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Posted by: Matthew Helms on Nov 14, 2018

It's here! The UPDATED Pediatric Pharmacy Residency Database. The PPAG Membership Committee has compiled a list of Pediatric Pharmacy Residencies, and it offers new benefits for current students and residents searching for a good residency program fit. The database provides an increased level of detail allowing you to search for your desired residency by:

(1) program status,
(2) inpatient and outpatient rotations offered,
(3) size of hospital, and
(4) any unique opportunities for residents within each program (just to name a few).

For your member-only access to the database, please go to: https://www.ppag.org/index.cfm?pg=ResidencyDB

 

Posted by: Matthew Helms on Nov 14, 2018

 

Kim Friend, PharmD , Ji Lee, PharmD, BCPPS, Bryan Hayes, PharmD, DABAT, FAACT, FASHP
Massachusetts General Hospital


 

Sodium bicarbonate (NaHCO3) is used for multiple indications including tricyclic antidepressant (TCA) and salicylate poisoning.  NaHCO3 possesses alkalinizing properties and may be used to replace electrolytes. It dissociates into sodium and bicarbonate, which can buffer excess hydrogen ions resulting in raised blood pH.[1]

In March of 2017, the Food and Drug Administration (FDA) declared a national shortage of injectable NaHCO3 due to manufacturing delays and an increase in demand.[2] During this critical shortage, hospitals have resorted to removing NaHCO3 from crash carts and rationing supplies to focus use in the most critical scenarios.  Currently, the most obvious substitute, sodium acetate, is also in short supply.

TCAs are pharmacologically complex and work on multiple receptors, including sodium membrane channels. Blockade of these channels slow depolarization of the myocardium resulting in delayed conduction and reduced automaticity of the atria and ventricles.[4] Toxic effects after TCA overdose appear within 1-2 hours of ingestion. Patients presenting to the emergency department after a TCA overdose often exhibit altered mental status, seizures, and hypotension with QRS prolongation on EKG.  A QRS interval >100 milliseconds (msec) was predictive of seizures and >160 msec with ventricular dysrhythmias, in one study.[5] 

Salt loading using NaHCO3 or hypertonic saline (HTS) overwhelms the sodium channel to reverse the effects of TCAs and generates a gradient. NaHCO3 has the possible added benefit of increasing pH, which may escalate TCA plasma protein binding resulting in reduced pharmacologically active unbound drug and reduced insult to myocardial contractility.[6]

In the absence of NaHCO3, HTS may be a reasonable treatment alternative but remains controversial due to lack of evidence.  Thus far, animal studies show evidence of corrected QRS widening and hypotension with HTS. Pentel and Benowitz demonstrated that 6 mEq/kg of HTS was non-inferior to NaHCO3 in reversing QRS prolongation secondary to desipramine toxicity in rats.[7]  More recently, a randomized, controlled comparison of HTS with NaHCO3 for TCA toxicity by McCabe and colleagues, evaluated the effects of these agents at treating nortriptyline toxicity in swine.[7]  Twenty-four animal subjects were divided equally into 4 treatment arms: control (10 mL/kg D5W), sodium bicarbonate (3 mEq/kg of 8.4% NaHCO3), hypertonic saline (10 mL/kg of 7.5% HTS), and hyperventilation (to maintain a target pH 7.5-7.6 + 10 mL/kg D5W).  Treatment groups were evaluated for efficacy against TCA toxicity and mortality defined as survival at 60 minutes. The results of this experiment indicated that HTS was more effective at reversing cardiotoxicity caused by TCA overdose than NaHCO3. QRS duration was recorded as mean±standard deviation at baseline, during toxicity, and post treatment among each arm. Swine treated with HTS demonstrated a decrease in QRS by 78±14 ms while those treated with NaHCO3 exhibited a decrease in QRS duration by 51±28 ms.[7] The improvement in QRS duration between the HTS and NaHCO3 treatment arms proved statistically significant (p<0.05). [8] Furthermore, the HTS arm exhibited higher survival rate (83%) at 60 minutes compared with NaHCO3 (33%).

Though limited, human case reports have demonstrated success with HTS in TCA overdose patients refractory to NaHCO3.  Most notably, a 29-year old woman admitted to the ICU after 8g ingestion of nortriptyline was intubated, treated with gastric lavage, hyperventilation, vasopressor therapy with dopamine and norepinephrine with only transient improvement.[9]  Subsequently, with a pH approaching 7.5, she was given additional sodium with 7.5% HTS via rapid infusion.  Within three minutes, EKG monitoring showed narrowing of the QRS and resolution of hypotension. Currently, no published reports exist in the pediatric population.

While data remains scant, HTS may be a reasonable treatment option for TCA overdose in the absence of NaHCO3, sodium acetate, and in refractory cases. Drs. S. Srisruma and J. Cao of the Rocky Mountain Poison and Drug Center in Denver, Colorado suggest HTS may be helpful as adjunct therapy in TCA toxicity in alkalotic patients.[3]  

The sodium content in 100 mL of 3% HTS is equivalent to that in 50 mL of 8.4% NaHCO3.  HTS has been shown to be safe and effective when administered via a peripheral line, although central access is preferred.[12]  HTS should be used with caution due to risk of hyperchloremic acidosis, hypernatremia, and osmotic demyelination if administered too rapidly.  The risks of therapy should be weighed against the potential benefits.  Further studies are warranted and NaHCO3 remains the agent of choice, if accessible.

Resources:

  1. National Center for Biotechnology Information. PubChem Compound Database; CID=516892. <https://pubchem.ncbi.nlm.nih.gov/compound/sodium_bicarbonate#section=Top> Accessed 22 May 2017.
  2. “FDA Drug Shortages.” Accessdata.fda.gov. N.p., n.d. Wb. 22 May 2017
  3. http://www.emdocs.net/efficacy-of-hypertonic-saline-for-tricyclic-antidepressant-overdose/
  4. Feighner JP. Mechanism of action of antidepressant medications. J Clin Psychiatry. 1999;60 Suppl 4:4-11.
  5. Boehnert MT, Lovejoy FH. Value of the QRS duration versus the serum drug level in predicting seizures and ventricular arrhythmias after an acute overdose of tricyclic antidepressants. N Engl J Med. 1985;313(8):474-9.
  6. Kerr GW, Mcguffie AC, Wilkie S. Tricyclic antidepressant overdose: a review. Emerg Med J. 2001;18(4):236-41.
  7. Pentel P, Benowitz N: Efficacy and mechanism of toxicity of desipramine toxicity in rats. J Pharmacol Exp Ther. 1984;230:12-19.
  8. McCabe JL, Cobaugh, Menegazzi JJ, et al. Experimental tricyclic antidepressant toxicity: a randomised, controlled comparison of hypertonic saline solution, sodium bicarbonate and hyperventilation. Ann Emerg Med. 1998;32:329-33.
  9. McKinney PE, Rasmussen R. Reversal of severe tricyclic antidepressant-induced cardiotoxicity with intravenous hypertonic saline solution. Annals of Emergency Medicine. 2003;42:20-4.
  10. Høegholm A, Clementsen P. Hypertonic sodium chloride in severe antidepressant overdosage. J Toxicol Clin Toxicol. 1991;29(2):297-8.
  11. Paksu MS, Zengin H, Ilkaya F, et al. Can empirical hypertonic saline or sodium bicarbonate treatment prevent the development of cardiotoxicity during serious amitriptyline poisoning? Experimental research. Cardiovasc J Afr. 2015;26(3):134-9.
  12. Brenkert TE, Estrada CM, McMorrow SP, et al. Intravenous hypertonic saline use in the pediatric emergency department. Pediatric Emer Care 2013;29:71-73.

Posted by: Matthew Helms on Apr 19, 2018

The Pediatric Pharmacy Advocacy Group (PPAG), a global authority on neonatal pharmacy information, has agreed to license its comprehensive content library to eBroselow, makers of the SafeDose application suite. For more information, please see the press release: www.ebroselow.com/ebroselow-announces-agreement-share-ppag-knowledge-base/

 

Posted by: Matthew Helms on Apr 19, 2018

PPAG is pleased to announced new Fellows in the Pediatric Pharmacy Advocacy Group (FPPAG). The Fellows program recognizes pediatric pharmacists who distringuish themselves in the profession and demonstrate sustained practice excellence, contribute to the total body of knowledge, educate and mentor future members of the profession, and demonstrate active leadership in professional activities. 

Jared Cash, PharmD, MBA, BCPS, FPPAG

Jared Cash is the Director of Pharmacy at Intermountain Healthcare’s Primary Children’s Hospital is Salt Lake City, UT. He is also an adjunct Assistant Professor at the University of Utah College of Pharmacy. He received his Bachelors of Pharmacy from the University of Utah in 1996 and his Doctor of Pharmacy from the University of Florida in 1996. Dr. Cash is a Board Certified Pharmacotherapy Specialist. He recently completed a Masters of Business Administration. During his 26 years at Primary Children’s Hospital he has been a Pediatric Intensive Care Pharmacist, PALS instructor, Pediatric Intensive Care Team Leader, Clinical Coordinator, and a Pharmacy Manager. Dr. Cash served on the PPAG Board of Directors from 2011-2017, as President in 2015-2016.

David Knoppert, BScPh, FPPAG

David Knoppert completed a Degree in Honors Biology in 1976, then a Bachleor's Degree in Education in 1977. He graduated with a BScPhm from the University of Toronto in 1980, then completed a Hospital Residency in London, Ontario during 1980-81. In 2004 he completed a MSc degree in Clinical Epidemiology at Western University. From 1981 to 1983 he was a staff pharmacist at The Hospital for Sick Children in Toronto. In 1986 Mr. Knoppert completed a MScPhm at The University of Toronto. 1986 he began as an NICU Pharmacist and Drug Information Pharmacist at St Joseph's Hospital in London, ON. In 1989 he became the Clinical Coordinator, and continued to practice in the NICU. In 2011 Mr. Knoppert followed the Perinatal Program Transfer to London Health Sciences Centre where he became the Pediatric Clinical Coordinator and Residency Coordinator until he retired in November of 2013. In 2014 he became a part time Coordinator for Pharmacy Students from the University of Waterloo. At that time he also joined the Board for the Canadian Council on Continuing Education in Pharmacy (CCCEP). He continues to be a Board member of the International Alliance for Better Medicines in Children (IABMC). Mr. Knoppert served at President of PPAG in 2011-12 during his term on the Board between 2008-13.

Jamie Miller, PharmD, BCPS, BCPPS, FPPAG

Jamie Miller is an Associate Professor in the Department of Pharmacy Clinical and Administrative Sciences at the University of Oklahoma College of Pharmacy and Adjunct Associate Professor of Pediatrics at the OU College of Medicine. Dr. Miller currently practices as a Clinical Pharmacy Specialist in the Neonatal Intensive Care Unit at the Children’s Hospital at OU Medical Center in Oklahoma City. In addition, Dr. Miller is the Residency Program Director for the PGY1 Pharmacy Residency at the University of Oklahoma College of Pharmacy and OU Medical Center. Dr. Miller received her Doctor of Pharmacy degree from Southwestern Oklahoma State University College of Pharmacy. Following graduation, she completed a PGY1 Pharmacy Residency and PGY2 Pediatric Pharmacy Residency at the University of Oklahoma College of Pharmacy and OU Medical Center. Among her professional affiliations, she is a member of the Pediatric Pharmacy Advocacy Group, American Society of Health-System Pharmacists, and American Association of Colleges of Pharmacy. Her research/scholarship focuses on sedation/analgesia and drug withdrawal in critically-ill neonates, infants, and children.

Katherine Pham, PharmD, FPPAG

Kathy Pham, PharmD is the Director of Policy and Professional Affairs at the American College of Clinical Pharmacy. Her career path as taken an interesting turn from clinical practice to advocacy to public policy work. Her clinical career started after receiving her BSPharm and Pharm.D. degrees from Rutgers, the State University of NJ. She then completed a Pharmacy Practice Residency with Emphasis in Pediatrics at the University of Illinois at Chicago. She went on to teach as Assistant Professor of Pharmacy Practice at Long Island University. She further developed her pediatric clinical practice at St Joseph's Children's Hospital in NJ before her 8 year career at Children's National Medical Center, where she was the NICU Clinical Specialist as well as the Residency Program Director of the PGY1 Pharmacy and PGY2 Pediatric Pharmacy Residency programs. She became Board-certified in Pediatric Pharmacotherapy in 2017. She then pursued a unique opportunity as the Senior Officer of the Drug Safety Project at the Pew Charitable Trusts before recently joining ACCP at the start of 2018.

Hanna Phan, PharmD, FPPAG

Dr. Hanna Phan is an Associate Professor in Pharmacy Practice and Science at the College of Pharmacy and in the Department of Pediatrics at the College of Medicine at the University of Arizona (UA). She is also an Associate Research Scientist for the UA Asthma and Airway Disease Research Center and Faculty for the UA Pediatric Pulmonary Center (PPC). Dr. Phan practices as a Clinical Pharmacy Specialist in Pediatric Pulmonary Medicine at Banner University Medical Center-Tucson, practicing in both Pediatric Pulmonary Clinics and the Adult CF center. She established the Post-Graduate Year 2 (PGY-2) Pediatric Pharmacy Residency at Banner University Medical Center–Tucson, Diamond Children’s in 2009 and served as Residency Program Director through 2015. Dr. Phan earned her Doctor of Pharmacy (PharmD) from the University of Michigan and completed a Postdoctoral Fellowship in Pediatric Pharmacotherapy at The Ohio State University. Dr. Phan has received state and national recognition for her clinical practice, professional service, and research from organizations such as the Arizona Pharmacy Association, Pediatric Pharmacy Advocacy Group (PPAG), American College of Clinical Pharmacy (ACCP), and the American Society of Health-System Pharmacists (ASHP) Foundation. She was a Director-at-Large on the PPAG board from 2014-2017 and has previously chaired the PPAG Research Committee (2013-2014) and is currently a Co-Chair for the PPAG Recertification Advisory Committee. She has given invited lectures nationally and internationally, and authored various book chapters and peer-reviewed manuscripts in the area of pediatric pharmacotherapy. Dr. Phan’s current research interests include patient-caregiver education and medication adherence, pediatric medication safety, and interprofessional care of children with chronic conditions such as cystic fibrosis and asthma.

 

Posted by: Matthew Helms on Apr 18, 2018

George Giacoia, MD has been named the 2018 recipient of the Sumner J. Yaffe Lifetime Achievement Award in Pediatric Pharmacology and Therapeutics. The Award recognized significant and sustained contributions toward the improvement of children’s health thought the expansion of the field of pediatric pharmacology and therapeutics.

Dr. Giacoia is currently the Program Director of the Pediatric Clinical and Developmental Pharmacology Training Network at the Eunice Kennedy Shiver National Institute of Child Health and Human Development (NICHD), a division of the National Institutes of Health. He is also the Program Director for the US Pediatric Formulations Initiative, a program he helped develop. Prior to his current appointment, he served as the Program Director for the Pediatric Pharmacology Research Unit Network, also a program he initiated. During his distinguished 20-year career at the NIH, Dr. Giacoia developed the US Pediatric Therapeutics Initiative under the Best Pharmaceuticals for Children Act (BPCA). He also spearheaded the Newborn Initiative in partnership with the FDA.

Prior to his service at the NICHD, for nearly 20 years Dr. Giacoia was a Professor of Pediatrics and Division Head of Neonatology and the University of Oklahoma College of Medicine in Tulsa, and Director of the Eastern Oklahoma Perinatal Center at St. Francis Hospital. He also was the Director of the Division of Neonatology and Buffalo Children’s Hospital. Dr. Giacoia was a physician and Director of Nurseries at DeWitt Army Hospital, Baltimore City Hospitals, and Johns Hopkins Hospitals. In addition to serving on the faculty at the University of Oklahoma, Dr. Giacoia has held faculty appointments at Georgetown University, the State University of New York at Buffalo, and Johns Hopkins University.

Dr. Giacoia is a Fellow of the American Academy of Pediatrics and Associate Fellow of the American College of Obstetricians & Gynecologists. He is a member of the Drug Information Association and the American Society of Clinical Pharmacology and Therapeutics. Dr. Giacoia has received two NICHD Merit Awards.

The 2018 Yaffe Award Lecture will be given during the 27th Annual PPAG Meeting in Salt Lake City, UT on April 27, 2018.

About PPAG
The mission of PPAG is to advocate for safe and effective medication use in children through education, collaboration, and research. The association’s 1,400 members include pharmacists, pharmacy residents, pharmacy technicians, and pharmacy students who practice in various inpatient and outpatient care settings.
For more information about the organization, go to www.ppag.org

For media inquiries, contact:
Matthew Helms, PPAG Executive Director
T. 901-820-4434
E. matthew.helms@ppag.org

 


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