Gabapentin use in the neonatal intensive care unit and beyond: Single center report of 104 cases

BACKGROUND

We aimed to describe our experience with gabapentin use in infants admitted to our neonatal intensive care unit (NICU), including neurodevelopmental follow-up after discharge.

METHODS

We performed a retrospective medical record review of infants prescribed gabapentin during admission to the University of Virginia NICU from 01/01/2015 to 04/30/2021. We report clinical characteristics including gabapentin indication, dosing and side-effects while in the NICU, discharge data, and assessments in outpatient developmental follow-up clinic.

RESULTS

Gabapentin was prescribed to 104 infants (median gestational age 29 weeks, median postmenstrual age at initiation 41 weeks). Sixty-one percent of infants were male. The primary indication was irritability in 86%, and 67% were receiving at least one other neurosedative medication. Median maximum dose was 25 mg/kg/day (IQR 15-35 mg/kg/day) and 84% were discharged home on gabapentin. The majority required equipment at discharge (64% gastrostomy or nasogastric tube feeds, 54% supplemental oxygen or mechanical ventilation, and 40% both). At the first neurodevelopmental follow-up appointment, at least one area of delay was identified in 93% of infants and by 2 years corrected age 66% had a diagnosis of global developmental delay.

CONCLUSIONS

NICU patients treated with gabapentin often require complex post-discharge care and require close neurodevelopmental follow up.

Effect of dexmedetomidine on heart rate in neonates with hypoxic ischemic encephalopathy undergoing therapeutic hypothermia

BACKGROUND

Sedation is recommended to optimize neuroprotection in neonates with hypoxic ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH). Dexmedetomidine is an alternative agent to opioids, which are commonly used but have adverse effects. Both TH and dexmedetomidine can cause bradycardia. In this study, we describe our experience with dexmedetomidine and fentanyl in neonates undergoing TH for HIE, with a focus on heart rate (HR).

METHODS

We performed a retrospective chart review from 2011-2019 at a level IV NICU comparing sedation with dexmedetomidine (n = 14), fentanyl (n = 120), or both (n = 32) during TH for HIE. HR trends were compared based on sedation and gestational age. Neonates were included if they underwent TH and received sedation and were excluded if cooling was initiated past 24hours (h) from birth or if they required ECMO.

RESULTS

Of the 166 neonates included, 46 received dexmedetomidine, 14 as monotherapy and 32 in combination with fentanyl. Mean hourly HR from 12-36 h after birth was significantly lower for infants on dexmedetomidine versus fentanyl monotherapy (91±9 vs. 103±11 bpm, p < 0.002). Dexmedetomidine was decreased or discontinued in 22 (47.8%) neonates, most commonly due to inadequate sedation with a low HR. Lower gestational age was associated with higher HR but no significant difference in dexmedetomidine-related HR trends.

CONCLUSIONS

Despite an association with lower HR, dexmedetomidine may be successfully used in neonates with HIE undergoing TH. Implementation of a standardized protocol may facilitate dexmedetomidine titration in this population.

Alarms, oxygen saturations, and SpO2 averaging time in the NICU

BACKGROUND

Alarm overload is a significant concern in the Neonatal Intensive Care Unit (NICU). Selecting a longer oxygen saturation (SpO2) averaging time will reduce the number of alarms but may mask fluctuations in oxygenation.

OBJECTIVE

Characterize bedside monitor alarms in the NICU and estimate the impact of longer SpO2 averaging time and alarm delay.

METHODS

All bedside monitor alarms were analyzed over a 12-month period in the University of Virginia NICU, using the default averaging time (8 seconds) and SpO2 alarm limits set at 88-95% for infants on supplemental oxygen. In 10 VLBW infants, SpO2 averaging time was lowered to 2 seconds for 24 hours and events of SpO2 out of the target range were estimated with 2-, 8-, or 16-second averaging time, with and without a 15-second alarm delay.

RESULTS

There were 3,263,590 alarms in the unit over 12 months. Low or high SpO2 alarms constituted 79% of the total, and 55% of these events lasted <15 seconds. In 10 infants we estimated that increasing SpO2 averaging time from 2 to 16 seconds would have led to 53% fewer SpO2 alarms but the mean duration of alarms would have been 2.15-fold longer. Adding a 15-second alarm delay to 2-second SpO2 averaging in this analysis decreased SpO2 alarms by 67%.

CONCLUSION

Longer SpO2 averaging times mask the number and severity of events of aberrant oxygenation in preterm infants without decreasing total alarm time. Incorporating an alarm delay with shorter SpO2 averaging times can reduce alarm number and duration, and allow more accurate assessment of oxygenation, which may be important for research into consequences of aberrant oxygenation in this vulnerable population.

First Report of In-Vitro Boscalid-Resistant Isolates of Alternaria solani Causing Early Blight of Potato in Idaho

Early blight of potato (Solanum tuberosum) is caused by Alternaria solani and occurs annually to some degree in Idaho. The timing of its appearance and rate of disease progress determine the impact on the potato crop. Though losses rarely exceed 20%, they can be higher and occur in stored potatoes if the disease is not controlled. Early blight is managed mainly by cultural practices such as plant nutrition, water management, and avoidance of plant stress, but also with the use of foliar fungicides. Currently, the main fungicides labeled for control of early blight are in the carboxamide and strobilurin fungicide groups. Development of resistance to some fungicide groups may contribute to the loss of control of early blight. Isolates of A. solani from Idaho potatoes were tested for resistance to boscalid in the carboxamide group. Diseased potato leaves with early blight symptoms were collected from fields near Parma, Rupert, and Aberdeen in southern Idaho in 2009 and 2010 and Bonners Ferry in northern Idaho in 2010. To obtain A. solani isolates from leaves, small pieces of leaf tissue (5 × 5 mm) were taken from the center of early blight lesions and streaked across the surface of a thin layer (3 mm) of water agar. Plates were incubated at 25°C overnight to allow spores to germinate. Single germinated A. solani spores were transferred to acidified potato dextrose agar and incubated in the dark at 25°C. Germinated spores were identified based on spore morphology. Spores of A. solani can be easily distinguished from other Alternaria spp. found on potato because they are ellipsoid to oblong and taper to a long beak that is usually as long as the spore body. The identity of cultures grown from single spores was confirmed by colony and spore morphology. Sensitivity of A. solani isolates to boscalid was determined by the spiral gradient endpoint method (2). For all isolates, the effective concentration for 50% reduction in growth was outside the range of the spiral plate dilution series (i.e., isolates were either completely insensitive or completely sensitive to boscalid). In total, 46 isolates (20 collected in 2009 and 26 collected in 2010) were tested against boscalid. Experiments were carried out twice with 2009 isolates using mycelial strips and conidial suspensions. Experiments with 2010 isolates were carried out three times using only conidial suspensions. Of the isolates from 2009, 15% were insensitive. There was no difference between the use of mycelial strips or conidial suspensions. In 2010, 62% of isolates were insensitive. By location, 72% of isolates from Parma, 73% from Rupert, 63% from Aberdeen, and 44% from Bonners Ferry were insensitive. Resistance to boscalid has been reported in A. alternata isolates from pistachio (1,3). However, to our knowledge, this is the first report of resistance to boscalid in isolates of A. solani on potato. These data suggest that resistance to boscalid is widespread in Idaho, even in areas like Bonners Ferry where potato cultivation is limited. Boscalid insensitivity in vitro may not translate directly to commercial production and currently there is no evidence to suggest that boscalid has failed to control early blight in Idaho. However, the discovery of insensitive isolates suggests that boscalid should be considered at high risk of resistance development. References: (1) H. Avenot et al. Plant Dis. 91:1345, 2007. (2) H. Förster et al. Phytopathology 94:163, 2004. (3) N. Rosenzweig et al. (Abstr.) Phytopathology 93(suppl.):S75, 2003.

Physiologic and pharmacologic considerations for hypothermia therapy in neonates

With mounting evidence that hypothermia is neuroprotective in newborns with hypoxic-ischemic encephalopathy (HIE), an increasing number of centers are offering this therapy. Hypothermia is associated with a wide range of physiologic changes affecting every organ system, and awareness of these effects is essential for optimum patient management. Lowering the core temperature also alters pharmacokinetic and pharmacodynamic properties of medications commonly used in asphyxiated neonates, necessitating close attention to drug efficacy and side effects. Rewarming introduces additional risks and challenges as the hypothermia-associated physiologic and pharmacologic changes are reversed. In this review we provide an organ system-based assessment of physiologic changes associated with hypothermia. We also summarize evidence from randomized controlled trials showing lack of serious adverse effects of moderate hypothermia therapy in term and near-term newborns with moderate-to-severe HIE. Finally, we review the effects of hypothermia on drug metabolism and clearance based on studies in animal models and human adults, and limited data from neonates.

Pharmacokinetics of etanidazole (SR-2508) in bladder and cervical cancer: evidence of diffusion from urine

Following an IV infusion of 2.0 g/m2 of Etanidazole, the mean tumor concentration 40 min after injection was 126 micrograms/g in bladder cancer and 65 micrograms/g in cervical cancer. The tumor/plasma concentration ratio was 1.88 in bladder and 0.85 in cervical cancer. This high tumor concentration in bladder cancer could be accounted for by diffusion from a highly concentrated urine. This renders bladder cancer a suitable clinical model for testing this sensitizer.