title: Optimizing pediatric esmolol dosing using computerized practitioner order entry.
abstract: OBJECTIVE
  The aims of this study were to 1) describe the cardiovascular dose-response of esmolol and dose-limiting adverse effects in pediatric patients; 2) assess an institutional guideline for protocol adherence, efficacy, and achievement of therapeutic targets for pediatric patients with tachyarrhythmias or systemic hypertension; and 3) revise the protocol accordingly.
  
  
  METHODS
  In this prospective study, pediatric/neonatal subjects were identified using a medication utilization report in the electronic medical record and treated with esmolol for blood pressure or rhythm control at Rady Children's Hospital San Diego between November 1, 2012, and February 28, 2013. Inclusion criteria required subjects to be under intensive care and have bedside telemetry monitoring. Data collection consisted of patient demographic information, administration history of esmolol, concurrent administration of other cardiovascular medications, patient cardiovascular goals, and vital signs.
  
  
  RESULTS
  A total of 8 subjects representing 10 administrations of esmolol were included in the study. Whereas esmolol was found to be safe and effective overall for control of hypertension and tachyarrhythmia, protocol adherence was poor, leading to subtherapeutic dosing schemes, dose changes prior to achievement of presumed steady-state pharmacokinetics, and erratic dosing to target effect.
  
  
  CONCLUSIONS
  After the review, the data were revealed at a program-wide conference and consensus was reached on a new, data-driven protocol. As a result of this quality improvement initiative, the new protocol provides more precise dosing and clearly delineated therapeutic targets and is designed to reflect specific esmolol pharmacokinetics. The effort emphasizes the need to construct foundations for follow-up quality improvement efforts in intensive care pharmacology.
authors.affiliation: Rady Children's Hospital, San Diego, California.
authors.forename: Tihua
authors.initials: T
authors.lastname: Chao
authors.affiliation: Rady Children's Hospital, San Diego, California ; University of California, San Diego, School of Medicine, San Diego, California.
authors.forename: James C
authors.initials: JC
authors.lastname: Perry
authors.affiliation: Rady Children's Hospital, San Diego, California.
authors.forename: Gale L
authors.initials: GL
authors.lastname: Romanowski
authors.affiliation: Rady Children's Hospital, San Diego, California ; University of California, San Diego, School of Medicine, San Diego, California.
authors.forename: Adriana H
authors.initials: AH
authors.lastname: Tremoulet
authors.affiliation: University of California, San Diego, School of Medicine, San Diego, California ; University of California, San Diego, Skaggs School of Pharmacy, San Diego, California.
authors.forename: Edmund V
authors.initials: EV
authors.lastname: Capparelli
keywords: computerized practitioner order entry; esmolol; pediatrics; pharmacology; quality improvement