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Dosing of enteral acetaminophen in critically ill children: a cohort study
Nadia Roumeliotis1,2, Helena Frndova3, Eleanor Pullenayegum4
1Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada nadia.roumeliotis@gmail.com.
Insights
Acetaminophen underdosing and overdosing are frequent in pediatric intensive care units (PICU). Electronic prescribing reduced cumulative overdoses but increased single dose errors.
Area of Science:
- Pediatric Pharmacology
- Drug Safety
- Pharmacoepidemiology
Background:
- Acetaminophen is a common medication in pediatric hospitals.
- Accurate dosing is critical for patient safety, especially in intensive care settings.
Purpose of the Study:
- To determine the frequency of acetaminophen underdosing and overdosing in a pediatric intensive care unit (PICU).
- To identify risk factors associated with acetaminophen dosing errors.
Main Methods:
- Retrospective cohort study of drug administrations in a tertiary care PICU.
- Analysis of over 147,000 doses of enteral acetaminophen administered to pediatric patients.
- Generalized estimating equation regression used to assess risk factors.
Main Results:
- 5.3% of doses were single underdoses and 3.1% were single overdoses.
- Older age and cardiac admission were risk factors for both underdosing and overdosing.
- Electronic prescribing increased single dose errors but decreased cumulative overdoses.
Conclusions:
- Acetaminophen underdosing and overdosing are common in the PICU.
- Pharmacoepidemiology can effectively detect these dosing errors.
- Electronic prescribing has a complex impact on acetaminophen dosing accuracy.
Objective:
Acetaminophen is the most common medication prescribed in children's hospitals. The aim of the study was to estimate the frequency and risk factors for acetaminophen underdosing and overdosing in the paediatric intensive care unit (PICU).
Design:
Retrospective cohort of drug administrations in a large tertiary care PICU.
Patients:
All PICU admissions, less than 18 years of age, admitted between 1 January 2008 and 1 January 2018, having received at least one dose of enteral acetaminophen.
Methods:
The primary outcome was acetaminophen underdosing and overdosing, defined as doses exceeding the 10% upper and lower limits of the standard reference range (10-15 mg/kg) and 10% above daily maximum dose (75 mg/kg). A generalised estimating equation regression assessed patient risk factors for single underdosing, single overdosing and cumulative daily overdosing of acetaminophen.
Results:
Of the 147 485 doses of enteral acetaminophen administered, 7814 (5.3%) were single underdoses (1 in every 19 doses) and 4640 (3.1%) were single overdoses (1 in every 32 doses). There were 6813 cumulative overdose days (1 in every 9 patient-days). Risk factors for both underdosing and overdosing included older age and cardiac admission, whereas risk factors for cumulative overdosing were young age and cardiac admission. Electronic prescribing increased the risk of underdosing and overdosing, but decreased cumulative acetaminophen overdosing (relative risk 0.51, p=0.001).
Conclusion:
Acetaminophen underdosing and overdosing are common in the PICU and can be detected with pharmacoepidemiology. Electronic prescribing increased the risk of single underdosing and overdosing, although it reduced the risk of cumulative overdosing.
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