Prehospital medication dosing deviates from recommended weight-based guidelines

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Compared with guideline-recommended weight-based dosing in the pediatric population, a study recently published in Pediatrics found a wide range of dosing deviations of administered medications in a prehospital setting.

In this setting, the correct dosing of medications has implications for improving outcomes and avoiding adverse events, which is why major stakeholders like The American Academy of Pediatrics, American College of Emergency Physicians, Emergency Nurses Association, National Association of Emergency Medical Technicians, and the National Association of EMS Physicians (NAEMSP) have put more emphasis on prehospital readiness in emergency medical services (EMS) related to the pediatric population.

Previously, the evaluation of errors or deviations in a pediatric prehospital setting has been limited by specific disease and region. Investigators aimed to “describe deviations from nationally recommended dosing of common medications administered to children using a large representative registry of prehospital encounters.”

To do so, study investigators performed a retrospective cohort study with deidentified prehospital patient care records from the 2020 to 2021 ESO Data Collaborative, which included electronic health records from approximately 2000 EMS agencies based in the United States. Data on interventions conducted by EMS clinicians, dispatch, demographics, vital signs, clinical presentation, and assessments are aspects of the dataset. The study, approved by ESO and Ann & Robert H. Lurie Children’s Hospital of Chicago Institutional Review Board, included all pediatric encounters in patients under 18 years who received at least 1 non-nebulized medication during the study period. Patients without a reported age were excluded from the study.

Lorazepam, diazepam, midazolam, fentanyl, hydromorphone, morphine, ketorolac, epinephrine, diphenhydramine, and methylprednisolone were investigated in the study. Evaluations of benzodiazepines were limited to encounters with an impression of seizures, while evaluations for diphenhydramine were limited to patients with an impression of anaphylaxis or allergy. Epinephrine was considered in 2 ways because of the medication’s “substantially different uses,” according to the study authors, one being intravenous (IV), the other being intramuscular (IM). IM epinephrine was only evaluated for those with a clinical impression of anaphylaxis or allergy. Two reference standards were used for medication dosing, accounting for differences in dosing by route and maximum doses. The Pediatric Advanced Life Support (PALS) were the guidelines used for the epinephrine, while dosing recommendations for the remaining 9 medications were from the National Association of State EMS Officials (NASEMSO), a panel made up of the American College of Emergency Physicians, the American Academy of Pediatrics Committee on Pediatric Emergency Medicine, and the NAEMSP. The NASEMSO guidelines recommend fixed weight-based dosing with maximums. A 20% or greater deviation from the ideal weight-appropriate dose was defined as a medication dosing deviation by the investigators. For children without a documented weight, investigators estimated weight using the “Best-Guess” formula, which “has been previously demonstrated to have greater accuracy for age-based weight estimation compared with other techniques,” according to the study.

Age, sex, type of service (advanced life support, basic life support, or critical care), transport disposition, agency status (volunteer, nonvolunteer, or mixed), agency type (community nonprofit, fire department, governmental nonfire, private nonhospital, and tribal), and primary and secondary clinician impressions were descriptive variables collected.

After identifying exclusions, 990,497 children were identified over the 2-year period and 63,963 (6.4%) received at least 1 non-nebulized medication. Of non-nebulized doses, 53.9% were for the drugs included in the study. The median age of these children was 13.4 years (interquartile range, 5.5-16.2 years) and boys made up 54.9% of the group. Of the encounters, 93.8% were treated by an advanced life support provider, of which 91.7% were transported to the hospital.

Overall consistency with national guidelines among the 80.3% of children that received a study drug and had a documented weight was 42.6 per 100 administrations. Methylprednisolone (75.1%), intramuscular epinephrine (67.9%), and ketorolac (56.4%) were the most common medications with appropriate dosing. Of the studied medications, the lowest consistency in relation to national guidelines were diazepam (19.5%) and lorazepam (21.2%). Underdose deviations were the most common, ranging from 5.4% for IV epinephrine to 74.7% for lorazepam. The most common medication for overdosing was IV epinephrine (49.3%), while the least frequent medication for overdosing was morphine (3.0%). Overall and specific drugs were similar when compared between agency types, as community nonprofit organizations were accurate 41.5% of time, 42.7% of the time for fire-based services, and 46.7% of the time for government nonfire based services.

Findings for estimated dosages from weights that were calculated by age were similar, as overall consistency with national guidelines was 35.5 per 100 administrations with the most common deviation being an underdose. When evaluation was limited to IV epinephrine for patients with cardiac arrest, appropriate dosing was administered in 47.2%, while dosing was too high in 48.4% and too low in 4.4% for patients with a documented weight (n = 1918). Appropriate dosing was deemed appropriate in 29.8%, too high in 51.8%, and too low in 18.3% of patients when estimated weights for age was used (n = 2504.)

From a nationally representative prehospital dataset, a wide range of deviations in dosing for prehospital pediatric patients were identified by study investigators, compared to guideline-recommended, weight-based doses. These results could have multiple purposes and “should be a target for future educational, quality improvement, and research activities,” the authors concluded.

Reference:

Ramgopal S, Martin-Gill C. Deviation From National Dosing Recommendations for Children Having Out-of-hospital Emergencies [published online ahead of print, 2023 Jul 10]. Pediatrics. 2023;e2023061223. doi:10.1542/peds.2023-061223