/VDRL titer at least 4-fold higher than the mother’s titer. Ten days of penicillin G treatment is preferred, even if ampicillin was started initially, for ruling out sepsis, because the efficacy of ampicillin for treating congenital syphilis is unknown (Answer B is incorrect). Benzathine penicillin G is the recommended treatment for neonates born to mothers treated with penicillin more than 4 weeks before delivery but during the pregnancy AND the neonate has a normal physical examination and an RPR/VDRL titer less than 4-fold higher than the mother’s titer (Answer C is incorrect). In this case, the neonate’s initial respiratory symptoms most likely occurred because of transient tachypnea of the newborn rather than sepsis or pneumonia because they resolved quickly; this, in conjunction with blood cultures that are negative at 48 hours, makes it reasonabe to discontinue ampicillin and gentamicin. |
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Term
A 2600-g girl was born at 36 weeks’ gestational age to a mother in a methadone treatment program for her heroin addiction. The mother has received methadone 80 mg daily for the past 7 months and has been adherent. The neonate is admitted to the NICU for initial respiratory distress in the delivery room and for monitoring of withdrawal symptoms. Finnegan scores have been assessed every 4 hours since birth. Scores for the rst 24 hours are 4, 6, 5, 8, 7, and 8. Which is the best recommendation for the management of this neonate at risk of abstinence syndrome?
A. No pharmacologic intervention for withdrawal is currently indicated. B. Start clonidine.
C. Start methadone.
D. Start phenobarbital |
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Definition
Answer: A
This infant is at high risk of developing NAS because of in utero exposure to methadone. When using the Finnegan Scoring Tool to assess neonates at risk of withdrawal, three consecutive scores of 8 or higher or two consecutive scores of 12 or higher indicate the need for pharmacologic management of withdrawal. Lower scores may indicate mild withdrawal symptoms that should be managed with nonpharmacologic interventions (e.g., swaddling; minimal handling; reduced environmental noise; subdued lighting; frequent, small feedings). Although this neonate is not currently showing severe signs of withdrawal requiring pharmacologic intervention, she should continue to be monitored because withdrawal from methadone typically manifests on days 2–6 of age (Answer B, C, and D are incorrect). If severe withdrawal does occur, an opioid agent (e.g., morphine, methadone) is the treatment of choice. Clonidine is an effective adjunctive therapy with morphine. Phenobarbital is not as effective for monotherapy as is an opioid agent because phenobarbital does not treat the GI symptoms or seizures. |
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Term
A 32-year-old woman is seen by her physician for symptoms of depression. She is 30 weeks pregnant and has not previously taken medication for her depression. She has chronic hypertension that is well controlled but no other signi cant medical history. Her current medications include a prenatal vitamin and methyldopa. The physician is considering three different drugs with which to treat her depression. Drug 1 is pregnancy category B. Drugs 2 and 3 are pregnancy category C. Which is the best assessment of the risk of these drugs when used in a pregnant woman?
A. Drugs 2 and 3 have a higher risk of fetal harm than drug 1.
B. Drugs 2 and 3 have the same level of risk (i.e., are equally as safe in pregnancy).
C. Drugs 1, 2, and 3 may all be acceptable options for treating this mother’s depression.
D. This mother’s depression should not be treated during pregnancy because the risks outweigh the
benefit. |
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Definition
Answer: C
The current FDA pregnancy categories do not provide a scale of risk (i.e., the risk of harm does not increase from category A to category X). These pregnancy categories only provide information on whether evidence that exposure to the drug during pregnancy, in animals and/ or humans, has been associated with fetal harm (Answer A is incorrect). For example, the main difference between category B and category C is that animal studies have not shown fetal harm for drugs categorized as B, whereas animal studies have shown harm for drugs in category C. It is important to recognize that harm in animals does not always translate to the same effect in humans. Neither category contains information regarding the safety in pregnant humans. The current categories also do not consider the severity, treatability, or reversibility of fetal harm, so drugs in the same category can cause very different degrees of harm—what is the same within the category is the type of evidence supporting whether harm occurs (Answer B is incorrect). In addition, the pregnancy categories address only the potential risk to the fetus from drug exposure. They do not consider the risk to the fetus or mother if the mother’s condition is untreated (Answer D is incorrect). Overall, drugs from any category, except for category X, may be reasonable treatment options for a pregnant woman. When determining which drug to use in a pregnant woman, the clinician must evaluate many factors, including the specific teratogenic/fetotoxic effects, their incidence (if known), and the mother’s medical history (i.e., current diagnoses and medications) and must weigh the potential benefits of treatment against the risks to the fetus from drug exposure as well as the risk of not treating. For these reasons, the current pregnancy categories are not very helpful clinically, and a new system has been proposed. |
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Term
A 2-month-old boy who was born at term and has no signi cant medical history is being breastfed. His mother is prescribed tobramycin ophthalmic solution 2 drops in both eyes every 4 hours for 10 days for a severe conjunctivitis. Which is the best recommendation regarding breastfeeding during this mother’s treatment?
A. Therapy should be switched to an agent with a higher molecular weight.
B. Tobramycin ophthalmic can be used, but breast milk should be discarded during therapy (i.e., “pump
and dump”) and formula used.
C. Tobramycin ophthalmic can be used, and breastfeeding can continue without modi cations. D. Tobramycin ophthalmic can be used, breastfeeding can continue, and the infant should receive probiotics. |
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Definition
Answer: C
When assessing whether a drug is safe for administration during lactation, several factors must be considered— the molecular weight, protein binding, half-life, and oral bioavailability of the drug can affect the transfer of the drug into the breast milk and the subsequent oral absorption by the infant; the maternal serum concentration can affect the concentration in the breast milk; potential adverse effects of the drug in the infant; and the risk-benefit of continuing breastfeeding during therapy. The likelihood of significant maternal serum concentrations of tobramycin after ophthalmic administration is very low. Similarly, tobramycin’s oral bioavailability is very low; therefore, the amount of drug available to the infant and the extent to which it is absorbed will not lead to a significant exposure (Answer A is incorrect). Because tobramycin exposure is likely to be low from breastfeeding, GI flora should not be altered; therefore, probiotics would not be of benefit (Answer D is incorrect). “Pumping and dumping,” which eliminates all the benefits of breastfeeding, is generally not recommended (Answer B is incorrect). |
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Term
R.C. is a 9-year-old girl who presents to the emer- gency department (ED) with complaints of generalized abdominal pain and malaise for the past 3 days, which has steadily increased during the past 24 hours such that she cannot tolerate oral intake and has a decreased appe- tite. She will undergo a workup for acute appendicitis. Physical examination reveals a heart rate (HR) of 133 beats/minute, a respiratory rate (RR) of 20 breaths/min- ute, and a blood pressure (BP) of 112/61 mm Hg. Weight on admission is 32 kg.
1. The ED physician consults you for assistance in determining the appropriate maintenance uid and rate for R.C. Which is the most appropriate recommendation?
2.
A. Dextrose 10% in 0.9% normal saline plus potassium chloride 40 mEq/L at 108 mL/hour.
B. Dextrose 5% in 0.225% normal saline plus potassium chloride 40 mEq/L at 108 mL/hour.
C. Dextrose 5% in 0.45% normal saline plus potassium chloride 20 mEq/L at 70 mL/hour.
D. Dextrose 10% in 0.45% normal saline plus potassium chloride 40 mEq/L at 70 mL/hour. |
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Definition
Answer: C
Using the Holliday-Segar method for calculating maintenance intravenous fluids, this patient should receive 72.5 mL/hour (maintenance intravenous fluids = 10 kg x 100 mL/kg + 10 kg x 50 mL/kg + 12 kg x 20 mL/kg = 1740 mL/day = 72.5 mL/hour). When choosing between Answers C and D, Answer D is incorrect because it will provide greater than maintenance requirements of dextrose. Specifically, dextrose 10% in 0.45% normal saline plus potassium chloride 40 mEq/L would provide dextrose 5.3 g/kg/day, which is greater than the 3 g/kg/day needed for maintenance. Answer A is incorrect because the rate of 108 mL/hour is around 1.5 times the maintenance rate, and the fluid choice would provide more dextrose than needed to meet maintenance requirements. Answer B is incorrect because 108 mL/ hour is 1.5 times maintenance. |
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Term
R.C. is a 9-year-old girl who presents to the emer- gency department (ED) with complaints of generalized abdominal pain and malaise for the past 3 days, which has steadily increased during the past 24 hours such that she cannot tolerate oral intake and has a decreased appe- tite. She will undergo a workup for acute appendicitis. Physical examination reveals a heart rate (HR) of 133 beats/minute, a respiratory rate (RR) of 20 breaths/min- ute, and a blood pressure (BP) of 112/61 mm Hg. Weight on admission is 32 kg. Twenty-four hours after your initial uid recom- mendation, R.C.’s laboratory values are as follows:
Fluids, Electrolytes, and Nutrition
139 6.5
104 22 23 0.9
105
The physician would like to increase the rate of the intravenous uid to be 1.5 times the maintenance rate. Which is the most appropriate recommendation?
A. Dextrose 5% in 0.45% normal saline plus
potassium chloride 10 mEq/L at 165 mL/hour.
B. Dextrose 5% in 0.45% normal saline at 105
mL/hour.
C. Dextrose 10% in 0.225% normal saline plus
potassium chloride 10 mEq/L at 105 mL/hour.
D. Dextrose 10% in 0.45% normal saline plus
potassium chloride 20 mEq/L at 165 mL/hour. |
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Definition
Answer: B
This patient’s serum creatinine is elevated, which is one sign of ongoing dehydration and a sign that the initial fluid choice was inadequate. In addition, the patient’s serum potassium is elevated to 6.5 mEq/L (normal 3.5– 5.5 mEq/L). As such, it is most appropriate to remove potassium from the intravenous fluids at this time, especially because the rate will be increasing. Answer B is correct because the rate of 105 mL/hour is 1.5 times the maintenance rate of 70 mL/hour. Answer A is incorrect because the rate of 165 mL/hour is more than 2 times the maintenance rate and would provide potassium chloride at 1.2 mEq/kg/day, which is not clinically warranted with a serum potassium of 6.5 mEq/L. Answer C is incorrect because dextrose 10% would provide too much glucose, and potassium is not needed at this time. Answer D is incorrect because dextrose 10% would provide too much glucose, and potassium is not needed at this time; further, the rate of 165 mL/hour is incorrect. |
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Term
E.B., a 16-year-old female adolescent (weight 61.3 kg), presents in the ED after a snowboarding accident with severe hypotension (BP 65/45 mm Hg). She is disori- ented, and her laboratory values point toward intravas- cular dehydration.
3. Which is the most appropriate uid to recommend for initial resuscitation?
A. Administer 25% albumin 10 mL/kg.
B. Administer dextrose 5% in 0.225% normal
saline plus potassium chloride 20 mEq/L at 95
mL/hour.
C. Administer 0.9% normal saline 20 mL/kg. D. Administer 5% albumin 50 mL/kg. |
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Definition
Answer: C
The patient presents with a severe intravascular deficit, as evidenced by the patient’s hypotension and disorientation. During the emergency phase of resuscitation, the most appropriate first-line therapy is to administer a normal saline bolus at a dose of 10–20 mL/kg. This will restore intravascular volume and perfusion. Although providing albumin and blood (colloids) may be useful, these would not be first-line therapies without a clear source of bleeding. In addition, when volume expansion is desired, 5%, rather than 25%, albumin should be used, making Answer A incorrect. Furthermore, the dose of albumin provided in Answer D is above what would typically be indicated, making Answer D incorrect. Answer B provides maintenance fluids. In the setting of severe hypotension, it is first necessary to restore intravascular volume with a bolus; thus, Answer B is incorrect. |
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Term
E.B., a 16-year-old female adolescent (weight 61.3 kg), presents in the ED after a snowboarding accident with severe hypotension (BP 65/45 mm Hg). She is disori- ented, and her laboratory values point toward intravas- cular dehydration. E.B. does not respond to the initial therapy given in the ED. An hour after her initial presentation, her abdo- men is rigid, and an emergency computed tomography (CT) scan reveals a liver laceration. Repeat laboratory tests show a hematocrit of 17% (previously 26%). Which is the most appropriate uid to recommend? A. Administer 5% albumin 10 mL/kg.
B. Administer dextrose 5% in 0.225% normal saline plus potassium chloride 20 mEq/L at 95 mL/hour.
C. Administer 0.9% normal saline 40 mL/kg. D. Administer whole blood 20–30 mL/kg. |
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Definition
Answer: D
This patient has not responded to the normal saline bolus that was given in the ED, and now, the patient has a clear sign of intra-abdominal bleeding. Administering blood will expand the intravascular volume while increasing hematocrit and the oxygen-carrying capacity of the blood, which is necessary to continue perfusing vital organs, especially during an acute trauma. Answer A is incorrect because there is now a clear source of bleeding. In addition, a dose of 10 mL/kg in the setting of severe hypotension would be insufficient to restore intravascular volume. Answer B is incorrect; this maintenance fluid would be needed after correcting the acute phase of dehydration. Similar to Answer A, simply increasing the volume of the normal saline bolus will not help correct this acute issue because there is a clear source of bleeding. |
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Term
E.H. is a 19-month-old boy with a 3-day history of vom- iting, diarrhea, and decreased urine output. He is given a diagnosis of gastroenteritis and dehydration. His current weight is 10 kg (previous weight 10.45 kg). His BP is stable on admission. Which set of physical signs and symptoms would be most expected for his severity of dehydration?
A. Anuria, absent tears, capillary re ll greater
than 8 seconds.
B. Decreased skin turgor, capillary re ll greater
than 5 seconds, slightly increased HR.
C. Normal HR, slightly dry mucosa, capillary
re ll 2 seconds.
D. Normal skin turgor, capillary re ll greater than
8 seconds, dry mucosa. |
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Definition
Answer: B
The percentage of dehydration is calculated as 4.3% [% dehydration = (10.45 kg − 10 kg)/10.45 kg x 100 = 4.3%]. Therefore, this patient would be classified as having moderate dehydration (i.e., 4%–6% dehydration for children). Signs and symptoms typically associated with moderate dehydration include slightly increased HR, normal-low systolic BP, markedly decreased urine output, 6%–10% weight loss, dry mucosa, reduced tears, deep-set eyes, decreased skin turgor, cool skin, reduced fontanelle, capillary refill of greater than 5 seconds, and irritability. Answer A is incorrect because these symptoms would be more consistent with severe dehydration. Answer C is incorrect because these symptoms would be more consistent with mild dehydration. Answer D is incorrect because the symptoms of dehydration are mixed between mild, moderate, and severe. |
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Term
E.H. is a 19-month-old boy with a 3-day history of vom- iting, diarrhea, and decreased urine output. He is given a diagnosis of gastroenteritis and dehydration. His current weight is 10 kg (previous weight 10.45 kg). His BP is stable on admission. Which is the best recommendation for correcting E.H.’s dehydration at this time? A. Dextrose 5% in 0.45% normal saline plus potassium chloride 20 mEq/L at 70 mL/hour x 8 hours, followed by dextrose 5% in 0.45% normal saline plus potassium chloride 20 mEq/L at 56 mL/hour x 16 hours.
B. Dextrose 5% in 0.45% normal saline plus potassium chloride 20 mEq/L at 19 mL/hour x 24 hours.
C. 200 mL 0.9% normal saline bolus, followed by dextrose 5% in 0.45% normal saline plus potassium chloride 20 mEq/L at 43 mL/hour x 16 hrs D. 450 mL 0.9% normal saline bolus, followed by dextrose 5% in 0.45% normal saline plus potassium chloride 20 mEq/L at 43 mL/hour x 24 hrs |
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Definition
449 mL). In addition, using the Holliday-Segar method for maintenance needs, the patient requires 1023 mL/day for maintenance. The most appropriate way to administer this is to provide one-half of the deficit over the first 8 hours and one-half over the next 16 hours. Likewise, the maintenance needs should be replaced by one-third over the first 8 hours and by two-thirds over the next 16 hours. Answer B is incorrect Answer: A
Based on 4.3% dehydration, this patient’s fluid deficit is around 450 mL (fluid deficit = 4.3% x 10.45 kg/100 = because this would only replace the deficit; it would not also provide maintenance requirements. Answer C is incorrect because a bolus is not indicated at this time (i.e., BP stable). In addition, this patient will require maintenance fluids for 24 hours rather than 16. Answer D is incorrect because a bolus is not indicated at this time (i.e., BP stable). |
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Term
S.C. is a 7-day-old term infant (weight 3.8 kg) born at 41 weeks’ gestation who will receive standard infant formula. Which enteral nutrition regimen is most appropriate for S.C. to meet his caloric needs? A. Enfamil (20 kcal/oz), 72 mL every 3 hours.
B. Similac Special Care Advance 24 (24 kcal/oz), 60 mL every 3 hours.
C. Portagen (20 kcal/oz), 72 mL every 3 hours. D. Similac PM 60/40 (20 kcal/oz), 60 mL every 3
hours. |
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Definition
Answer: A
Because the patient is a term infant who will be receiving standard enteral formula, the most appropriate choice is Enfamil. Enfamil is 20 kcal/oz, as are most standard infant formulas. Because this patient will require about 100 kcal/ kg/day to support adequate growth and development (20– 30 g/day), he will require formula at 570 mL/day. Most term neonates will feed about every 3 hours; therefore, a volume of 72 mL every 3 hours will provide the nutritional support needed. Answer B is incorrect because Similac Special Care Advance 24 is a more calorically dense formula than is used for premature neonates. Answer C is incorrect because Portagen is a special formula consisting of medium-chain fatty acids used for patients with chylothorax or chyle leaks. Answer D is incorrect because Similac PM 60/40 is a specialty formula used for infants with renal or cardiovascular problems. |
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Term
B.B. is a 6-month-old boy (weight 6 kg) with short bowel syndrome who is parenteral nutrition (PN)- dependent. On admission, his direct bilirubin is 3.2 mg/dL, and he is found to have scleral icterus. Which is the best approach to managing B.B. at this time? A. Hold PN for 48 hours.
B. Add cysteine 40 mg per gram of amino acid. C. Decrease soybean oil–based intravenous fat emulsion (IVFE) dose to 1 g/kg/day or less.
D. Add heparin 0.5 unit/mL. |
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Definition
Answer: C
Elevated bilirubin greater than 2 mg/dL in PN-dependent children is most likely caused by the development of PNALD. The exact cause of PNALD is unknown; however, it is multifactorial and is associated with prolonged use, lack of enteral nutrition, recurrent episodes of infection/sepsis, and low birth weight/ gestational age. Although many of these factors depend on one another, an independent risk factor for developing PNALD is the administration of soybean oil–based IVFE because of the presence of proinflammatory mediators, phytosterols, and omega-6 fatty acids. Although this has not been conclusively determined, expert consensus agrees that the reduction of soybean oil–based IVFE to doses of 1 g/kg/day or less may prevent and/or treat the development of PNALD. Answer A is incorrect because this patient is PN-dependent (i.e., short bowel syndrome); further, holding PN for 48 hours will unlikely result in normalization of direct bilirubin/PNALD. Answer B is incorrect because cysteine is added to neonatal PN to increase the calcium-phosphorus solubility. Answer D is incorrect because heparin is added to neonatal PN solutions to maintain line patency. |
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Term
A.J. is a 45-day-old female infant (born at term) (weight 2.3 kg) who is receiving the following par- enteral nutrition (PN) regimen (note: the PN infuses for 24 hours per day):
potassium chloride 20 mEq/L at 70 mL/hour x 8 hours, followed by dextrose 5% in 0.45% normal saline plus potassium chloride 20 mEq/L at 56 mL/hour x 16 hours.
B. Dextrose 5% in 0.45% normal saline plus potassium chloride 20 mEq/L at 19 mL/hour 24 hours.
C. 200 mL 0.9% normal saline bolus, followed by dextrose 5% in 0.45% normal saline plus potassium chloride 20 mEq/L at 43 mL/hour 16 hours.
D. 450 mL 0.9% normal saline bolus, followed by dextrose 5% in 0.45% normal saline plus potassium chloride 20 mEq/L at 43 mL/hour 24 hours.
x
x
x
Total volume Lipids (20%) Amino acids Dextrose Electrolytes
Multivitamin Trace minerals Other additives:
299 mL/day
12 mL
2.6% (7.8 g)
15.5% (46.4 g)
Potassium acetate 3.4 mEq Potassium chloride 4.1 mEq Sodium acetate 1.1 mEq Sodium chloride 5.2 mEq Sodium phosphate 2.7 mmol Magnesium sulfate 1.3 mEq Calcium gluconate 6.2 mEq 3.3 mL
0.2 mL/kg
Famotidine 0.5 mg/kg Levocarnitine 10 mg/kg
Which most accurately represents how many kilocalo- ries per kilogram per day A.J. receives from this PN? A. 213 kcal/kg/day.
B. 93 kcal/kg/day.
C. 200 kcal/kg/day. D. 87 kcal/kg/day. |
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Definition
Answer: B
Intravenous fat emulsion at 20% provides 2 kcal/mL (or 9 kcal/g), amino acids provide 4 kcal/g, and dextrose provides 3.4 kcal/g. As such, the total caloric provision of this particular PN regimen is as follows: 12 mL x 2 kcal/mL +7.8gx4kcal/g+46.4gx3.4kcal/g=213kcal.Then, accounting for the child’s weight, the total kilocalories per kilogram provided is 93 kcal/kg. Answer A is incorrect because it fails to account for the child’s weight, providing the total calories provided instead of the kilocalories per kilogram. Answers C and D are incorrect; each answer uses incorrect values to calculate calories, specifically: 12 mLx2kcal/mL+2.6x4kcal/g+15.5x3.4kcal/g=87for Answer D and, for Answer C, 87 x 2.3 = 200. Both options are incorrect and fail to use the total grams of amino acid and dextrose in the calculation. |
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Term
A 9-day-old neonate (weight 1.535 kg) with con- genital diaphragmatic hernia is currently NPO (nothing by mouth) and receiving PN. The PN for- mulation is as follows: 20% Intralipid 23 mL (3 g/ kg), TrophAmine 4% (3.5 g/kg), and dextrose 21.4% (28.7 g/day). The total volume of the PN is 134 mL, and it is infusing at a rate of 5.6 mL/hour. Which best represents the calculated dextrose infusion rate (DIR)?
A. 19.9 mg/kg/minute. B. 13 mg/kg/minute. C. 17.5 mg/kg/minute. D. 14 mg/kg/minute. |
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Definition
Answer: B
Dextrose infusion rate is measured in milligrams per kilogram per minute. The DIR in this question can be calculated in two ways:
a. 28.7 g x 1000 mg/g = 28700 mg/day ÷ 1440 minutes/
day ÷ 1.535 kg = 13 mg/kg/minute
b. 21.4 g/100 mL x 5.6 mL/hour x 1000 mg ÷ 60 minute
÷ 1.535 kg = 13 mg/kg/minute
Because of mathematical miscalculations, Answers A, C, and D are incorrect. |
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Term
E.N. is a 7-month-old ex–31-week gestation boy with mild gastroesophageal re ux (i.e., twice weekly) who now weighs 4 kg (birth weight 1.1 kg). When plotted on standardized growth charts, he is below the 5th percentile for age and is given a diagnosis of failure to thrive. Which is the most likely risk factor for this?
A. Early hospitalization.
B. Undiagnosed metabolic disorder.
C. Low birth weight because of prematurity. D. Gastroesophageal reflux. |
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Definition
| There are several risk factors for failure to thrive; in this case, the patient’s low birth weight because of prematurity is the most likely cause. Although the patient has gastroesophageal reflux, his case is mild; therefore, Answer D is incorrect. Although severe gastroesophageal reflux may be a cause of failure to thrive, this is unlikely the main causative factor in mild cases. Answer A is incorrect because early hospitalization alone has not been linked to failure to thrive. Answer B is incorrect because it is unlikely that the patient has an undiagnosed metabolic disorder, given that he has gained weight during the first 7 months of life, despite being below the 5th percentile. Moreover, metabolic disorders would likely be diagnosed earlier and are rare. |
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Term
A 1-day-old neonate (weight 800 g), 27 weeks’ ges- tational age, will receive PN. However, because of dif culty securing central venous access, she will receive nutrition through a peripheral venous cath- eter. Which most accurately re ects what the PN must be compounded to be?
A. 900 mOsm/L or less. B. 1200 mOsm/L or less. C. 1300 mOsm/L or less. D. 1500 mOsm/L or less. |
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Definition
. Answer: A
The maximum osmolarity for PN infused through a peripheral catheter is 900 mOsm/L. Parenteral nutrition above this must be infused through a central venous catheter to prevent phlebitis, making all other answers incorrect. |
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Term
T.W. is a 23-hour-old female neonate born at 28 weeks’ gestation (birth weight 1100 g). Admitted to the neonatal intensive care unit with pure esopha- geal atresia, she will require nutrition support. Central access is secured. Which initial nutrition support regimen is most appropriate for T.W.?
A. Nutren Junior (1 kcal/mL) at 3.7 mL/hour plus dextrose 10% at 1.8 mL/hour.
B. PN at 3.7 mL/hour with nal dextrose concen- tration 10%, amino acids 4 g/kg/day, and IVFE 1 g/kg/day.
C. PN at 5.5 mL/hour with nal dextrose concen- tration 17%, amino acids 3 g/kg/day, and IVFE 3 g/kg/day.
D. Similac PM 60/40 at 25 mL every 3 hours. |
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Definition
Answer: B
It is most appropriate to administer PN to this patient right now. Pediatric patients with pure esophageal atresia lack the ability to ingest nutrition by the oral route initially and must wait until surgical repair or until gastric or jejunal access is secured. Furthermore, Answers A and D are incorrect because of the choice of enteral formula. Even if this patient could be fed enterally, a standard premature enteral formula would be better. Of the two PN regimens provided, Answer B is correct for initiation. Dextrose and IVFE are initiated at a low dose and titrated slowly toward goal calories. Answer C is incorrect; this is not appropriate for initial PN therapy because of the percentage of dextrose as well as the lipid dose. |
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Term
J.H. is a 9-year-old boy (weight 35 kg) who has had generalized abdominal pain, localized to the right lower quadrant, and malaise for the past 4 days. He has been unable to tolerate any oral intake because of persistent nausea and vomiting, and he has a decreased appetite. He now presents to the ED, where he will be evaluated for acute appendicitis. On examination, the patient feels warm to the touch. His initial temperature on admission was 36.5°C. However, in the ED, his temperature increased to greater than 38.5°C. He has an HR of 130 beats/ minute, a RR of 32 breaths/minute, and a BP of 111/60 mm Hg, with a pulse oximetry of 96%. Laboratory values:
137 104 33 4.1 23 0.4
102 15.4
11.4 33.8
336
Ca: 10.4 mg/dL
Which most accurately re ects J.H.’s maintenance uid needs using the Holliday-Segar method? A. 700 mL/day; 29.2 mL/hour.
B. 1800 mL/day; 75 mL/hour.
C. 840 mL/day; 35 mL/hour.
D. 1500 mL/day; 62.5 mL/hour. |
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Definition
Answer: B
The correct answer is B; the Holliday-Segar method for calculating maintenance intravenous fluids would be as follows:10kgx100mL/hour+10kgx50mL/kg+15 kg x 20 mL/kg = 1800 mL, which is equivalent to 75 mL/hour. Answers A, C, and D are calculated incorrectly, making them incorrect. |
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Term
J.H. is a 9-year-old boy (weight 35 kg) who has had generalized abdominal pain, localized to the right lower quadrant, and malaise for the past 4 days. He has been unable to tolerate any oral intake because of persistent nausea and vomiting, and he has a decreased appetite. He now presents to the ED, where he will be evaluated for acute appendicitis. On examination, the patient feels warm to the touch. His initial temperature on admission was 36.5°C. However, in the ED, his temperature increased to greater than 38.5°C. He has an HR of 130 beats/ minute, a RR of 32 breaths/minute, and a BP of 111/60 mm Hg, with a pulse oximetry of 96%. Laboratory values:
137 104 33 4.1 23 0.4
102 15.4
11.4 33.8
336
Ca: 10.4 mg/dL
According to J.H.’s laboratory values, which maintenance intravenous uid would be best to recommend? A. Dextrose 5% in 0.225% normal saline plus potassium chloride 20 mEq/L.
B. Dextrose 10% plus potassium chloride 10 mEq/L.
C. 0.225% normal saline.
D. Dextrose 10% in 0.45% normal saline plus potassium chloride 20 mEq/L. |
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Definition
Answer: A
The correct answer is A; dextrose 5% in 0.225% normal saline plus potassium chloride 20 mEq/L at 75 mL/ hour would provide the patient with the following: dextrose at around 2.6 g/kg, sodium at around 2 mEq/ kg, and potassium at around 1 mEq/kg. This is within the estimated maintenance needs for pediatric patients. The dextrose 10%–containing fluids (Answers B and D) would provide too much dextrose, and 0.225% normal saline (Answer C) is a hypotonic fluid that would cause cells to lyse. Of note, if dextrose 5% in 0.45% normal saline plus potassium chloride 20 mEq/L were provided as an option, this would also be an acceptable fluid to choose. |
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Term
J.G., a 5-year-old boy with a history of bilateral renal artery stenosis complicated by renovascular hyper- tension and bromuscular dysplasia, underwent bilateral renal artery-reimplantation, superior mesenteric artery bypass, and patch aortoplasty. He presents to the ED today and is admitted for concern about possible bowel obstruction secondary to poor appetite, no stools x 48 hours, and nausea/vomiting x 3 days. A naso- gastric tube is placed, and on placement, copious bilious uid is suctioned from his stomach. Which choice of uids is best to replace J.G.’s ongoing losses?
A. Dextrose 5% in 0.45% normal saline.
B. 0.9% normal saline plus potassium chloride 10 mEq/L. C. 0.45% normal saline.
D. Dextrose 5% in 0.9% normal saline. |
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Definition
Answer: B
The correct answer is B; the patient’s ongoing loss of bile/ gastric fluid is best replaced by 0.9% normal saline plus potassium chloride 10 mEq/L because of the electrolyte composition of bile/gastric fluid. Dextrose is unnecessary when choosing a fluid for replacing losses, and 0.45% normal saline does not contain sufficient sodium content to adequately replace the sodium that would be lost in the output of bile (Answers A, C, and D). As a reminder, replacement of ongoing losses should be considered separately from normal maintenance requirements. In clinical practice, replacement fluids are often administered in a 0.5 mL/1 mL or 1 mL/1 mL fashion. |
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Term
P.L.’s mother has called the pharmacy for a recommendation for an ORT for her 5-year-old son (weight 20 kg), who is currently experiencing a mild case of nausea, vomiting, and diarrhea. Which is the most appro- priate recommendation to make?
A. Gatorade 50 mL/hour for each stool or emesis.
B. Pedialyte 100 mL/kg plus 10 mL/kg for each stool or emesis.
C. Initiation of loperamide 0.08–0.24 mg/kg/day divided into three daily doses. D. Pedialyte 50 mL/kg plus 10 mL/kg for every stool or emesis. |
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Definition
Answer: A
The correct answer is A; the percentage of dehydration is 5% [% dehydration = (15.8 kg – 15 kg)/15.8 kg x 100]. For a 3-year-old child, this would be classified as moderate dehydration. Answers B and C are incorrect because of mathematical miscalculation. Answer D is incorrect; for a 3-year-old child, 5% dehydration is considered moderate, whereas 5% would be considered mild if this patient were an infant. |
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Term
S.B., a 13-year-old girl (weight 55 kg) who presents to the ED after a motor vehicle accident, has severe hypoten- sion (60/40 mm Hg). She is lethargic and has the following signs on physical examination: rapid HR (180 beats/ minute) and delayed capillary re ll (10 seconds). Which is the best initial therapy to provide S.B.?
A. Dextrose 5% in 0.45% normal saline plus potassium chloride 20 mEq/L at 92 mL/hour.
B. Dextrose 5% in 0.45% normal saline plus potassium chloride 20 mEq/L at 1000 mL/hour x 1 hour. C. 0.9% normal saline at 92 mL/hour.
D. 0.9% normal saline at 2000 mL/hour x 30 minutes. |
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Definition
Answer: A
The correct answer is 0.79 L (790 mL). The fluid deficit is calculated by multiplying the percentage of dehydration by the pre-illness weight. Therefore, 0.05 x 15.8 kg = 0.79 L. Answers B, C, and D are incorrect because of mathematical miscalculations. |
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Term
S.B., a 13-year-old girl (weight 55 kg) who presents to the ED after a motor vehicle accident, has severe hypoten- sion (60/40 mm Hg). She is lethargic and has the following signs on physical examination: rapid HR (180 beats/ minute) and delayed capillary re ll (10 seconds). S.B. is unresponsive to two normal saline boluses, and her abdomen is then found to be rigid. An emer- gency CT scan reveals a large hematoma in her abdomen. Subsequently, her hematocrit is 19%, and her BP remains at 60/40 mm Hg. Which therapy would be best to recommend at this time?
A. 0.9% normal saline at 1000 mL/hour x 1 hour.
B. Whole blood at 20 mL/kg.
C. 0.9% normal saline at 92 mL/hour.
D. Lactated Ringer solution at 92 mL/hour. |
|
Definition
Answer: D
The correct answer is D. Use of antidiarrheal agents is not recommended during acute episodes of gastroenteritis (Answer C). Similarly, use of sports drinks as oral rehydration for pediatric patients experiencing nausea, vomiting, and/or diarrhea is not recommended (Answer A). Typically, these drinks provide excessive carbohydrates, which can worsen diarrhea. Use of commercially available oral rehydration solutions such as Pedialyte is recommended. For mild dehydration, a dose of 50 mL/kg followed by 10 mL/kg for each stool and/or emesis is recommended. Answer B is incorrect because this would be indicated for more moderate/ severe dehydration. |
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Term
S.B., a 13-year-old girl (weight 55 kg) who presents to the ED after a motor vehicle accident, has severe hypoten- sion (60/40 mm Hg). She is lethargic and has the following signs on physical examination: rapid HR (180 beats/ minute) and delayed capillary re ll (10 seconds). Which is the best initial therapy to provide S.B.?
A. Dextrose 5% in 0.45% normal saline plus potassium chloride 20 mEq/L at 92 mL/hour.
B. Dextrose 5% in 0.45% normal saline plus potassium chloride 20 mEq/L at 1000 mL/hour x 1 hour.
C. 0.9% normal saline at 92 mL/hour.
D. 0.9% normal saline at 2000 mL/hour x 30 minutes. |
|
Definition
Answer: D
Answer D is correct. This patient presents with severe hypotension and is in the emergency phase of intravenous fluid replacement. The most appropriate first-line therapy is the administration of a normal saline bolus to reestablish intravascular volume, maintain hemodynamics, and prevent tissue damage. The most appropriate first-line option is normal saline or lactated Ringer solution. Answers A and B are incorrect because of the fluid choice. Answer A provides maintenance fluid requirements, but it will not correct the acute phase of resuscitation/restore BP. Answer B is incorrect because it uses maintenance fluids at a bolus dose. When administering a bolus, normal saline or lactated Ringer solution is more appropriate. Answer C is incorrect; although 92 mL/hour is the maintenance rate needed, the patient requires a bolus for initial therapy. |
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Term
S.B., a 13-year-old girl (weight 55 kg) who presents to the ED after a motor vehicle accident, has severe hypoten- sion (60/40 mm Hg). She is lethargic and has the following signs on physical examination: rapid HR (180 beats/ minute) and delayed capillary re ll (10 seconds). S.B. is unresponsive to two normal saline boluses, and her abdomen is then found to be rigid. An emer- gency CT scan reveals a large hematoma in her abdomen. Subsequently, her hematocrit is 19%, and her BP remains at 60/40 mm Hg. Which therapy would be best to recommend at this time?
A. 0.9% normal saline at 1000 mL/hour x 1 hour.
B. Whole blood at 20 mL/kg.
C. 0.9% normal saline at 92 mL/hour.
D. Lactated Ringer solution at 92 mL/hour. |
|
Definition
Answer: B
The correct answer is B. With a falling hematocrit value and obvious signs of bleeding, the most appropriate fluid is blood. This will expand the intravascular volume while increasing the hematocrit and oxygen-carrying capacity of the bloodstream. Answer A is incorrect because providing an additional bolus is unlikely to result in efficacy at this point. Answers C and D are incorrect because providing maintenance fluids at a rate of 92 mL/hour will not acutely correct the patient’s hypotension. |
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Term
C.G. is a term neonate (weight 3.2 kg) with a caloric goal of 100 kcal/kg/day. She is receiving breast milk, and she feeds eight times per day. Which represents the best volume (milliliters) that C.G. must consume at each feed to meet her caloric goals for the day?
A. 60 mL per feed.
B. 27 mL per feed.
C. 160 mL per feed.
D. 40 mL per feed. |
|
Definition
Answer: A
The correct answer is A. This patient must consume 320 kcal/day to support normal growth and development. Breast milk provides around 20 kcal per 30 mL. As such, the patient must consume 480 mL = 60 mL per feed. Answers B, C, and D are incorrect because of mathematical miscalculations. |
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Term
A 2-month-old (weight 3.4 kg) is receiving PN with the following macronutrients: DIR 14 mg/kg/minute, amino acids 3.2 g/kg/day, and IVFE 3 g/kg/day (51 mL). Which most accurately re ects the infant’s caloric intake for the day?
A. 111 kcal/kg/day.
B. 379 kcal/kg/day.
C. 413 kcal/kg/day.
D. 130 kcal/kg/day. |
|
Definition
Answer: A
The correct answer is A. To solve this question, dextrose and amino acid must first be convert into grams per day: 68.5 g/day and 10.9 g/day, respectively. Then, calculate the caloric contribution from each macronutrient: 68.5 g x 3.4 kcal/g + 10.9 g x 4 kcal/g + 51 mL x 2 kcal/mL = 378.5 kcal/day = 111 kcal/kg/day. For those who like to use more streamline calculations, the answer can also be determined in a simpler way, without accounting for weight, as follows: glucose 14 mg/kg/minute = 20.16 g/ kg/day x 3.4 kcal/g = 68.54 kcal/kg/day + amino acids 3.2 g/kg/day x 4 kcal/g = 12.8 kcal/kg/day + IVFE 3 g/kg/ day x 9 kcal/g = 27 kcal/kg/day, for a total of around 111 kcal/kg/day. Answers B, C, and D are incorrect because of mathematical miscalculations. |
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Term
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Definition
| Osm 273 Na 139meq/L Cl 109meq/L K 4 meq/L Bicarb 28 meq/L Ca 3 mg/L |
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Term
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Definition
| Alcohol, ACE-Inhibitors, ambisentan, atenolol, bosentan, busulfan, carbamazepine, cocaine, cyclophosphamide, diethylstilbestrol, fluconazole, iodine, isotretinoin, lithium, methotrexate, metronidazole, misoprostol, mycophenolate mofetil, paroxetine, penicillamine, phenytoin, propythiouracil, SSRIs, statins, tamoxifen, tetracyclines, thalidomide, valproate, warfarin |
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Term
| Anti-infectives during pregnancy |
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Definition
| Penicillins, cephalosporins, and macrolides are safe for use in pregnancy. Tetracyclines and fluoroquinolones should be avoided. Aminoglycosides, sulfonamides, nitrofurantoin, and trimethoprim should be avoided but may be needed in certain cases so consider the risk versus benefit. Doses of antibiotics during pregnancy should be at the upper end of the dosing range due to the physiologic changes during pregnancy |
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Term
| Treatment UTI in pregnant women |
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Definition
| B-lactam antibiotics are first line therapy. . Duration of therapy should be 3 to 7 days with oral antibiotics; if the culture remains positive after the first course of antibiotics an additional 7 to 10 days of therapy should be completed. Intravenous antibiotics may be appropriate for the treatment of pyelonephritis |
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Term
| Sexually transmitted and vaginal infections in pregnant women |
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Definition
| Chlamydia, gonorrhea, hepatitis B, human immunodeficiency virus, and syphilis should be tested at the initial prenatal care screenings. Azithromycin and ceftriaxone are first-line agents for chalmydiosis and gonorrhea. Penicillin G benzathine intramuscularly once is the required treatment for syphilis |
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Term
| Pain medications for pregnant women |
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Definition
| Agents should be used at the lowest dose for the shortest duration of time. Acetaminophen and narcotic analgesics can be used |
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Term
| Nausea/Vomiting for pregnant women |
|
Definition
| Monotherapy with pyridoxine is recommended as first line for nausea and vomiting of pregnancy. The addition of doxylamine may be considered as this combination has fetal safety data based on more than a quarter of a million pregnancies. Second line treatment options include promethazine, dimenhydrinate, or metoclopramide by the American College of Obstetrics and Gynecology (ACOG). Ondansetron or corticosteroids may be considered in patients requiring intravenous fluid replacement due to dehydration as a result of nausea and vomiting of pregnancy. Ondansetron use has been suggested to increase the risk of cleft palate and corticosteroids have been associated with oral clefts and should be reserved as last line therapies |
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Term
| Ondansetron and corticosteroids use in pregnant women OK? |
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Definition
| Ondansetron use has been suggested to increase the risk of cleft palate and corticosteroids have been associated with oral clefts and should be reserved as last line therapies |
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Term
| Hypertension meds in pregnant women |
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Definition
| Methyldopa remains the most widely used drug for hypertension treatment due to the 40-year history of use in pregnancy. Second line agents include labetalol, nifedipine, hydralazine, and hydrochlorothiazide |
|
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Term
| Diabetes medications for pregnant women |
|
Definition
| Insulin does not cross the placenta and can achieve tight glycemic control. Glyburide and metformin are oral antidiabetic drugs that appear safe to use during pregnancy |
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Term
| Depression medication in pregnancy |
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Definition
| Depression during pregnancy may be associated with preterm delivery, low birth weight, and postpartum depression. SSRIs are first line agents despite the concern for pulmonary hypertension and a withdrawal reaction as women who stop therapy are five times more likely to relapse than those that continue treatment. ACOG recommends using a single antidepressant drug at higher doses over the use of combination therapy |
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Term
| Medications where maternal doses approach clinically significant levels in breastmilk |
|
Definition
| bupropion, diazepam, fluoxetine, citalopram, lithium, lamotrigine, and venlafaxine |
|
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Term
| Factors that increase drug excretion into breastmilk |
|
Definition
| Lack of ionization, Small molecular weight, Low volume of distribution, Low maternal serum protein binding, High lipid solubility, Long half-life (secondary to accumulation) |
|
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Term
| Age where drugs in breastmilk is a concern |
|
Definition
| neonates younger than 2 months and rarely in infants older than 6 months |
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Term
| Benefits of breastfeeding |
|
Definition
| Decreased incidence of lower respiratory system infection, pneumonia, respiratory syncytial vial (RSV) bronchiolitis, acute otitis media, nonspecific gastrointestinal infection, necrotizing enterocolitis (NEC), sudden infant death syndrome (SIDS), asthma, atopic dermatitis, eczema, celiac disease, inflammatory bowel disease, obesity, type 1 diabetes, and leukemia and improved neurodevelopmental outcomes are seen in breastfed infants |
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Term
| Contraindications for breastmilk |
|
Definition
| Minimal maternal contraindications to breastfeeding exist and include active untreated tuberculosis, HIV (in developed countries only), and certain illicit drug use (marijuana) |
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Term
| Recommendations for breastfeeding in which the mother is undergoing pharmacologic therapy must balance the benefits to the infant and the mother against the potential risk of drug exposure to the infant. There are a limited number of agents that are contraindicated and appropriate substitutes can often be found. The most comprehensive up-to-date resource for safety of maternal medications when a mother is breastfeeding is LactMed |
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Definition
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Term
| Maternal pain medications during breastfeeding |
|
Definition
| Preferred opioids include morphine, hydromorphone and butorphanol, Adverse events and infant death has occurred with the use of codeine and hydrocodone (metabolized by CYP2D6), Other agents not recommended. Oxycodone due to high excretion rates. Propoxyphene due to minimal data. Meperidine due to prolonged half-life resulting in accumulation in infants. Non-narcotic options including acetaminophen and ibuprofen should be considered |
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Term
| Galactagogues --drugs that increase breast milk production |
|
Definition
| Domperidone-FDA warning against the use in breastfeeding women due to published reports of arrhythmias, cardiac arrest and sudden death; Metoclopramide- Ability to increase prolactin concentrations has not been replicated in recent studies and Clearance is delayed in infants and risks include methemoglobinemia. Herbal products-Available data does not support the routine use |
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Term
| Agents for breastmilk production with evidence of infant harm |
|
Definition
| Yohimbe, Fenugreek, St John’s wort |
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Term
| Vaccines and breastfeeding women |
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Definition
| Breastfeeding does not interfere with the infant’s immune response to routine immunizations for the mother, Inactivated vaccines given to nursing mother do not pose a risk to the infant, Most live vaccines may be administered to breastfeeding mothers--except-- Smallpox: infants at high risk of developing vaccinia (The cowpox virus which is used to vaccinate against smallpox) after exposure and Yellow fever: infants at high risk of developing encephalitis |
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Term
| Pregnancy and Lactation Labeling Final Rule in effect June 30th, 2015 |
|
Definition
| Pregnancy and Lactation Labeling Final Rule in effect June 30th, 2015 requiring changes to the content and format of the information in the prescription drug label, Pregnancy letter categories will be removed and labeling will contain a pregnancy section including labor and delivery, a lactation section, and a females and males of reproductive potential section. |
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Term
| Pediatric obesity is of major concern as it becomes an important risk factor for |
|
Definition
| dyslipidemia, diabetes and atherosclerosis. In addition, other comorbidities related to insulin resistance exist; such as polycystic ovarian syndrome and nonalchoholic fatty liver disease. Disorders such as hypothyroidism, growth hormone deficiency and psuedohypoparathyroidism can lead to obesity in children. Obesity is also related to other non-endocrine comorbidities, including psychological issues, sleep apnea and orthopedic problems. |
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Term
| T or F it has been shown that correcting obesity in childhood will place the risk of adult morbidities (associated with obesity) back to a normal prevalence rate for the patient. |
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Definition
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Term
| Medications can contribute to pediatric obesity |
|
Definition
| glucocorticoids, insulin, and atypical antipsychotics (clozapine, risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone). While studies in human studies are still lacking, it seems certain that atypical antipsychotics may have some effect on beta cell function in addition to being obesogenic. |
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Term
| Consequences of pediatric obesity |
|
Definition
| The most commonly seen biochemical abnormality in pediatric obesity is insulin resistance, due to hyperinsulinemia. Metabolic syndrome within the pediatric population lacks a consistent definition between expert groups; however, dyslipidemia, altered glucose metabolism and hypertension are commonly used. |
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Term
| BMI correlation to obesity |
|
Definition
| A BMI above the 85 percentile is considered overweight. A BMI above the 95 percentile is considered obese. |
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Term
| Medications for obesity in children |
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Definition
| The only medication approved for obesity within the pediatric population is orlistat which inhibits intestinal lipase leading to ~ 30% reduction in fat and cholesterol absorption. This assumes ~ 30% fat content (or greater) at meals. It is usually given three times daily with each meal. FDA approval is for ages 12 and older, however the over-the-counter product states for over the age of 18. Side effects can be challenging and include flatus, abdominal cramping, fecal incontinence, oily spotting and flatus with discharge. Some patients may require vitamin supplementation as it can affect absorption of fat-soluble vitamins A, D, E and B-carotene (converted to vitamin A in the body). Lorcaserin (the exact mechanism in not fully known, but it promotes satiety) and phentermine-topiramate (phentermine is a sympathomimetic amine with similar pharmacologic activity to amphetamine; topiramate is an anticonvulsant) combination product are available for use in adults and are being studied in children. |
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Term
| Other agents which have been used, but are not FDA approved for obesity in children |
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Definition
| Other agents which have been used, but are not FDA approved for obesity in children include metformin, octreotide, leptin, topiramate and growth hormone. Very limited data is available and should only be used by providers who have extensive knowledge of these agents and have thoroughly vetted the short and long-term risks vs. benefits within the pediatric population. |
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Term
| Recommendations for bariatric surgery for obese children |
|
Definition
| The American Pediatric Surgical Association and American Academy of Pediatrics recommends bariatric surgery in those with a BMI over 40 kg/m2 and a severe concurrent comorbidity or if the BMI is over 50 kg/m2. |
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Term
| Normal growth for children |
|
Definition
| Normal growth, after 3 years of age until prior to the onset of puberty, should be approximately a 4-7 cm increase in height/year and about 2.5 kg of weight gain per year for both boys and girls. Growth stops after puberty due to estrogen-induced epiphyseal maturation and closure. |
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Term
| Definition of short stature |
|
Definition
| Short stature is usually defined as 2 or more standard deviations below the mean for age and gender within a population (below the 2.5th percentile). Percentiles are based on growth-curves for age and gender. |
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|
Term
| Definition Growth deceleration |
|
Definition
| Growth deceleration can be defined as a growth velocity that is below the 5th percentile for age and gender (i.e. < 5 cm/year after the age of 5 years). |
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|
Term
| Acquired forms of GHD can be from chronic diseases including: |
|
Definition
| renal insufficiency, irritable bowel disease, celiac disease, hypothyroidism, Cushing’s disease, brain injury, tumors, radiation treatment to the head or spine or malnutrition (especially in developing countries). |
|
|
Term
| Familial short stature (FSS) |
|
Definition
| amilial short stature (FSS), sometimes referred to as genetic short stature, and constitutional delay of growth and adolescence (CDGA), sometimes referred to as constitutional delay of growth and puberty (CDGP), or both are the most common causes of short stature. ~ 2% of the population |
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Term
| Growth hormone goal of treatment |
|
Definition
| GH therapy to achieve a maximum attainable adult height (attaining an adult height at the 5th to 10th percentile based on gender is a successful outcome) |
|
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Term
| treatment for short stature for peripubertal boys |
|
Definition
| low-dose androgen therapy (injectable testosterone) and a low dose of oral oxandrolone may aid growth acceleration. Of note, this agent will not increase final adult height. Oxandrolone is typically stopped after a documented increase in endogenous testosterone. |
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Term
| GH is also approved for use in.... |
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Definition
| FDA approved for children with ISS and height below the 1st percentile or -2.25 standard deviations. GH is also approved for use in Turner syndrome, renal insufficiency, adults with acquired immunodeficiency syndrome wasting, Prader-Willi syndrome, children born small for gestation age (SGA) who have not reached the 5th percentile by age two, SHOX gene haploinsufficiency, adults with irritable bowel syndrome and Noonan syndrome. |
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Term
| Growth Hormone products and dose range |
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Definition
| Available GH products (recombinant human growth hormone, somatropin (rDNA origin) injection is marketed in the United States under Genotropin® Nutropin®, Humatrope®, Norditropin®, Omnitrope®, Tev-tropin®, and Saizen® with current consensus guidelines recommending a dose in the range of 0.025 – 0.05 mg/kg/day. Cam go has high bas 0.1 mg/kg/day depending on indication. |
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Term
| She effect of growth hormone therapy |
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Definition
| Side effects are usually uncommon, however you must teach the families to monitor for: intracranial hypertension (ask parents to report severe headaches, nausea and vomiting related to headaches, and blurred vision), slipped capital femoral epiphysis (ask parents to report joint pain, hip pain, and limping or favoring one side over another), injection site irritation or lipodystrophy (highlight importance of injection site rotation). Fluid retention, pancreatitis, prepubertal gynecomastia, unmasking of underlying hypothyroidism, and advancement of scoliosis are all other potential complications. |
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Term
| Conditions where somatropin will influence treatment or exacerbate complications: |
|
Definition
| diabetes-watch for elevated blood sugars, in Turner syndrome - watch for otitis media and cardiovascular events, hypopituitarism, ensure other hormonal replacements are adequately titrated, suspected adrenal insufficiency must be checked and replaced with cortisol prior to GH start, chronic kidney disease, watch for progression of renal osteodystrophy), |
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Term
| Contraindications to prescribing GH include: |
|
Definition
| active malignancy, acute critical illness (eg. surgery, trauma, respiratory failure), Prader-Willi kids who are severely obese, have a history of upper airway obstruction or sleep apnea, or have severe respiratory impairment, children who have diabetic retinopathy, closed epiphysis (when using GH for growth promotion) or hypersensitivity to somatropin. |
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Term
| What growth hormone is used for infants initially? |
|
Definition
| Norditropin® samples might be available for urgent GH starts (i.e. infants with hypoglycemia) also congenital hypoparathyroidism |
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Term
|
Definition
| Cost can range from $10,000 to $60,000 per patient, per year. When treatment is complete, Finkelstein, Lee and colleagues (referenced below), provide conservative estimates that it costs between $35,000 to $50,000 per inch of height gained. |
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Term
|
Definition
| Outcomes (i.e. growth) will vary based on factors such as the age at diagnosis and when treatment began, parents height, doses prescribed, concurrent medical conditions and compliance. Based on data from various sources (see references below), one may see between 1.2 and 2.8 inches of growth with wide variation in the incremental gain. Treatment continues until completion of growth for adolescence. However, some may benefit from therapy into adulthood. |
|
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Term
| Future possibilities for GH delivery |
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Definition
| liquid formulations, long-acting GH formulations and dermal patches. |
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Term
| common thyroid disorders clinical pharmacists will encounter within the pediatric population are ... |
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Definition
| congenital hypothyroidism, acquired forms of hypothyroidism and Grave’s disease. |
|
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Term
|
Definition
| Congenital hypothyroidism (CH), Autoimmune (i.e. Hashimoto’s or chronic lymphocytic thyroiditis) |
|
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Term
|
Definition
| Grave’s disease is the most common form of hyperthyroidism in the pediatric population. Non-autoimmune hyperthyroidism, Thyroid nodules, Neonatal thyrotoxicosis, Infections of the thyroid |
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Term
|
Definition
| Hashimoto’s thyroiditis, the most common cause of acquired childhood hypothyroidism may occur alone or concurrent with other autoimmune diseases. It occurs more in females, usually occurring in early to mid-puberty (female to male ratio is 2:1). Prevalence is 1-2% of the population. |
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Term
|
Definition
| Grave’s disease occurs in approximately 1:10,000 in children with the peak incidence in 11-15 year olds and a 5:1 female to male ratio. Most children who develop Grave’s disease have a positive family history of an autoimmune thyroid disease. |
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Term
| Hypothyroidism lab findings |
|
Definition
| low serum T4 or low serum free T4, elevated TSH, presence of thyroid antibodies (thyroid peroxidase, antimicrosomal or thyroglobulin) |
|
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Term
| Hyperthyroidism lab findings |
|
Definition
| Elevated free triiodothyronine (T3), T4, low TSH, thyroid-stimulating immunoglobulin (TSIG) elevations, the presence of antithyroglobulin or antiperoxidase antiboides, elevated thyroglobulin (TG) |
|
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Term
| Hypothyroid general symptoms |
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Definition
| fatigue, cold intolerance, somnolence, proximal muscle weakness, delayed relaxation phase of ankle reflex, constipation, delayed growth, overweight for height, pallor, |
|
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Term
| Hyperthyroid general symptoms |
|
Definition
| emotional liability, disturbed sleep habits (night-mares), hyperactivity and short attention span, poor school performance, increased appetite but weight loss, diarrhea and increased gastro-intestinal motility, heat intolerance, excessive perspiration muscle weakness and fatigue. |
|
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Term
| Levothyroxine (L-thyroxine or T4) for CH |
|
Definition
Levothyroxine (L-thyroxine or T4)10-15 mcg/kg/day rapidly normalizes serum TSH and provides the best neurodevelopmental outcome at 5 years.
a. Babies who are adequately and promptly treated (in the first few weeks) will grow and develop normally.
b. Babies who are not treated adequately in the first few weeks will have lower intelligence quotients below those of unaffected children. |
|
|
Term
|
Definition
| Monitor 4 weeks after any dose change, monitor every 1-2 months for the first 6 months, at least every 3 months during the first year and at least every 6 months in older infants. |
|
|
Term
| Levothyroxine administration for babies |
|
Definition
| Thyroid suspensions may result in unreliable dosing. Crush the tablet and mix in a small volume of breast milk, formula (with the exception of soy-based formula) or water and feed to the infant at the same time each day. Do not dose concurrent with calcium or iron containing medications or fiber products. Approximately 10-20% of babies may have transient hypothyroidism. If the diagnosis is not clear, therapy can be stopped for 1 month when the child reaches 3 years of age to retest thyroid function. |
|
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Term
| Levothyroxine for Hashimoto’s thyroiditis |
|
Definition
a. 6-12 months: 5-8 mcg/kg of body weight
b. 1-3 years: 4-6 mcg/kg of body weight
c. 3-10 years: 3-5 mcg/kg
d. 10-18 years: 2-4 mcg/kg
2. Monitor free T4 and TSH every 3-6 months |
|
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Term
| Grave’s disease treatment |
|
Definition
| alliative treatment should be with propranolol 2mg/kg/day administered every 12 hours to block peripheral T4 conversion to T3. Monitor for bradycardia and hypoglycemia. Contraindications are asthma and heart block. Radio-iodine treatment, Antithyroid medications--Propylthiouracil is no longer recommended due to liver toxicity. Methimazole is the preferred medication in non-pregnant individuals. Starting doses are 0.4 to 0.7 mg/kg/day in 3 divided doses every 8 hours. The usual maintenance dose is about ½ the initial dose, surgery |
|
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Term
| Permanent neonatal diabetes (PNDM) |
|
Definition
Permanent neonatal diabetes (PNDM) is a rare form of diabetes with an estimated prevalence of 1 in 100,000 to 300,000 live births.
1. Diagnosed before 6 months of age; likely to be non-autoimmune and caused by a mutation in one of a number of possible genes related to insulin receptors.
2. Treated with orally administered sulfonylureas, enabling the release of endogenous insulin that is associated with significant improvement in hemoglobin A1c (A1c) and quality of life. |
|
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Term
| Cystic fibrosis related diabetes (CFRD) |
|
Definition
Cystic fibrosis related diabetes (CFRD) occurs in approximately 20% of adolescents and 40% to 50% of adults with cystic fibrosis.
a. Features of both T1DM and T2DM
b. CFRD is a distinct type of diabetes
i. Primarily caused by decreased insulin secretion from pancreatic islet cells in association with insulin resistance due to acute and chronic illnesses associated with cystic fibrosis.
ii.Those with CFRD require insulin due to the architectural derangement of the pancreatic islet cells secondary to the mucous plugging associated with cystic fibrosis. |
|
|
Term
| Medication-induced diabetes |
|
Definition
a. Glucocorticoids
b. Isotretinoin
c. Antipsychotics
d. Antirejection – cyclosporine, tacrolimus, sirolimus
e. L-asparaginase
f. Beta-adrenergic blockers
g. Vacor (rodenticide containing the active ingredient N-3 pyridylmethyl-N′-p-nitrophenyl urea)
h. Phenytoin
i. Alfa-interferon
j. Diazoxide
k. Nicotinic acid |
|
|
Term
| The incidence of pediatric diabetes is decreasing for both type 1 and type 2 diabetes diagnoses. T or F |
|
Definition
|
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Term
|
Definition
A. The overall risk for developing T1DM is approximately 0.3%. Individuals with a type 1 sibling have an increased risk of developing diabetes depending on the human leukocyte antigen haplotypes they share. In general, the risk is about 5%, or an increase of 15 times the general population.
The risk of a child developing T1DM (who has a parent with T1DM) is about 2-5% (the risk for development of T1DM is at the higher end of this estimate if the child’s father has diabetes).
Males and females are equally affected.
There does not appear to be a correlation with socioeconomic status.
Suspected environmental factors contributing to T1DM include influences from early nutrition (breastfeeding vs. cow’s milk) and early infections (prenatal rubella infection).
Immune System
1. Individuals have a genetic predisposition that is believed to be triggered by various environmental factors.
2. Increased prevalence among those with other autoimmune disorders. |
|
|
Term
|
Definition
Obesity
Sedentary lifestyle
Certain ethnic groups
1. Native American
2. Hispanic
3. African American
4. Native Hawaiians
5. Pacific Islanders
6. Asian Americans
Family history
Gestational diabetes
Signs of insulin resistance
1. Acanthosis nigricans |
|
|
Term
| four diagnostic criteria leading to the diagnosis of diabetes |
|
Definition
1. Symptoms and signs including polyuria, polydipsia, polyphagia, and weight loss in association with a random blood sugar level ≥200 mg/dL
2. Fasting blood sugar level ≥126 mg/dL on two separate occasions.
3. Oral glucose tolerance test in which 75 g of anhydrous carbohydrates are administered with a 2-hour blood glucose level ≥200 mg/dL.
4. Hemoglobin A1c value ≥6.5% (blood glucose of 139.85 mg/dL) (may be less efficacious in adolescents) |
|
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Term
|
Definition
1. Insulin deficiency resulting in hyperglycemia (usually >300 mg/dL).
2. Metabolic acidosis (pH less tha 7.3, serum bicarbonate less than 15 mmol/L).
3. Accumulation of ketone bodies. |
|
|
Term
|
Definition
1. Correction of fluid deficits.
2. Restore electrolyte and acid-base balance.
3. Initiation of insulin.
4. Treatment of concurrent infection/trauma, etc. |
|
|
Term
| DKA Criteria for Intensive Care Setting |
|
Definition
1. pH <= 7.0.
2. Consideration of age (especially in the very young).
3. Unconscious.
4. Blood glucose over 1000 mg/dL. |
|
|
Term
| Treatment – Diabetic Ketoacidosis (DKA) |
|
Definition
Initial intravenous fluids should be 20 mL/kg of 0.9% sodium chloride (i.e. normal saline, NS) infused over 1 hour. Begin insulin drip at 0.1 unit/kg/hour. 0.05 units/kg/hr for less than 6 years old. Add potassium based upon initial labs results. If no hyperkalemia, add 20 mEq/L KCl to the fluid replacement after the initial 20 mL/kg of isotonic saline (0.9% sodium chloride).
total infusion rate for both solutions should be 150% maintenance. Adjust fluids electrolytes and dextrose as needed |
|
|
Term
|
Definition
| mannitol 0.5 - 1 g/kg IV (10-20 g/m2) over 5-10 minutes, repeat q2-4h prn |
|
|
Term
| Treatment goals pediatric diabetes |
|
Definition
| generally, hemoglobin A1c goal of less than 7.5% (blood glucose goal range before meals of 90-130 mg/dL and bedtime of 90-150 mg/dL) is currently recommended for all pediatric patients. |
|
|
Term
| Insulin Requirements in T1DM |
|
Definition
In children aged 9 months to 2 years, a reasonable total daily dose (TDD) may be 0.25 to 0.5 units/kg/day.
Children between 1 and 6 years should receive approximately 0.5 to 0.6 units/kg/day, if they did not present at diagnosis in DKA. For children presenting with DKA, it may be necessary to start 1 unit/kg/day of insulin in view of glucose toxicity.
Children aged 7 years up to the onset of puberty typically require 0.75 units/kg/day. A starting, estimated range from 0.75 to 1.5 units/kg/day of insulin, (or more in some situations) may be necessary during puberty and during other times of stress and illness.
During the honeymoon phase (see pathophysiology, section II, 5), a very low dose of basal insulin (0.2–0.6 units/kg/day) may preserve β-cell function. |
|
|
Term
| standard approach to the treatment of pediatric diabetes |
|
Definition
Basal bolus therapy (also referred to as intensive insulin management (IIM) or multiple daily injections (MDI)) is currently considered the standard approach to the treatment of pediatric diabetes as a result of the Diabetes Control and Complications Trial (DCCT) and follow-up Epidemiology of Diabetes Interventions and Complications (EDIC).
Basal and bolus insulin products based on I/C ratios and CF or SF. SF or CF typically is used interchangeably. This calculated value estimates how much 1 unit of rapid-acting insulin will lower the blood glucose level in mg/dL. |
|
|
Term
| Pharmacological Agents for Pediatric Type 2 Diabetes |
|
Definition
| Insulin and metformin are only FDA approved for pediatric patients. Insulin may be used intermittently when there is concurrent illness, surgery, or when oral agents alone can no longer obtain desired blood glucose values. Insulin regimens utilized may be similar to those prescribed in youth with T1DM. |
|
|
Term
| metformin therapy for youth with T2DM |
|
Definition
| 500 mg taken with meals, usually twice daily; slowly increase the dose every week for 3 to 4 weeks until a maximum dose of up to 2000 mg/day has been achieved. |
|
|
Term
| metformin contraindications for youth with T2DM |
|
Definition
Metformin is contraindicated in individuals with impaired renal function, cardiopulmonary insufficiency, cirrhosis, excessive alcohol use, and hepatitis.
vi. Metformin should be temporarily stopped before radiographic studies involving iodinated contrast dye.
vii. Patients taking metformin should be counseled to also take a daily multivitamin, as metformin can cause poor absorption of vitamin B12 and/or folic acid. |
|
|
Term
| Complication pediatric diabetes |
|
Definition
| Chronic complications include retinopathy, nephropathy, neuropathy and ischemic heart disease and should be generally be monitored with annual screening. |
|
|
Term
| Adrenal insufficiency (AI) definition |
|
Definition
| Adrenal insufficiency (AI) is a condition where the adrenal cortex does not produce enough of the steroid hormones. |
|
|
Term
| common causes of AI a pediatric clinical pharmacist will encounter... |
|
Definition
| Addison’s disease is an autoimmune destruction of the adrenal cortex. This may occur in isolation or may be part of a polyglandular autoimmune disorder. Congenital Adrenal hyperplasia CAH is an autosomal recessive genetic disorder. About90% are due to 21-hydroxylase deficiency. They often present during the neonatal period and early infancy with adrenal insufficiency and salt wasting, or in the first few years of life with virilization. Females have ambiguous genitalia. |
|
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Term
|
Definition
| Addison’s disease is more common in females vs. males and more common in adults vs. children. |
|
|
Term
| CAH Congenital Adrenal Hyperplasia |
|
Definition
| CAH is more common in Yupik Eskimos (~ 1 in 300 babies) and occurs more in people of Ashkenazi Jewish, Hispanic, Slavic and Italian descent. |
|
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Term
| Treatment Addison’s disease |
|
Definition
| Both glucocorticoid and mineralocorticoid replacement is necessary. |
|
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Term
|
Definition
| CAH. In the classic form, both glucocorticoid and mineralocorticoid replacement is necessary as well as salt in infants. In the non-classic form, hydrocortisone may just be needed. Some patients are able to come off medications as adults. |
|
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Term
| Drug of choice for pediatric AI |
|
Definition
| Hydrocortisone (Cortef®) 8-15 mg/m2/day, typically given three times daily dosing is the drug of choice for replacement therapy in pediatric patients for AI. It has both glucocorticoid and mineralocorticoid effects. Dexamethasone or prednisone (in older teenagers or adults) may be used to replace cortisol. Fludrocortisone (Florinef®) (0.05 – 0.15 mg/day) is the medication used to replace mineralocorticoids. A dose of 0.1mg is usually given daily. Because it does not have glucocorticoid effects, is not affected by stress dosing, thus it is acceptable to suspend dosing if the patient is vomiting and receiving IM Solu-Cortef®. Newborns are very sensitive to mineralocorticoids and often need higher doses (0.15 – 0.3 mg/day). |
|
|
Term
| Sodium chloride (NaCl) replacement for AI |
|
Definition
| Sodium chloride (NaCl) replacement is used to prevent hyponatremia in patients with CAH until the infant/toddler can consume adequate amounts of food which provides the necessary salt intake. Instruct parents to have the child take salt tablets right after meals to lessen stomach upset and do not miss any doses. For babies, give with each feeding. Make a solution of 1 teaspoon (tsp) of salt in ¼ cup of water and add 1 tsp of this solution to each bottle. For breastfed babies, give using a medication pacifier or syringe 6-8 times/day. NaCL must be present to the nephrons for mineralocorticoids to promote reabsorption of sodium. |
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Term
|
Definition
If a patient is too ill to take oral medications, they must take them by injection (Solu-Cortef® replaces both glucocorticoids and mineralocorticoids). Patients who are vomiting or have diarrhea are asked to increase water consumption to avoid dehydration.
b. Example for oral stress dosing for primary adrenal insufficiency are:
i. For pts on hydrocortisone – stress dose with hydrocortisone. Triple the highest daily dose and give every 8 hours.
ii. For pts on prednisone – stress dose with prednisone. Triple the highest daily dose and give every 8 hours.
iii.For pts on dexamethasone – stress dose with dexamethasone. Triple daily dose and give every 24 hours. |
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Term
|
Definition
| Adrenal crisis occurs the most in patients with undiagnosed AI who have a severe stress occur such as trauma, surgery, etc. Adrenal crisis management should include immediately getting a basic metabolic profile to specifically assess for hyponatremia, hyperkalemia and hypoglycemia. Initiate intravenous or intramuscular Solu-Cortef® (0-3 years: 25 mg; 3-12 years: 50 mg; 12 and older: 100 mg). Begin intravenous fluids at 20-30 ml/kg normal saline bolus (with glucose if hypoglycemic). In addition, other underlying medical conditions should be addressed. |
|
|
Term
| Breastfed infants have different growth patterns compared with formula fed |
|
Definition
Breastfed infants have different growth patterns compared with formula fed infants in the first 12 months
i. caution should be exercised when interpreting results for breast fed infants using Center for Disease Control (CDC) growth charts
ii. Breastfed infants appear to grow faster than average during the first 6 months but more slowly thereafter
iii. They also tend to be taller and thinner compared with mostly formula fed infants |
|
|
Term
|
Definition
Only growth can be objectively measured to diagnosis FTT
An involuntary decline falling below 2 or more major percentile channels
Length <3rd percentile
BMI or weight for length < 3rd percentile |
|
|
Term
|
Definition
| BMI Weight in kg ÷ squared length/height in meters |
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|
Term
| Premature infants Caloric Requirements |
|
Definition
The nutritional goal for most preterm infants during hospitalization is for an energy intake of 120 kcal/kg /day
Equivalent to 150 to 160 mL/kg/ day of premature formula (24 kcal/oz or 80 kcal/100 mL) or 160 to 180 mL/kg/day of fortified human milk
Ad libitum fed preterm infants will often consume larger amounts |
|
|
Term
| patients with disease states that increase REE -Resting energy expenditure |
|
Definition
| CF, come cardiac disorders, REE is significantly increased after head injury, Burn patients require 2 X predicted REE |
|
|
Term
| Contraindications to Breast Feeding |
|
Definition
| Inborn error of carbohydrate metabolism, Infants can’t metabolize galactose, causes toxic buildup of this sugar, In the US, mothers who are infected with human immunodeficiency virus (HIV) |
|
|
Term
| Per the American Academy of Pediatrics, Breastfeeding is NOT contraindicated with the following conditions: |
|
Definition
| mothers who are hepatitis B surface antigen-positive, Mothers who are infected with hepatitis C virus (persons with hepatitis C virus antibody or hepatitis C virus- RNA-positive blood), exposed to low-level environmental chemical agents, Mothers who are seropositive carriers of cytomegalovirus (CMV) (not recent converters if the infant is term), thers who smoke tobacco (though they should be encouraged to quit) or have an occasional drink |
|
|
Term
| Pediasure and Boost calories |
|
Definition
|
|
Term
| Vitamin Status in Cystic Fibrosis (CF) |
|
Definition
| Pancreatic enzyme insufficiency often results in malabsorption of vitamins A, D, E, K, Deficiencies of antioxidants (e.g., vitamin C) and low concentrations of antioxidant enzymes (e.g., glutathione peroxidase) have been found in patients with CF, along with poor selenium and zinc status, also often iron deficient, may not take in recommended amounts of calcium, and are at risk for hyponatremia due to salt loss through the skin |
|
|
Term
| Vitamin Status in Short Bowel Syndrome |
|
Definition
| normal conditions, about 90% of digestion and absorption of significant macronutrients and micronutrients are accomplished in the proximal 100-150 cm of the jejunum, enzymatic digestion suffers because of the irreplaceable loss of enteric hormones produced by the jejunum; biliary and pancreatic secretions decrease; patients will require supplementation of fat soluble vitamins |
|
|
Term
| Aluminum toxicity from TPN |
|
Definition
| Normal contaminant of PN, Most important in the neonates, Calcium provides the most significant amount, FDA threshold is 5 mcg/kg/day, Neurotoxic as well as detrimental to the bone structure |
|
|
Term
| Parenteral Nutrition Associated Liver Disease (PNALD) |
|
Definition
| Multifactorial caused by sepsis, surgical procedures, bacterial overgrowth, lack of enteral stimulation, caloric intake and distribution of calories, fat source (phytosterols), protein source-- Identification and prevention strategies can reduce the impact |
|
|
Term
| Name 3 community acquired pneumonia organisms |
|
Definition
| Pneumonia can occur following infection from a variety of viruses or bacteria, including influenza, Respiratory Syncytial Virus (RSV), Streptococcus pneumoniae, and Mycoplasma pneumoniae. |
|
|
Term
| Most common pathogen for pneumonia in school aged children? |
|
Definition
| S. pneumoniae is the most common pathogen to cause pneumonia in school-aged children. |
|
|
Term
| Risk factors community acquired pneumonia |
|
Definition
| Recent history of upper respiratory tract infection, Comorbidities: asthma, bronchopulmonary dysplasia, cystic fibrosis, sickle cell disease, congenital heart disease, Others: lower socioeconomic status, crowded living environment, exposure to cigarette smoke (first- or second-hand) |
|
|
Term
| gold standard for diagnosis of pneumonia |
|
Definition
| radiology--CXR but a child who presents to his/her primary care provider with signs/symptoms that are strongly suggestive of pneumonia does not need radiography to confirm the diagnosis. Infants and children who present with any signs/symptoms of respiratory distress, fail to respond to an empiric course of antibiotics, or require hospitalization should undergo chest radiography |
|
|
Term
| Blood cultures obtained in an attempt to identify the causative organism for community acquired are positive what % of the time ? |
|
Definition
| Blood cultures may be obtained in an attempt to identify the causative organism, however, they are positive <10% of the time, so their utility in pneumonia is limited |
|
|
Term
| Sputum and urine testing for CA pneumonia? |
|
Definition
| Sputum cultures and urinary antigen testing have no utility in the diagnosis of pediatric pneumonias. Viral antigen testing may be helpful in differentiating viral pneumonia from bacterial pneumonia, especially in the outpatient setting; however, a positive viral antigen does not exclude a bacterial process. |
|
|
Term
| Best prevention of CA pneumonia? |
|
Definition
| Vaccination against the influenza viruse, S. pneumoniae, and H. influenzae type B can effectively decrease a child’s risk of developing pneumonia |
|
|
Term
| Which infants and children should be hospitalized for management of CA pneumonia? |
|
Definition
1. Infants younger than 6 months of age with bacterial pneumonia.
2. Those who cannot tolerate oral liquids, or appear to be dehydrated.
3. Those with hypoxia or respiratory distress.
4. Those with pneumonia due to a highly virulent organism (e.g., methicillin-resistant S. aureus).
5. Those for whom follow-up may be difficult (e.g., unreliable family/social situation, non-adherence). |
|
|
Term
| T or F Antibiotic therapy is generally not needed for preschool aged children (i.e., <4 years of age) because community-acquired pneumonia (CAP) is largely due to viral pathogens in this age group. |
|
Definition
|
|
Term
| Drug therapy for treatment of CAP in school-aged children and adolescents ? |
|
Definition
| Drug therapy for treatment of CAP in school-aged children and adolescents should primarily targets S. pneumonia. High-dose amoxicillin (90 mg/kg/day max 4000mg) is the drug of choice for outpatient management of bacterial CAP. |
|
|
Term
| Amoxicillin/clavulanate for CA pneumonia for school aged children and adolescents? |
|
Definition
| Amoxicillin/clavulanate provides no additional benefit over amoxicillin for S. pneumoniae, however, it will provide additional coverage of H. influenzae and may be beneficial in children who are not fully vaccinated |
|
|
Term
| Drug therapy for CA pneumonia for child with penicillin allergy? |
|
Definition
| 2nd or 3rd generation cephalosporin (specifically cefuroxime 15 mg/kg/dose PO every 12 hours (maximum 500 mg/dose), cefprozil 15 mg/kg/dose PO every 12 hours (maximum 500 mg/dose), or cefpodoxime 5 mg/kg/dose PO every 12 hours (maximum 200 mg/dose)) |
|
|
Term
| Drug therapy for children with type 1 hypersensitivity reactions to β-lactam antibiotics for CA pneumonia? |
|
Definition
| linezolid, levofloxacin, or clindamycin may be reasonable alternatives |
|
|
Term
|
Definition
| penicillin derivatives (penams), cephalosporins (cephems), monobactams, and carbapenems. |
|
|
Term
| first-line IV therapy for fully immunized children who are admitted with presumed bacterial CAP? |
|
Definition
| IV ampicillin or penicillin G if allergy or intolerance to amoxicillin, ceftriaxone or cefotaxime may be used, if has hypersensitivity reactions to β-lactam antibiotics, vancomycin, linezolid <12 years of age: 10 mg/kg/dose IV/PO every 8 hours; for children ≥12 years of age: 10 mg/kg/dose IV/PO every 12 hours (maximum 600 mg/dose), clindamycin (if susceptible), or levofloxacin <5 years of age: 10 mg/kg/dose IV/PO every 12 hours; for children ≥5 years 10 mg/kg/dose IV/PO daily (maximum 750 mg/day) (if susceptible) may be used. |
|
|
Term
| first-line IV therapy for NOT fully immunized children who are admitted with presumed bacterial CAP? |
|
Definition
| Children who are not fully immunized should receive ceftriaxone or cefotaxime, in order to provide coverage against S. pneumoniae and H. influenzae. |
|
|
Term
| positive blood culture S. pneumoniae isolates with a minimum inhibitory concentration (MIC) ≤2 mcg/mL what drug? |
|
Definition
| ampicillin or penicillin G are still preferred |
|
|
Term
| positive blood culture S. pneumoniae isolates with a minimum inhibitory concentration (MIC) ≥4 mcg/mL what drug? |
|
Definition
| ceftriaxone is preferred. |
|
|
Term
| For children with CA pneumonia in whom atypical organisms may be suspected (predominately school-aged children or adolescents), what drug should be considered? |
|
Definition
| the addition of azithromycin may be considered for both inpatient and outpatient management. |
|
|
Term
| For children with CA pneumonia who develop pulmonary complications, such as an empyema or lung abscess, what drug should be considered? |
|
Definition
| coverage against methicillin-resistant S. aureus should also be considered. Vancomycin or clindamycin (if community resistance rates are low) may be added to empiric therapy for CAP in these situations. |
|
|
Term
|
Definition
| mean inpatient cost of nearly $60,000 and mean length of stay of 19 days. |
|
|
Term
| common pathogens for CLABSI |
|
Definition
| gram-positive bacteria including Staphylococcus aureus, coagulase-negative staphylococci, and Enterococcus species, and gram-negative bacteria including Escherichia coli and Klebsiella species. Candida species are also commonly encountered. |
|
|
Term
| most common CLABSI for children |
|
Definition
| Coagulase-negative staphylococci and S. aureus are most common in children.3 It is common for organisms to contaminate the CVC through routine handling or device use. |
|
|
Term
| catheter-related bloodstream infection (CRBSI) |
|
Definition
| to be further delineated to a catheter-related bloodstream infection (CRBSI) confirmatory diagnostics are needed establishing the catheter as the source. Catheter tip cultures can be used to confirm CRBSI and the 2009 IDSA guidelines provides recommended technique, but removal of the catheter would be required. |
|
|
Term
| Differential time to positivity (DTP) |
|
Definition
| Differential time to positivity (DTP) is an alternate method to confirm CRBSI and doesn’t require catheter remove. With DTP method, the difference in time to positivity of cultures obtained from the CVC and either a peripheral sample or sample obtained from a different lumen. The premise behind DTP is that culture obtained from the colonized lumen will grow more quickly than that obtained peripherally or from non-colonized lumen. |
|
|
Term
|
Definition
| Vancomycin is mostly commonly initiated to provide activity against methicillin-resistant Coagulase-negative staphylococci and S. aureus. Linezolid is not recommended for empiric therapy. . Empiric fungal therapy may be needed in certain patient populations such as prolonged ICU stay, TPN receipt, or previous fungal CLABSI without catheter removal. |
|
|
Term
| LOT anti-invectives for CLABSI if catheter is retained? |
|
Definition
| Patients can be treated 10 – 14 days from the first negative cultures. patients should receive antibiotics through each lumen of the catheter. Longer durations may be needed in instances of endocarditis, osteomyelitis, or comorbid conditions. |
|
|
Term
| LOT anti-invectives for CLABSI if catheter is removed? |
|
Definition
I
deally the catheter, as the source of infection, can be removed if it is no longer required or if the patient is septic. Instances where there is a tunnel or port pocket infection would also warrant catheter removal. Treatment, in general, is 10 – 14 days from the first negative culture in instances of catheter removal. |
|
|
Term
|
Definition
| Bacterial and viral infectious causes are often difficult to differentiate. Common non-infectious causes being related to allergic reaction, foreign object (ie. contact lenses), or chemical reaction. |
|
|
Term
| Neonatal conjunctivitis (ophthalmia neonatorum) |
|
Definition
| usually acquired during birth and presents within the first month of life. Chlamydial conjunctivitis accounts for 17 – 40% of neonatal conjunctivitis. Infants born to mothers with active chlamydial infections have a 20 – 50% risk of developing conjunctivitis. Nontypeable Haemophilus influenzae, Streptococcus pneumoniae, Staphylococcus aureus, Staphylococcus epidermidis, and Klebsiella species are other bacterial causes of neonatal conjunctivitis. Herpes simples virus (HSV) is the most common viral pathogen in neonatal conjunctivitis. |
|
|
Term
| Conjunctivitis in older children |
|
Definition
| caused by trauma, toxin, and allergens, but bacteria are the most common cause and account for nearly up to 75% of infectious conjunctivitis. Preschool-aged children may be more likely to have bacterial causes, Nontypeable Haemophilus influenzae, Streptococcus pneumoniae, Staphylococcus aureus, Staphylococcus epidermidis, and Moraxella catarrhalis are the most commonly encountered organisms. Approximately 25% of children with conjunctivitis may have concurrent otitis media. |
|
|
Term
| Conjunctivitis in older children and adolescents |
|
Definition
| Neisseria gonorrhoeae and Chlamydia trachomatis associated conjunctivitis can be encountered in older children and sexually active adolescents and should raise the suspicion for sexual abuse. |
|
|
Term
|
Definition
| Enterovirus, adenovirus, coxsackievirus are commonly reported viruses with adenovirus being most common viral source. |
|
|
Term
| Diagnosis of conjunctivitis |
|
Definition
| Diagnosis of conjunctivitis is primarily based on clinical presentation and patient history. In general, gram stain and culture are not recommended because of poor sensitivity and the self-limited nature of the disease. |
|
|
Term
| Long acting insulin is ? % of your basal requirement |
|
Definition
|
|
Term
|
Definition
9 months to 2 years, (TDD) may be 0.25 to 0.5 units/kg/day.
1 and 6 years , 0.5 to 0.6 units/kg/day for no DKA, with DKA 1 unit/kg/day of insulin in view of glucose toxicity.
7 years up to the onset of puberty 0.75 units/kg/day. A starting, estimated range from 0.75 to 1.5 units/kg/day of insulin, (or more in some situations) may be necessary during puberty and during other times of stress and illness.
honeymoon phase a very low dose of basal insulin (0.2–0.6 units/kg/day) may preserve β-cell function. |
|
|
Term
| 1800 rule for insulin sensitivity |
|
Definition
| 1800/TDD = SF (the estimated amount 1 unit of insulin will drop the blood glucose value) |
|
|
Term
| Rule of 500 = 500/TDD for insulin to carb ratio |
|
Definition
| One unit of rapid-acting insulin (bolus) will cover 50 g of carbohydrates. |
|
|
Term
| pRIFLE (Risk, Injury, Failure, Loss, End-stage) AKI definition: |
|
Definition
Risk eCCl decrease by 25% 0.5 mL/kg/h for 8 hr
Injury eCCl decrease by 50% 0.5 mL/kg/h for 16 hr
Failure eCCl decrease by 75% or eCCl 35 mL/min/1.73m2 0.3 mL/kg/h for 24 hr or
anuric for 12 hr
Loss Persistent failure > 4 weeks
End Stage End-stage renal disease (persistent failure > 3 months) |
|
|
Term
| What paralytic should not be used with TBI ? |
|
Definition
|
|
Term
| antidote for aspirin toxicity? |
|
Definition
| 150 mEq Sodium Bicarbonate + 40 mEq KCL in 1L of D5W, infused continuously to maintain urine output 1‐2 ml/kg/hour and urine pH goal of 7.5 |
|
|
Term
If you are administering drugs into ECMO circuit, where is best place to administer?
A. Pre‐bladder
B. Intra‐bladder
C. Post‐bladder
D. Central venous access outside the ECMO circuit |
|
Definition
| D. Central venous access outside the ECMO circuit |
|
|
Term
|
Definition
|
|
Term
| Hypertonic saline should be considered for severe TBI with associated intracranial hypertension. What is the dose? |
|
Definition
– 6.5 – 10 ml/kg 3% NaCl IV bolus or 0.1 – 1 ml/kg/hr infusion – Titrate for ICP < 20 mm Hg, serum Osm < 360 mOsmol/L
– Serum Na up to 170 mEq/L acceptable |
|
|
Term
| Is there evidence of benefit of mannitol for pediatric ICP? |
|
Definition
|
|
Term
|
Definition
• Prophylaxis for first 7 days after severe TBI – Phenytoin
—20 mg/kg IV loading dose as soon as possible —Maintenance dosing titrated to therapeutic levels
• Longer duration of treatment is not supported by literature |
|
|
Term
|
Definition
Pentobarbital 3‐5 mg/kg IV bolus, followed by 1‐
5mg/kg/hr infusion, titrate to burst suppression – Monitor BP, maintain support of CPP |
|
|
Term
|
Definition
| hyperventilation, cooling, steroids |
|
|
Term
| Secondary Exam and Stabilization for ingestion |
|
Definition
If hemodynamically stable, proceed with thorough physical exam and history
– S: – A: – M: –P: –L: –E:
Signs and symptoms Allergies Medications
Past medical history Last meal
Events and exposures |
|
|
Term
|
Definition
|
|
Term
| Decontamination for ingestion |
|
Definition
| Activated charcoal, maybe whole bowel irrigation (PED-ES) for sustained release products-- do not gastric lavage or use ipecac or cathartics |
|
|
Term
| Are repeat doses of flumazanil recommended for bento ingestion? |
|
Definition
|
|
Term
| Fomepizole dose for ethylene glycol or methanol poisoning? |
|
Definition
| 15mg/kg IV bolus, followed by 10 mg/kg IV every 12 hours x 4 doses |
|
|
Term
| Antimicrobials while on ECMO |
|
Definition
Vancomycin and Gentamicin
– Increased volume of distribution – Decreased clearance
– Monitor peak/trough
—Increase dose and/or extend interval if needed • Suggested Dosing:
– Vancomycin: 15‐20 mg/kg IV every 18‐24 hours – Gentamicin: 2.5‐3 mg/kg IV every 18‐24 hours |
|
|
Term
|
Definition
Opioids and benzodiazepines
– Significant binding to circuit
– Fentanyl and midazolam more sequestered than morphine
—Morphine may be preferable to fentanyl
– Rapid titration, as higher doses often necessary
— Wean as tolerated while cannulated
— Consider empiric decreases with decannulation |
|
|
Term
|
Definition
• Phenobarbital
– Some evidence for doubling loading doses
– Use typical maintenance doses, adjust dose based on serum levels
– Increased elimination is common • Phenytoin and fosphenytoin
– Minimal data exist
– Difficult to achieve therapeutic levels |
|
|
Term
|
Definition
• Lipophilic drugs appear to be more sequestered
• Usetherapeuticmonitoringwhenavailable
• Titrateoradjusttoappropriateclinicaldrugeffect
• Considerexpectedtoxicities
– Risk vs. benefit
• Usepublishedreferenceswhenavailable
• Ifnodataexist,useIVadministrationsiteoutside of ECMO circuit |
|
|
Term
| Side effects of alprostadil are ? |
|
Definition
| Apnea, Fever, Bradycardia, Hypotension |
|
|
Term
| Post‐operative: Low Cardiac Output Syndrome (LCOS) |
|
Definition
• Inability of heart to adequately deliver oxygenated blood to end organs/tissues
• High circulating inflammatory mediators and “myocardial stunning” after cardiac surgery
– Reduced cardiac output
– Increased pulmonary vascular resistance – Increased systemic vascular resistance
• Signs/symptoms
– Delayed capillary refill
– Cool extremities
– Decreased urine output
– Metabolic acidosis
– Increased serum lactate levels |
|
|
Term
| Infective Endocarditis (IE) Prevention |
|
Definition
Prophylaxis against IE is reasonable for the following patients at highest risk for adverse outcomes from IE who undergo dental procedures that involve manipulation of either gingival tissue or the periapical region of teeth or perforation of the oral mucosa:
• Patients with prosthetic cardiac valves or prosthetic material used for cardiac valve repair
• Patients with previous IE
• Patients with CHD
• Unrepaired cyanotic CHD, including palliative shunts and conduits
• Completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure
• Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (both of which inhibit endothelialization)
• Cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve |
|
|
Term
| Infective Endocarditis (IE) Treatment |
|
Definition
Dental Procedure Regimens
Agent
Single dose 30 to 60 min before procedure
Adults
Children
Oral
Amoxicillin
2g
50 mg/kg
Unable to take PO
Ampicillin
OR
Cefazolin or ceftriaxone
2 g IM/IV 1 g IM/IV
50 mg/kg IM/IV 50 mg/kg IM/IV
Allergic to PCN/ampicillin‐oral
Cephalexin*†
OR
Clindamycin
OR
Azithromycin or clarithromycin
2g 600 mg 500 mg
50 mg/kg 20 mg/kg 15 mg/kg
Allergic to PCN/ampicillin and unable to take PO
Cefazolin or ceftriaxone† OR Clindamycin
1 g IM/IV 600 mg IM/IV
50 mg/kg IM/IV 20 mg/kg IM/IV
*Or other first‐ or second‐generation oral cephalosporin in equivalent adult or pediatric dosage †Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with PCN or ampicillin |
|
|
Term
| Kawasaki Disease (KD) diagnosis |
|
Definition
Diagnostic Criteria for Kawasaki Disease
Fever (>39°C) for at least 5 days
Plus at least 4 of the following:
Polymorphous exanthem
Bilateral bulbar conjunctival injection without exudate Changes in lips and oral cavity
Erythema, fissured cracked lips, strawberry tongue or diffuse injection of oral and
pharyngeal mucosa
Cervical lymphadenopathy (≥1.5 cm diameter), usually unilateral Changes in extremities
Acute: erythema of palms and soles; edema of hands and feet
Subacute: periungual peeling of fingers and toes (in second and third week)
Plus exclusion of other diseases with similar clinical features
Can also have incomplete Kawasaki Disease, where all standard criteria are not met. However, supplemental laboratory criteria can be used for diagnosis. |
|
|
Term
| Medications for Pediatric Bradycardia |
|
Definition
Atropine
0.02 mg/kg IV/IO, 0.04‐0.06 mg/kg ET*; repeat if needed
(min dose: 0.1 mg, max: 0.5mg)
Higher doses may be used with organophosphate poisoning
Epinephrine
0.01 mg/kg (0.1 mL/kg 1:10,000) IV/IO 0.1 mg/kg (0.1 mL/kg 1:1000) ET* Max 1 mg IV/IO; 2.5 mg ET
May repeat every 3‐5 minutes
IV: intravenous; IO: intraosseous; ET: via endotracheal tube *Flush with 5 mL normal saline and follow with 5 ventilations |
|
|
Term
| Medications for Pediatric Tachycardia with Pulse |
|
Definition
Adenosine
0.1 mg/kg IV (max 6 mg) Second dose: 0.2 mg/kg (max 12 mg)
Monitor EKG; rapid IV/IO bolus with flush
Amiodarone
5 mg/kg IV/IO; may repeat twice up to 15 mg/kg (max single dose 300 mg)
Monitor EKG, BP; adjust rate to urgency (IV push during cardiac arrest, 20‐60 min with perfusing rhythm)
Expert consult strongly recommended prior to perfusing rhythm; use caution when administering with drugs that prolong QT
Procainamide
15 mg/kg IV/IO
Adult dose: 20 mg/min IV infusion to total maximum dose of 17 mg/kg
Monitor EKG, BP; give slowly over 30‐60 min. Use caution when administering with drugs that prolong QT (obtain expert consult)
EKG: electrocardiogram; IV: intravenous; IO: intraosseous |
|
|
Term
| Treatment of Kawasaki's disease |
|
Definition
Intravenous immunoglobulin 2 g/kg for 1 dose plus oral aspirin 80-100 mg/kg/day div QID untilafebrile and inflame markers reduced then 3‐5 mg/kg/day once afebrile
— Continued until no evidence of CAA and inflammatory markers normalized, usually 6‐8 weeks
— With CAA, continue indefinitely until echocardiogram is negative and inflammatory markers normalize
Avoid i ibuprofen, methylpred controversial, not reach; |
|
|
Term
| Vaccines after IVIG dose 2gm/kg |
|
Definition
| OK to give inactivated —Delay live, attenuated immunizations for 11 months |
|
|
Term
| Primary prevention of acute rheumatic fever (ARF) is achieved by identification of group A streptococcus (GAS) and providing adequate treatment with antibiotics. |
|
Definition
Benzathine penicillin G IM for one dose is appropriate treatment for GAS.
Amoxicillin is an appropriate antibiotic for treatment of GAS; however, the recommended duration of amoxicillin in primary prevention of ARF is 10 days.
Clindamycin for a 10 day course is an appropriate choice for primary prevention of ARF. However, this option should be reserved for individuals who are allergic to penicillin.
Azithromycin is an appropriate choice for primary prevention of ARF. However, this option should be reserved for individuals who are allergic to penicillin and the duration should be 5 days, not 1 dose. |
|
|
Term
| appropriate regimen for secondary prevention of acute rheumatic fever in a patient with a history of non-compliance |
|
Definition
| Benzathine penicillin G, given once monthly |
|
|
Term
|
Definition
• Acute=Onsetinfirst24hoursofchemotherapy initiation
• Delayed=Onsetafterfirst24hoursofchemotherapy initiation. May last for 5 days.
• Anticipatory=Triggeredbysights,smells,orsounds due to inadequate CINV control in the past.
• Refractory=Occursinpatientswithhistoryofsevere CINV with prior chemotherapy cycles despite optimal antiemetic prophylaxis |
|
|
Term
|
Definition
• Prior experiences with chemotherapy
• Psychosocial factors
• History of depression or motion sickness
• Age (children > adults)
• Gender (females > males)
• History of nausea/vomiting
• Emetogenic potential of chemotherapy agents |
|
|
Term
| Emetogenicity of Chemotherapy |
|
Definition
• Level 4 ‐ High (> 90% emesis rate)
– Cisplatin (all doses), cyclophosphamide (> 1500 mg/m2) or
dactinomycin
• Level 3 ‐ Moderate (30‐90% emesis rate)
– High dose methotrexate (> 250 mg/m2), cyclophosphamide
(< 1500 mg/m2) or doxorubicin
• Level 2 ‐ Low (10‐30% emesis rate)
– Etoposide, intermediate dose methotrexate (50 – 250 mg/m2)
• Level 1 ‐ Minimal (< 10% emesis rate)
– Asparaginase, bevacizumab, low dose methotrexate (<50
mg/m2), vincristine
• Combination regimens more emetogenic than single agents – Cyclophosphamide + doxorubicin |
|
|
Term
| Antiemetic Guidelines for CINV |
|
Definition
Emetogenic Potential
Before Chemotherapy
After Chemotherapy
High
5HT3 receptor antagonist + dexamethasone
+ (fos)aprepitant*
Dexamethasone x 2 days (+ aprepitant* x 2 days if using oral)
Moderate
5HT3 receptor antagonist + dexamethasone
Dexamethasone x 3 days
Low
Dexamethasone or phenothiazine
None
Minimal
None
None
* If patient is > 12 years of age and no known or suspected drug‐drug interactions |
|
|
Term
|
Definition
– Long acting
– Strongest affinity for 5HT3 receptor
– FDA labeled indication for children but not included in
pediatric CINV guidelines
– Effective for acute and delayed CINV
• Toxicities
– Common: headache, transient elevation of hepatic transaminases, constipation
– Rare and Serious: QT prolongation |
|
|
Term
|
Definition
• Synergistic with 5HT3 antagonists
• Antiemesis mechanism not well understood
• Antiemesispropertiesmostlyevaluatedwith dexamethasone and methylprednisolone
• Do not add steroid for emesis control if already a component of cancer therapy
• Avoidusewithbraintumortreatmentregimens
• Toxicities
– Common: insomnia, indigestion, agitation, |
|
|
Term
| Neurokinin‐1 Receptor Antagonists for NINV |
|
Definition
• Inhibits activity of Substance P at neurokinin‐1 receptor
• Dosing based on adults; no dosing or efficacy studies in
children
• Aprepitant ‐ oral 3‐day regimen
• Fosaprepitant ‐ single IV dose (prodrug)
• Potential for cytochrome P‐450 drug interactions
– moderate inhibitor of 3A4 (inducer of 3A4 with use > 1 week)
– weak inducer of 2C9
• Toxicities
– Common: fatigue, hiccups, dyspepsia
– Rare and serious: hypersensitivity with IV |
|
|
Term
| Adjunctive Antiemetics for CINV |
|
Definition
• Most appropriate in the “add‐on” setting due to lower CINV efficacy and higher rate of adverse effects
• Lorazepam has specific utility for anticipatory CINV
• Risk of extrapyramidal symptoms with dopamine antagonists
• Cannabinoids and Olanzapine may be better suited for adolescents |
|
|
Term
|
Definition
• Recombinantkeratinocytegrowthfactor
• Indicatedtopreventmucositisonlyinpatients with hematologic malignancies receiving myeloablative chemotherapy/radiation prior to stem cell transplant
• Stimulatestheproliferation,differentiationand migration of epithelial cells in GI tract
• Toxicities
– Common: rash, edema, itching of skin; taste alteration |
|
|
Term
| Supportive Care for Oral Mucositis |
|
Definition
• Aggressive pain management – Topical anesthetics
– Systemic opioids
• Gastricacidsuppression
• Hydration and nutrition support
• Gentleoralhygienewithblandrinse
– Sponge or gauze saturated with diluted saline or sodium bicarbonate solution
• Cytokine and antimicrobial support for neutropenia |
|
|
Term
| Immune Thrombocytopenia (ITP) background |
|
Definition
• Immunologic destruction and production of normal platelets
– Loss of tolerance to glycoproteins expressed on platelets and megakaryocytes
• Primary: unknown etiology • Secondary:
– Autoimmune disorders (systemic lupus erythematosus)
– Viral illness (hepatitis C, Varicella‐Zoster, HIV)
– Vaccinations (measles‐mumps‐rubella vaccine)
– Drugs (heparin, penicillin) |
|
|
Term
| Immune Thrombocytopenia (ITP) symptoms and diagnosis |
|
Definition
• Symptoms:
– Isolated thrombocytopenia (< 100 x 109/L) – Petechiae
– Mucosal hemorrhage (mild to severe)
– Intracranial hemorrhage (rare)
– Fatigue
• Diagnosis
– Thorough patient and family history
– Physical exam
– CBC and evaluation of peripheral blood smear – Bone marrow biopsy (only if atypical findings) |
|
|
Term
|
Definition
• Consideration factors
– Initialplateletcount
– Patientage
– Bleedingsymptoms
– Health‐relatedqualityoflife – Needforprocedures
– Adverseeffectsoftherapy
• Observationreserved for mild cases; 80% of cases in
children spontaneously resolve within 6 to 12 months
• Pharmacotherapymoderate to severe cases
– Corticosteroids
– Intravenousimmuneglobulin(IVIG) – Rho(D) IVIG |
|
|
Term
|
Definition
Dose
No standard regimen defined.
(prednisone 2 to 4 mg/kg/day for 5 to 14 days)
Response rate in children
• Avoid long term (> 1 month) regimens
• High dose Dexamethasone has been used for refractory ITP • Toxicities:
– Common:hypertension,psychological,GIdistressandulcers, hyperglycemia
– Uncommontorare:adrenalinsufficiency |
|
|
Term
|
Definition
Dose
0.8 to 1 g/kg/day for 1 or 2 days (4 to 6 hour infusion)
Response rate in children
• Premedication with acetaminophen, antihistamine and corticosteroid
• Toxicities:
– Common: headache, infusion reactions
– Uncommontorare:asepticmeningitis,renal insufficiency,anaphylaxis
if patient has IgA deficiency |
|
|
Term
|
Definition
• Binds to Rh(D) antigen on erythrocytes
– Facilitateclearingofantibody‐coatedcells – Inhibitclearanceofopsonizedplatelets
Dose
50 to 75 mcg/kg for 1 dose (15 to 30 minute infusion)
Response rate in children
50 to 80%
Onset
1 to 3 days
Duration of Response
3 to 4 weeks
• Contraindicated in asplenic patients or those with hemoglobin < 8 g/dL • Toxicities
– Common:infusionhypersensitivityreactions
– Rareandserious:hemolyticanemia,disseminatedintravascular
coagulopathy, intravascular hemolysis (black box warning), renal insufficiency |
|
|
Term
|
Definition
• Monoclonal CD‐20 antibody
• Recommended after front line treatments or splenectomy failure to control
bleeding
Dose
375 mg/m2 for 4 weekly doses
Response rate in children
57 to 68%
Onset
5 weeks
Duration of Response
6 to 12 months
• Premedication with acetaminophen, antihistamine and corticosteroid
• Toxicities:
– Common:Infusionreactions(hypersensitivity,serumsickness)
– Rareandserious:Viralreactivation(hepatitisCandJohnCunningham
(JC) virus) |
|
|
Term
| Chronic/Refractory ITP Options |
|
Definition
• Splenectomy
– Usuallydelayedforchronicdiseasesetting(>12months)
– Optionforpersistent(<12months),severediseaseunresponsiveto
pharmacotherapy agents
– 70to80%sustainedresponserate
– Immunizationsagainstencapsulatedorganismspriortoprocedure
• Thrombopoietin receptor antagonists (data limited in children) – Romiplostim
– Eltrombopag
– Stimulateplateletproductionbythebonemarrowmegakaryocyte • Immunosuppression
– Examples:azathioprine,mycophenolatemofetil – Usenotsupportedbyevidence |
|
|
Term
| Iron Deficiency Anemia (IDA) |
|
Definition
• Scopeofproblem
– Most common cause of anemia worldwide.
– 5 times more common in undeveloped countries – Affects 5 million in United States
—2 to 3% are toddlers (1 to 3 years of age) —3% are adolescent females
• Additional symptoms – Impaired Cognition
– Cold intolerance
– Restless leg syndrome – Pica |
|
|
Term
|
Definition
• DietIntervention
– Infants – iron fortified cereals at 6 months
– Toddlers and young children
—Limit cow’s milk to 20 ounces per day
—Increase meat consumption (lean meat, seafood)
– Avoid/minimize substances that inhibit iron
absorption:
—Coffee and tea
—Calcium containing foods or supplements —Antacids and gastric acid suppressants
– Ascorbic acid (vitamin C) promotes iron absorption |
|
|
Term
|
Definition
• HGB rise of at least 1 g/dL expected in 4 weeks following oral supplementation
• Ifresponse,continueoralironandrecheckin2to 3 monthsmost likely IDA resolution
• Ifnoresponse
– Additional studies (serum ferritin, HGB electropheresis, vitamin B12, folate, stool samples)
– Assess compliance
– Consider switch to IV iron preparation |
|
|
