Archives of disease in childhood
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Local Guidelines for peri-operative pain management in children published in 2012 recommended that paracetamol dosing was calculated using ideal body weight (IBW) to prevent inadvertent overdosing in overweight and obese children.1 The purpose of this audit was to establish compliance with these guidelines. The oral paracetamol dose recommended was 20-30 mg/kg as a single dose then 15-20 mg/kg every 4-6 hrs with a maximum of 90 mg/kg/day. IV paracetamol doses were as recommended in BNF for Children (BNFC).2 BNFC states that paracetamol doses totalling 150 mg/kg may cause severe hepatocellular necrosis and renal tubular necrosis but the potential for adverse effects in some children can be seen with doses as little as 75 mg/kg in 24 hrs. ⋯ 100 inpatient prescriptions (71 elective and 29 non-elective) and 35 discharge prescriptions were analysed.1. Weight was annotated for 84% of inpatient prescriptions and 94% of discharge prescriptions; height was not documented for any patient. Therefore data was analysed basing IBW on 50th centile of the UK growth charts.2. The following results are based on IBW: ▸ Six inpatients prescribed oral paracetamol were classified as overweight or obese; doses ranged from 17.4-30 mg/kg/dose. ▸ Four patients prescribed IV paracetamol were classified as overweight or obese; doses ranged from 20-23 mg/kg/dose. ▸ Four patients prescribed the combined route of PO/IV paracetamol were classified as overweight or obese; doses ranged from 18-24 mg/kg/dose. ▸ Six patients prescribed oral paracetamol on discharge were classified as overweight or obese; doses ranged from 13-33 mg/kg/dose.3. Paracetamol was prescribed as IV/PO in 32 inpatients.4. IV paracetamol was prescribed in 52 patients; 20 were not reviewed at 48 hrs for a switch to oral route. Of these, only 3 were appropriate prolonged IV prescriptions.Conclusion Audit findings showed inadequate compliance with local prescribing guidelines posing a risk of inappropriately high doses of paracetamol being prescribed to overweight and obese children. In addition, unnecessarily prolonged IV use was observed. Following feedback local guidelines were amended in 2015 to recommend that in obese children, dosing should reflect lean body mass and ideal weight for height. The maximum daily dose was also reduced to 75 mg/kg/day. Prescribers require education regarding this important issue.
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All-cause infant and childhood mortality has decreased in the UK over the last 30 years. Advances in paediatric critical care have increased survival in paediatric intensive care units (PICUs) but may have affected how and when children die in PICU. We explored factors affecting length of stay (LOS) of children who died in PICU over an 11-year period. ⋯ Increased LOS in children who die in PICU is driven by a decreased proportion of early deaths and an increased proportion of late deaths. This trend, combined with an increase in the severity of illness in early deaths, is consistent with a reduction in early mortality for acutely ill children, but a prolongation of life for those children admitted to PICU with life-limiting illnesses.
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To evaluate clinical management of acute pain with respect to pain assessment, scoring and timing of analgesia and whether appropriate supportive medicines were prescribed alongside strong opiates. A previous pain audit found dosing of analgesia was appropriate but did not assess clinical management against pain scores. Our paediatric guideline does not currently stipulate guidance on appropriate time frames to administer analgesia and re-assess pain. Standards were developed with a multidisciplinary team to audit against. ⋯ Despite lack of guidance around timing of pain assessment and administration of drugs, pain scores were being recorded regularly and acted upon, although not within a structured time frame. Observation charts allowed for assessment of pain scores at 15-minute intervals but only 'on the hour' documentation were observed. Specific guidance around timing of analgesia administration and assessment will be introduced to the revised guideline with medical and nurse training sessions to standardise practice and improve management of pain, in addition to safe prescribing of opiates.
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Clarity and accuracy of the pharmacy aspects of cancer clinical trial protocols is essential. Inconsistencies and ambiguities in protocols have the potential to delay research and jeopardise both patient safety and the collection of credible data. The Chemotherapy and Pharmacy Advisory Service (CPAS) was established in 2007 by the UK National Cancer Research Network, currently known as National Institute for Health Research Clinical Research Network, to improve the quality of pharmacy-related content in cancer clinical trial protocols. This abstract describes the scope of CPAS, its methodology of mandated protocol review and an analysis of the issues found and reported in paediatric oncology and haematology trials. ⋯ Review by CPAS of pharmacy content of paediatric oncology and haematology clinical trial protocols prior to final approval is feasible and exposes many undetected clinically relevant issues that could hinder efficient trial conduct and/or patient safety. This analysis has highlighted that the majority of suggestions were deemed clinically significant and effectively incorporated into the final protocols. The refinement of existing and development of further pharmacy-related guidance documents by CPAS might support more effective and safer clinical research.
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Whilst the prescribing of both in-patient and discharge medicines is electronic, there was no automatic notification to clinical pharmacists when a discharge prescription was ready to be screened. The notification required a member of medical or nursing staff to bleep their pharmacist informing them of a prescription's availability. This manual process led to a delay in pharmacist screening which impacted on discharge. Prescriptions designated for pre-packed or patient's own medicine use were not seen at all by a clinical pharmacist. The initial intention was to develop a text messaging service; however this was not possible due to significant cost implications and its inflexibility. ⋯ The use of an electronic messaging system has met its primary aim to decrease the time delay from signing to pharmacist screening it has also increased pharmacist efficiency as evidenced by the increased workload.One limitation of this system is that it requires a regular e-mail check, for available prescriptions. The report runs every 15 minutes, an email is only sent if a prescription is found.The notification of all discharge prescriptions containing medicines has led to the identification of errors which have required intervention, in those prescriptions that a pharmacist would not have previously seen. These interventions have been for children who have received pre-packed antibiotics directly from the wards or for those where we have provided one-stop dispensing.It is hoped to role out this system across other areas of the organisation which should also enjoy this significant improvement in discharge prescription turnaround.