Objective Limited data exist on the effects of therapeutic hypothermia (TH) on renal function and pharmacokinetics in pediatric patients after cardiac arrest (CA). The objective was to describe the differences in vancomycin disposition in pediatric patients following CA treated with either TH or normothermia (NT) using population pharmacokinetic modeling. Design Single-center, retrospective cohort study Setting A tertiary care hospital pediatric and cardiac intensive care unit Patients Fifty-two pediatric patients (30 days to 17 years old) who experienced a CA, received vancomycin, and were treated with TH (32–34°C) or NT (36.3–37.6°C) between January 1st, 2010 and September 30th, 2014 were reviewed. Interventions None. Measurements/Results A two-compartment model with linear elimination, weight effects on clearance (CL), inter-compartmental clearance (Q), central volume of distribution (V1), and peripheral volume of distribution (V2) adequately described the data despite high variability due to the small sample size. The typical value of clearance in this study was 4.48 L/h (0.19 L/h/kg0.75) for a normothermic patient weighing 70kg and a glomerular filtration rate (GFR) of 90 mL/min/1.73m2. Patients treated with normothermia, but with reduced or poor renal function (≤90 mL/min/1.73m2) had up to an 80% reduction in vancomycin clearance compared to those with normal renal function (90–140 mL/min/1.73m2). Patients with normal renal function, but treated with TH versus NT experienced up to 25% reduction in vancomycin clearance. Patients treated with TH and with poor renal function experienced up to an 84% reduction in vancomycin clearance. Conclusion Patients receiving hypothermia and/or with decreased renal function had lower vancomycin clearances based on a retrospectively fitted two compartment model in children who experience cardiac arrest.

There is a paucity of data on infant intravenous prostacyclin use, the gold standard for therapy for severe pulmonary hypertension (PH). This review aimed to evaluate the safety, tolerability, and outcomes of infant prostacyclin use. A retrospective observational study was performed in a large pediatric hospital with a dedicated pediatric PH program. Subject medical records, bedside flow sheets, and progress notes were reviewed to identify use of intravenous epoprostenol or treprostinil within the first year of life. The indication for prostacyclin use was recalcitrant hemodynamic compromise associated with PH, identified as either idiopathic PH, persistent PH of the newborn, PH associated with congenital diaphragmatic hernia, congenital heart disease, bronchiolitis, or chronic lung disease. Prostacyclin-related adverse events included 7 episodes of hypotension, 6 episodes of perceived pain, 2 episodes of cyanosis, and 1 episode of feeding intolerance. Prostacyclin was stopped only for cyanotic episodes associated with use in severe chronic lung disease. Two hemorrhagic events occurred during extracorporeal membrane oxygenation, which were unlikely to be prostacyclin related. Outcomes included 21 deaths unrelated to prostacyclin, 1 lung transplant, 6 PH resolutions, 8 transitions to oral PH medications, and 1 continuation of treprostinil. In conclusion, efficacy could not be evaluated in this study because of the loss of equipoise for neonatal prostacyclin use. Prostacyclin use was well tolerated in neonatal diseases associated with PH, but dose titration was limited by hypotension and hypoxemia.

Alteplase appears to show efficacy for treatment of thrombus-related venous catheter occlusion in pediatric patients; however, data regarding its use in occluded dialysis catheters are limited.

Fluid management is challenging in critically ill pediatric cardiac patients. A myriad of causes may be contributory, including intrinsic myocardial dysfunction with its associated neuroendocrine response, renal dysfunction with oliguria, and systemic inflammation with resulting endothelial dysfunction. The development of fluid overload has been associated with adverse outcomes, including acute kidney injury, prolonged mechanical ventilation, increased vasoactive support, prolonged hospital length of stay, and mortality. An in-depth understanding of the many factors that influence volume status is necessary to guide optimal management.