Critical care pharmacotherapy: description of an innovative pediatric residency elective experience utilizing clinical pharmacy faculty as preceptor

Abstract
Objective: The objective of this brief report is to describe a pediatric pharmacotherapy curriculum pilot rotation experience for medical residents using a clinical pharmacy faculty preceptor. The goal of the experience was for the resident to gain additional training in drug use in critically ill children, as specific training in this area for medical residents may be inadequate.
Setting: The medical resident and clinical pharmacy faculty member rotated in a multi-disciplinary 18 bed Pediatric Intensive Care Unit (PICU). Patient-specific drug therapy plans were developed and discussed in depth along with various topic discussions covering common pediatric intensive care issues.
Conclusions: This pilot experience demonstrates the use of pediatric critical care pharmacotherapy education in an elective rotation. This experience has the potential to be significantly expanded to include more residents, a longer duration, and an examination of its impact on clinical knowledge. This is the first report of clinical pharmacy faculty acting as a preceptor in a pediatric rotation.


Phenobarbital toxicity from a highly concentrated veterinary formulation: review and case report

Abstract
Introduction: Phenobarbital, a barbiturate traditionally used in the treatment of seizure disorders, is considered safe and effective when its serum concentration is maintained between 10 to 40 mcg/mL. Toxic levels can induce coma, respiratory failure or shock syndromes. Strategies to manage phenobarbital overdose are necessary due to its potential for abuse and serious adverse effects.
Case presentation: We present an acute case of intoxication from high-concentration veterinary acquired phenobarbital, complicated by ethanol abuse in a 47-year-old male. He presented to the hospital with an initial phenobarbital serum concentration of 124 mcg/mL. Patient was status-post motor vehicle accident and unresponsive with an initial Glasgow Coma Scale (GCS) score of 3. On day two of hospitalization, hemodialysis (HD) was initiated due to the patient’s persistent comatose state. The phenobarbital serum level declined from 112 mcg/mL to 62 mcg/mL and GCS score improved to 10 after one 4-hour session of HD. On hospital day three, a second HD accelerated the removal of phenobarbital from a serum concentration of 59 mcg/mL to 30 mcg/mL and resulted in a GCS score of 14. On hospital day six, the patient’s phenobarbital serum level measured 24 mcg/mL and neurological status significantly improved, prompting his hospital discharge.
Discussion: The history and pharmacokinetic properties of the barbiturate class are discussed, with an emphasis on phenobarbital. Modalities for management of phenobarbital toxicity are reviewed from the medical literature and compared to our case. Patient specific factors influencing the case are further discussed, leading to the decision for hemodialysis treatment.
Conclusion: In severe phenobarbital intoxication, hemodialysis is a safe and effective method of extracorporeal elimination.


Invasive pulmonary aspergillosis in an immunocompetent host

Abstract
Invasive pulmonary aspergillosis (IPA) is a rare opportunistic mycosis with a usually fatal ending if misdiagnosed or untreated. Environmental exposure to species of the Aspergillus genus is almost never an issue for immunocompetent hosts and no disease will develop from it, however, when a patient’s immune system is impaired, the fungus will be able to invade the host’s system and the invasive mycosis will ensue. We report a patient with no important past medical history, chronic infections requiring prolonged antibiotic therapy or steroid dependent diseases, that presented to our facility to be treated for chronic sphenoid sinusitis secondary to Aspergillus fumigatus, and was later on found to have IPA.
Invasive pulmonary aspergillosis in an immunocompetent host


Electric velocimetry and transthoracic echocardiography for non-invasive cardiac output monitoring in children after cardiac surgery

Abstract
Objective: Assessment of cardiac output (CO) is essential in the management of children after cardiac surgery. Electric velocimetry (EV) is a newly developed monitoring method for CO and stroke volume (SV). However, applicability in a pediatric population, particularly after cardiac surgery, remains unclear. We sought to assess agreement of CO measured by EV and transthoracic Doppler echocardiography (TTE).
Design: Prospective observational study.
Setting: A cardiac intensive care unit (CICU) at a tertiary children’s hospital in Shizuoka, Japan.
Patients and participants: Children <18-year-old admitted to the CICU after cardiac surgery. Intervention: All patients underwent measurement of SV and CO using EV and TTE between 1 to 3 days after surgery. Measurements and results: Thirty patients were analyzed. We collected data on patient demographics, body surface area, vital signs, SV, CO, laboratory examination, drugs used, and type or surgery. There were significant correlations between EV and TTE in SV and CO values (r=0.909, p<0.001 and r=0.831, p<0.001, respectively). Bland-Altman analysis showed a good agreement between EV and TTE in SV and CO values (bias 1.33 mL, 0.08 L/min, and 0.02 L/min/m2, respectively, and limits of agreement -8.59 to 9.93 mL and -0.97 to 1.05 L/min, respectively). Mean percentage error for SV and CO values between EV and TTE were 13.76% and 13.19%, respectively. Conclusions: There is good correlation and clinical agreement between EV and TTE in measuring SV and CO. Electric velocimetry can be used in the hemodynamic monitoring of children after cardiac surgery. Electric velocimetry and transthoracic echocardiography for non-invasive cardiac output monitoring in children after cardiac surgery


An unusually large pleural cyst

A 93-year-old lady presented to the hospital complaining of 3 weeks of dysphagia, weight loss, dyspnea, and audible wheezing. Two days after admission, she was intubated and placed on assisted mechanical ventilation due to severe respiratory distress. A chest radiograph (CXR) showed a curvilinear, well circumscribed left superior paramediastinal opacity with suspected underlying mass (Figure 1, Panel A, arrow). Computed tomography (CT) of the chest with intravenous contrast revealed a large cystic mass measuring 9.3 x 6.4 x 4.6 cm, extending from the left supraclavicular region, immediately inferior to the thyroid gland, to the left hilar region (Figure 1, Panel B, arrow). The patient underwent open thoracotomy, where mass communication to the thoracic duct was noted, and complete surgical excision of a cyst filled with turbid and pale yellow fluid was achieved. Pathology report confirmed the diagnosis of a pleural cyst. The patient had no recurrence on CT and CXR after 4 weeks.
An unusually large pleural cyst