P3.M254: Expansion of Non-Weight-Based Dosing QI From Adult Congenital Heart Disease Patients to ‘Big Kids’

Purpose/Objectives: While the use of weight-based medication in pediatrics is commonplace, in adults and larger children it can lead to rates of continuous infusion medications exceeding the recommended adult doses. In an effort to align practice with standards of care in adult medicine, our group first created an Adult Congenital Heart Disease orderset including non-weight-based dosing of infusions for patients >18 years of age and >50kg admitted to a children’s hospital. Subsequently, we sought to expand the availability of this dosing strategy for patients younger than 18 years of age but >50kg ideal body weight (IBW) to promote safe and appropriate dosing of common cardiac infusions and neurosedatives in this population.

Design/Methods: This initiative was a collaboration between the Departments of Cardiology, Critical Care, Anesthesiology and Pharmacy. After evaluation, the following infusion medications were selected: fentanyl, midazolam, bumetanide, furosemide, amiodarone and diltiazem. Approval was received from hospital leadership. Our interventions included several internal educational seminars for providers detailing literature review and proposed initiative, the rollout of the electronic health record order build and subsequent informational postings placed in provider workrooms. For analysis, the calendar year of 2022 was the pre-intervention period and the 6 months following the updated ordering capability describes the post-intervention period. Outcomes data was collected for fentanyl and midazolam infusions.

Results: Eleven patients received fentanyl doses >250 mcg/hr in the pre-intervention period compared to 0 patients following the interventions. Midazolam was administered with a rate of >10 mg/hr to 7 patients in the pre-intervention period with a maximum dose of 30 mg/hr. No patients received more than 8 mg/hr of midazolam following the interventions. Of patients meeting the criteria for non-weight-based dosing, this dosing regimen was used in 44% of patients initiated on fentanyl (N=9) and 50% of patients who were prescribed midazolam (N=6). No patients received non-weight-based dosing if the criteria for inclusion in the policy were not met.

Conclusion/Discussion: Using a non-weight-based dosing strategy for patients >50kg (IBW) resulted in lower maximal dose exposure to fentanyl and midazolam for patients admitted to a pediatric hospital. While the non-weight-based dosing orders were not utilized in all eligible patients, we hypothesize that education on the dosing for these medications contributed to a lower maximal infused dose and, therefore, lower drug exposure. Further expansion to include other neurosedative medications, common cardiac infusion and electrolyte replacement is ongoing.