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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Determine the role that the rate and extent of organ development plays in the variation of absorption, distribution, metabolism, and elimination of medications in the pediatric population.

  • Compare and contrast the pharmacokinetic and pharmacodynamic differences between pediatric and adult patients, as well as among various pediatric age groups.

  • Identify and manage challenges in pediatric pain management.

  • Identify and manage challenges in pediatric drug formulation and administration.

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PATIENT PRESENTATION

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Chief Complaint

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Nursing reports of new-onset fever and hypotension, increased number of apnea episodes, and “infant acting different.”

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HPI

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Alexander Halstrom is a premature 730-g male infant born at 25 4/7 weeks, now day of life 22, who is currently intubated, sedated, on vasopressors and parenteral nutrition with new-onset fever, increased number of apnea episodes, and a 1-day history of “acting different” according to nursing reports.

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PMH

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  • Prematurity: born at 25 4/7 weeks with APGARs of 1, 4, and 6

  • Extremely low birth weight (ELBW) = 760 g

  • Respiratory distress syndrome (RDS)

  • Anemia

  • Apnea of prematurity

  • At risk for retinopathy of prematurity

  • Cholestasis

  • Diaper dermatitis

  • Grade II intraventricular hemorrhage (IVH)

  • Hypotension

  • Microcephaly, head circumference below 10th percentile

  • Newborn sepsis

  • NPO, receiving nutritional support

  • Patent ductus arteriosus (PDA)—small with left-to-right shunt

  • Pulmonary hemorrhage

  • Immunizations up-to-date

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FH

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Infant born to a 24-year-old Gravida 2 Para 0 Abortion 1 (G2 P0 AB1) mother secondary to polyhydramnios, nonreassuring fetal status, and premature onset of labor

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Maternal labs: HBsAg (–), rubella (–), VDRL (–), and HIV (–) with unknown GBS status who received partial penicillin prophylaxis prior to delivery and indomethacin for tocolysis.

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Mother denies drug and alcohol use during pregnancy.

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SH

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  • Noncontributory

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Current Meds

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  • Ampicillin 73 mg IV every 12 hours (200 mg/kg per day)

  • Gentamicin 1.8 mg IV every 8 hours (7.5 mg/kg per day)

  • Caffeine 3.7 mg IV every 24 hours (5 mg/kg per day)

  • Phenobarbital 3.7 mg IV every 24 hours (5 mg/kg per day; off-label use for cholestasis)

  • Morphine continuous infusion 10 mcg/kg/hour

  • Midazolam continuous infusion 0.05 mg/kg/hour

  • Dopamine continuous IV infusion 10 mcg/kg/min

  • TPN at total fluid volume of 150 mL/kg per day

  • Nystatin 100,000 U/g cream one application to affected area PRN

  • Aquaphor, one application to affected area PRN

  • Glycerin suppository, one PR every 24 hours PRN constipation

  • Acetaminophen 7.3 mg PO/PR every 6 hours PRN pain/fever (10 mg/kg/dose)

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All

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  • NKDA

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Physical Examination

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Gen
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Intubated, sedated, premature infant in an isolette with hypotension who requires intensive cardiac and respiratory monitoring and continuous vital sign assessment.

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