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The aim of this study was to describe the off-label conditions of use for levosimendan in the paediatric population of a tertiary referral hospital. This is a retrospective observational study conducted between January 2007 and January 2014. Inclusion criteria were as follows: 100 % of paediatric patients who received intravenous perfusions of levosimendan during the study period. The following data were gathered: age, sex, diagnosis, dose administered, duration and date of the perfusion, number of perfusions per patient, previous inotropic and concomitant treatment, side effects and survival. A total of 32 patients were included in the study (56 % male). The mean age at the moment of administration was 4 months (range 2 days-15 years). During the study period, a total of 70 infusions were recorded. Fifteen of the 32 patients (46.9 %) received repeat doses, with a mean interval between doses of 8 days (range 3-37 days). The doses used were between 0.05 and 0.2 mcg/kg/min. Loading doses were not used in any cases. At the moment of receiving the infusion, all of the patients were receiving conventional treatment without any response, including inotropic support in 88 % of the cases. The administration of levosimendan was only suspended in one case due to the appearance of severe hypotension. In the rest of the administrations, it was well tolerated, without registering any severe side effect during the infusion process. Levosimendan proved to be a safe, effective strategy in our paediatric population. The good tolerance observed may be related to the absence of an initial bolus or loading dose.

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BackgroundPostoperative chylothorax is usually the result of iatrogenic injury to the thoracic duct or surrounding collateral lymphatic ducts during surgery. There are currently no recommendations for the management of refractory cases to optimal medical and surgical interventions.PurposeTo describe a case of refractory chylothorax in which the alpha adrenergic stimulant midodrine was successfully used.Material and methodsRetrospective case report and literature search related to the treatment of refractory chylothorax review. Data source: electronic medical records and PubMed data and Uptodate.ResultsA 4-year-old girl (weight 16 kg) underwent extracardiac Fontan surgery, and at the postoperative period presented with high chylous output from chest tubes. In the beginning, conservative treatment based on pleural drainage and dietary measures (enteral/parenteral nutrition poor in fat and with medium chain triglycerides) was performed. On postoperative days 6 and 25, an octreotide infusion (dose range 1 to 12 μg/kg/h) was initiated for 17 and 42 days, respectively, showing reduction in chyle leak but not its resolution. On postoperative day 41, pleurodesis with 320 mg tetracycline (20 mg/kg) was performed and repeated for 2 more days. Later, on postoperative day 69, bilateral pleurodesis with talc was done but was not effective. In view of the lack of effectiveness of the above measures, a literature search was performed and an article that described the successful use of midodrine in an adult refractory case of chylothorax was found. Despite not finding any reference in the paediatric population, due to the state of malnutrition, immunosuppression and coagulopathy of the patient, it was decided to prescribe off-label midodrine at a dose of 1 mg/8 h. Treatment was continued for 16 days and the drained volume was reduced from 20 mL/h to imperceptible. No adverse effects related to treatment with midodrine were observed.ConclusionChylothorax is a possible complication after thoracic duct injury during cardiothoracic surgery. Therapeutic strategies should be based on pleural drainage, diet, octreotide and, in persistent cases, pleurodesis. Midodrine may be a therapeutic option when the above measures are not effective.References and/or AcknowledgementsLiou DZ, et al. Midodrine: a novel therapeutic for refractory chylothorax. Chest 2013;144:1055-7No conflict of interest.

BackgroundPeritonitis is a frequent complication in peritoneal dialysis. Intraperitoneal administration of antibiotics appears to improve the response to intravenous treatment.PurposeTo describe a case of intraperitoneal administration of vancomycin in a paediatric patient and evolution of plasma levels.Material and methodsProspective case tracking and collaboration in the identification and interpretation of plasma levels of vancomycin.ResultsThe case was a 3-month-old girl (4.2 kg) that after cardiac surgery presented with acute tubular necrosis and needed continuous venovenous haemodiafiltration (CVVHDF). After 16 days of CVVHDF, this was changed to peritoneal dialysis. 6 days after initiation of peritoneal dialysis, peritonitis developed, and ceftazidime and vancomycin intraperitoneally were prescribed. Vancomycin was prescribed at a dose of 15 mg/L of dialysate (37.5 mg in each bag of 2.5 L). The first determination of plasma levels of vancomycin (at 24 hours) was 14.63 µg/mL and it was recommended to continue with the same dose. Treatment with intraperitoneal vancomycin continued for 21 days. During that time 11 determinations of plasma levels of vancomycin were made (range 8.19–32.93 µg/mL). A level of 32.93 µg/mL on day 10 of treatment indicated an error in the preparation of the dialysis fluid (presentation of dialysate was modified from 2.5 L to 2 L and the same vancomycin amount was added). Intraperitoneal administration of vancomycin (15 mg/L of dialysis fluid) was effective (negativisation crop) and safe (serum creatinine levels maintained).ConclusionIntraperitoneal administration of vancomycin is an effective alternative in methicillin resistant microorganism infections in patients undergoing peritoneal dialysis. In paediatric patients, the percentage of absorbed vancomycin is unknown. Monitoring plasma levels allows safe dosage and avoids nephrotoxicity associated with high plasma concentrations of vancomycin.References and/or acknowledgementsPaediatric and Neonatal Dosage Handbook. 22 Edition. American Pharmacists Association.No conflict of interest