Faculty Bibliography

OBJECTIVES: To report our experience with the use of IV enoxaparin in neonatal and pediatric patients in the ICU. DESIGN: We performed a case control from January 1, 2009, to June 30, 2012, comparing patients that received IV enoxaparin to controls that received subcutaneous enoxaparin. Cases were matched to controls in a 1:2 manner. IV enoxaparin doses were infused over 30 minutes and anti-Factor Xa levels were drawn 4 hours after the start of the IV infusion or 4 hours after a subcutaneous dose. SETTING: The pediatric and cardiac ICUs of a tertiary/quaternary, free-standing, academic children's hospital. PATIENTS: Forty-five neonatal and pediatric patients receiving prophylactic or therapeutic enoxaparin. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fifteen cases and 30 controls were included. Of 15 patients, 13 received IV enoxaparin for treatment and two received IV enoxaparin for prophylaxis as compared with 25 of 30 controls receiving subcutaneous enoxaparin for treatment and five receiving subcutaneous enoxaparin for prophylaxis. The ages for the cases ranged from 21 days to 16 years with a median weight of 5 kg, and the ages for controls ranged from 10 days to 23 years with a median weight of 31 kg. The median duration of IV therapy was 11 days (range, 1-120 d) and the median duration for subcutaneous therapy was 15 days (range, 3-85 d). The mean initial IV dose was 1.14 +/- 0.38 mg/kg/dose q12h, and the mean initial subcutaneous dose was 0.85 +/- 0.2 mg/kg/dose subcutaneous q12h (p = 0.003). The mean therapeutic IV dose was 1.31 +/- 0.52 mg/kg/dose q12h, and the mean therapeutic subcutaneous dose was 0.9 +/- 0.3 mg/kg/dose q12h (p = 0.016). There were no adverse events reported related to bleeding, thrombosis, or hypersensitivity in any of the cases or controls evaluated. CONCLUSION: The pharmacodynamics of a 30-minute IV enoxaparin infusion was found to produce therapeutic 4 hour anti-Factor Xa levels similar to subcutaneous doses. Although this was a small study, there were no adverse events, suggesting the safety profile of IV enoxaparin may be similar to subcutaneous dosing with the added benefit of less pain associated with IV dosing. These findings suggest that IV enoxaparin may be a viable option for anticoagulating critically ill children and its use warrants further study.

Sepsis brings about neuroendocrine dysfunction in children that differs significantly from that of adults and can thus be difficult to interpret and manage. Aggressive treatment of sepsis with appropriate and judicious use of antibiotics remains a top priority. Strict glycemic control in children has been associated with significant risk of hypoglycemia, which may independently contribute to morbidity and mortality. Timely initiation of hydrocortisone in persistently hypotensive children with fluid-refractory, catecholamine-resistant shock is controversial, but its use in children with suspected or proven adrenal insufficiency is suggested. Fluid and electrolyte abnormalities must be corrected. Treatment of thyroid dysfunction has been shown to be beneficial in certain specific populations but cannot be extrapolated to all septic patients with the current available data.

Hemangiomas are the most common benign tumor of infancy. Most hemangiomas remain asymptomatic and can be managed by close observation; however, immediate treatment is indicated for hemangiomas that may cause significant complications. Periocular hemangiomas warrant close evaluation and early, active treatment of those with the potential to threaten or permanently compromise vision. Herein we review the clinical features of periocular hemangiomas, differential diagnosis, possible ophthalmologic complications and sequelae, and therapeutic modalities

It has been suggested that deficits in symptom awareness and attribution in schizophrenia are relatively independent of core symptoms of the disorder. Many studies report conflicting findings, however, which may be explained by differences in study design and target population. In this study 33 individuals with schizophrenia or schizoaffective disorder were assessed longitudinally using standard symptom and insight measures, with analyses focusing on associations with psychotic, depression and anxiety symptoms. Both cross-sectional and longitudinal analyses showed significant but only moderate associations between insight and symptoms of depression and disorganization, with no consistent relationships with positive and negative symptoms. Higher levels of depression were associated with improved awareness and attribution, whereas higher levels of disorganized symptoms were associated with deficits in awareness and attribution. The results are compared with the previous literature, and it is suggested that insight deficits in schizophrenia may vary depending on factors such as course and phase of illness.