title: A child presenting with acute renal failure secondary to a high dose of indomethacin: a case report.
abstract: BACKGROUND
  Acute renal failure caused by nonsteroidal anti-inflammatory drugs administered at therapeutic doses is generally mild, non-anuric and transitory. There are no publications on indomethacin toxicity secondary to high doses in children. The aim of this article is to describe acute renal failure secondary to a high dose of indomethacin in a child and to review an error in a supervised drug prescription and administration system.
  
  
  METHODS
  Due to a medication error, a 20-day-old infant in the postoperative period of surgery for Fallot's tetralogy received a dose of 10 mg/kg of indomethacin, 50 to 100 times higher than the therapeutic dose. The child presented with acute, oligo-anuric renal failure requiring treatment with continuous venovenous renal replacement therapy, achieving complete recovery of renal function with no sequelae.
  
  
  CONCLUSIONS
  In order to reduce medication errors in critically ill children, it is necessary to develop a supervised drug prescription and administration system, with controls at various levels.
authors.affiliation: Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain. pielvi@ya.com.
authors.forename: Felipe
authors.initials: F
authors.lastname: González
authors.forename: Jesús
authors.initials: J
authors.lastname: López-Herce
authors.forename: Cinta
authors.initials: C
authors.lastname: Moraleda