Implementation of an ICU bundle along with staff education and case conferences is effective for improving delirium screening, detection, and treatment and is associated with decreased delirium prevalence.

The probability of achieving an AUC/MIC > 400 using only a trough serum concentration and an MIC with patients receiving 15 mg/kg every 6 hours is variable based on the method used to calculate the AUC. An AUC/MIC of 400 in children correlated to a trough concentration of 11 mg/L using a trapezoidal Method to calculate AUC.

OBJECTIVE: To compare withdrawal symptoms among pediatric intensive care patients receiving clonidine to those not receiving clonidine while being weaned from long-term dexmedetomidine. METHODS: This retrospective analysis evaluated Withdrawal Assessment Tool-1 (WAT-1) scores and hemodynamic parameters in pediatric patients on dexmedetomidine for 5 days or longer between January 1, 2009, and December 31, 2012. The primary objective was to compare withdrawal symptoms based on the number of elevated WAT-1 scores among patients on clonidine to those not on clonidine, while being weaned from long-term dexmedetomidine. The secondary objective was to describe withdrawal symptoms associated with long-term dexmedetomidine use. RESULTS: Nineteen patients (median age, 1.5 years; interquartile range [IQR], 0.67–3.3) received 20 treatment courses of dexmedetomidine for at least 5 days. Clonidine was received by patients during 12 of the treatment courses. The patients in the clonidine group had an average of 0.8 (range, 0–6) elevated WAT-1 scores 24 hours post wean compared to an average of 3.2 (0–8) elevated WAT-1 scores in the no clonidine group (p = 0.49). There were no significant difierences between prewean and postwean systolic or diastolic blood pressures among the 2 groups. The average heart rate during the postwean period was 112 beats per minute (bpm) (range, 88.5–151.5) in the clonidine group compared to 138.4 bpm (range, 117.8–168.3) in the no clonidine group (p = 0.003). In the clonidine group, the mean change in heart rate postwean compared to prewean was an increase of 3.6 bpm (range, −39.6 to 47.5), compared to a mean increase of 29.9 bpm (range, 5.5–74.7) in the no clonidine group (p = 0.042). CONCLUSIONS: There was no difierence in WAT-1 scores between groups, with the clonidine group displaying a trend towards fewer elevated WAT-1 scores during the 24 hours post dexmedetomidine wean. Patients who received clonidine had significantly lower heart rates than the no clonidine group.

OBJECTIVE To describe the use of pharmacologic treatment in critically ill children treated according to a delirium protocol and compare those treated with antipsychotics to those treated non-pharmacologically. METHODS The study included a retrospective matched cohort describing patients who were pharmacologically treated for delirium compared to those with delirium but not treated in a PICU from December 2013 to September 2015, using a delirium management protocol. Patients were matched by age, sex, diagnosis, mechanical ventilation (MV), and presence of delirium. RESULTS Of 1875 patients screened, 188 (10.03%) were positive for delirium. Of those, 15 patients (8%) were treated with an antipsychotic for delirium. Patients with delirium treated with antipsychotics were younger, had more delirium days (6 vs. 3, p=0.022), longer MV days (14 vs. 7, p=0.017), and longer PICU length of stay (34 vs. 16 days, p=0.029) than in the untreated group. Haloperidol, risperidone, and quetiapine were used in 9, 6, and 2 patients, respectively. Two patients were treated with multiple antipsychotics. Antipsychotic treatment was initiated on day 2 of delirium for 8 of 15 patients (53.3%). Ten patients in the treatment group had improved delirium scores by day 2 of treatment. No significant differences in sedation exposure between groups. No significant adverse effects were reported. CONCLUSIONS No significant adverse events seen in this small cohort of critically ill pediatric patients with delirium treated with antipsychotic therapy. Patients with early-onset delirium refractory to non-pharmacologic treatment may have a more effective response to antipsychotic therapy than patients with late-onset refractory delirium.

Aortitis is a rare disorder involving inflammation of one or more layers of the aortic wall and is a risk factor for acute aortic syndromes, including aortic dissection and rupture. 1 It presents with nonspecific symptoms such as abdominal pain, back pain, fever, malaise, and elevated inflammatory markers, which make diagnosis challenging. Aortitis can be classified as either infectious or noninfectious. Infectious causes are rarer than noninfectious, which include rheumatologic disorders such as giant cell arteritis and Takayasu arteritis. 1 We report a case series of fulminant aortitis associated with the use of granulocyte colony-stimulating factor (G-CSF), a myeloid growth factor indicated to reduce the duration of neutropenia and neutropenia-related clinical sequelae.We searched the FDA adverse event reporting system (FAERS) and the medical literature through April 5, 2018 for post-marketing cases of aortitis in patients treated with G-CSFs. In addition to filgrastim and pegfilgrastim, the biologic tbo-filgrastim and the biosimilar filgrastim-sndz were included in this search, as well as lipegfilgrastim and lenograstim, two chemically distinct G-CSFs that are only available outside of the US. Cases were included if there was a temporal exposure to a G-CSF and a diagnosis of aortitis was reported by a health care professional. Cases were excluded if the adverse event was not aortitis, aortitis was attributed to an alternate etiology, or insufficient information was provided.We identified 15 FAERS cases of G-CSF associated aortitis that met our case definition, four of which were also published in the literature. Nine cases were associated with the long acting pegfilgrastim, four with filgrastim, and one with lenograstim. Twelve cases occurred in women and the mean patient age was 62 years old. Table 1 In all cases, aortitis was unlikely attributed to underlying disease or other drugs. Two cases received G-CSF as a stem cell donor, one of which was an otherwise healthy 55-year old female who developed aortitis 6 days after her initial dose of filgrastim. 4 All patients with an underlying cancer diagnosis (n = 13) received chemotherapy concomitantly with the G-CSF product. Cases received a variety of chemotherapeutic agents, (bevacizumab, carboplatin, cisplatin, cyclophosphamide, docetaxel, doxorubicin, epirubicin, fluorouracil, paclitaxel, pertuzumab, rituximab, trastuzumab, and vincristine) none of which have been associated with aortitis. None of the cases had a history of aortic disease.