A child presenting with acute renal failure secondary to a high dose of indomethacin: a case report

Area of Science:

• Pediatric Nephrology
• Clinical Pharmacology
• Medication Safety

Background:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) at therapeutic doses typically cause mild, transient renal impairment.
• Limited data exists on high-dose indomethacin toxicity in pediatric populations.
• This case highlights a rare instance of severe acute renal failure in an infant due to a medication error.

Purpose of the Study:

• To describe a case of acute renal failure in a child resulting from an excessively high dose of indomethacin.
• To review a medication error within a drug prescription and administration system.
• To emphasize the importance of robust safety protocols in pediatric critical care.

Main Methods:

• A 20-day-old infant, post-surgery for Fallot's tetralogy, received an accidental indomethacin overdose (10 mg/kg).
• The infant developed acute, oligo-anuric renal failure.
• Treatment involved continuous venovenous renal replacement therapy.

Main Results:

• The infant experienced severe acute renal failure requiring intensive intervention.
• Complete recovery of renal function was achieved without any lasting complications.
• The case underscores the potential for severe toxicity from NSAID overdose in neonates.

Conclusions:

• High-dose indomethacin can precipitate severe acute renal failure in infants.
• Supervised drug prescription and administration systems with multi-level controls are crucial for preventing medication errors in critically ill children.
• Enhanced vigilance and system improvements are necessary to ensure patient safety in pediatric pharmacotherapy.