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Intensive Care Interventions Among Children With Toxicologic Exposures to Cardiovascular Medications
Michael D Simpson1,2, C James Watson3, James D Whitledge1,4
1Harvard Medical Toxicology Program, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
Insights
Pediatric intensive care unit (PICU) interventions for cardiovascular medication exposures are uncommon. However, exposures to antiarrhythmics, calcium channel blockers, and alpha-2 agonists increase the risk for PICU admission in children.
Area of Science:
- Toxicology
- Pediatric Critical Care
- Cardiovascular Pharmacology
Background:
- Cardiovascular medications, despite their rarity in pediatric toxicologic exposures, pose significant risks due to potent hemodynamic effects.
- Pediatric intensive care unit (PICU) interventions are infrequently required for toxicologic ingestions, but specific drug classes necessitate careful consideration.
Purpose of the Study:
- To determine the prevalence of PICU interventions in pediatric patients exposed to cardiovascular medications.
- To identify risk factors associated with the need for PICU interventions in this population.
Main Methods:
- A secondary analysis was conducted using data from the Toxicology Investigators Consortium Core Registry, spanning January 2010 to March 2022.
- The study included 1,091 pediatric patients (≤18 years) with toxicologic exposure to cardiovascular medications across 40 international sites.
Main Results:
- Approximately 17.9% of patients required PICU intervention, with 14.4% receiving intensive hemodynamic support.
- Younger children (<2 years) were less likely to need PICU intervention (OR, 0.42).
- Exposures to alpha-2 agonists (OR, 2.0) and antiarrhythmics (OR, 4.26) were significantly associated with PICU intervention. Sensitivity analysis highlighted calcium channel antagonists (OR, 2.12) and antiarrhythmics (OR, 4.82) as key risk factors.
Conclusions:
- PICU interventions for pediatric cardiovascular medication exposures are infrequent but associated with specific drug classes.
- Age and exposure to certain cardiovascular agents like antiarrhythmics and calcium channel blockers are critical factors in determining the need for PICU care.
- These findings can aid in risk stratification and guide disposition decisions in cases of pediatric cardiovascular medication toxicity.
Objectives:
Interventions requiring a PICU are rare in toxicologic exposures, but cardiovascular medications are high-risk exposures due to their hemodynamic effects. This study aimed to describe prevalence of and risk factors for PICU interventions among children exposed to cardiovascular medications.
Design:
Secondary analysis of Toxicology Investigators Consortium Core Registry from January 2010 to March 2022.
Setting:
International multicenter research network of 40 sites.
Patients:
Patients 18 years old or younger with acute or acute-on-chronic toxicologic exposure to cardiovascular medications. Patients were excluded if exposed to noncardiovascular medications or if symptoms were documented as unlikely related to exposure.
Interventions:
None.
Measurements And Main Results:
Of 1,091 patients in the final analysis, 195 (17.9%) received PICU intervention. One hundred fifty-seven (14.4%) received intensive hemodynamic interventions and 602 (55.2%) received intervention in general. Children less than 2 years old were less likely to receive PICU intervention (odds ratio [OR], 0.42; 95% CI, 0.20-0.86). Exposures to alpha-2 agonists (OR, 2.0; 95% CI, 1.11-3.72) and antiarrhythmics (OR, 4.26; 95% CI, 1.41-12.90) were associated with PICU intervention. In the sensitivity analysis removing atropine from the composite outcome PICU intervention, only exposures to calcium channel antagonists (OR, 2.12; 95% CI, 1.09-4.11) and antiarrhythmics (OR, 4.82; 95% CI, 1.57-14.81) were independently associated with PICU intervention. No independent association was identified between PICU intervention and gender, polypharmacy, intentionality or acuity of exposure, or the other medication classes studied.
Conclusions:
PICU interventions were uncommon but were associated with exposure to antiarrhythmic medications, calcium channel antagonists, and alpha-2 agonists. As demonstrated via sensitivity analysis, exact associations may depend on institutional definitions of PICU intervention. Children less than 2 years old are less likely to require PICU interventions. In equivocal cases, age and exposure to certain cardiovascular medication classes may be useful to guide appropriate disposition.
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