Application of therapeutic drug monitoring in the establishment of pharmacovigilance system for children with digoxin poisoning
10.3760/cma.j.cn114015-20200714-00770
- VernacularTitle:治疗药物监测在儿童地高辛中毒警戒制度建立中的应用
- Author:
Wenwen CHEN
1
;
Yongxian JIANG
;
Wanjun TAO
;
Jia YANG
;
Gen LI
Author Information
1. 电子科技大学医学院附属医院·成都市妇女儿童中心医院药学部，成都 611731
- Publication Type:Journal Article
- Keywords:
Drug monitoring;
Digoxin;
Medication errors;
Poisoning;
Child
- From:
Adverse Drug Reactions Journal
2021;23(1):35-38
- CountryChina
- Language:Chinese
-
Abstract:
A 4-month and 19-day-old girl with a body weight of 4.4 kg was treated with 5% digoxin oral solution 0.9 ml (0.045 mg) once per 12 hours after repair of ventricular septal and atrial septal defects. Spironolactone, hydrochlorothiazide, and captopril were given at the same time. The blood concentration of digoxin was detected on the 6th day of medication, and the pharmacist found that it was more than 5.0 μg/L, and immediately went to the ward to see the child. The bedside electrocardiograph showed that the baby girl had reduced heart rate (80 beats/min), arrhythmia, third-degree atrioventricular block, complete right bundle-branch block, and ST-T changes. Digoxin poisoning was diagnosed and digoxin was immediately discontinued. Three days later, the blood concentration of digoxin decreased to 1.66 μg/L, and her heart rate and electrocardiograph returned to normal. By reviewing the medication information of the baby, a digoxin poisoning event due to overdose of digoxin and drug interactions was diagnosed. Due to the event, the use of digoxin in hospitalized children in the whole hospital from January 2017 to May 2019 was investigated. Among 323 children, 14 children (4.3%) overdosed with digoxin; 235 children (72.8%) were treated with digoxin for more than 5 days, but the detection rate of blood concentration was only 12.8% (30/235); 67.5% children (240/323) were prescribed drugs that might interact with digoxin or increase the risk in digoxin treatment. Through the analysis of risk factors, improvement measures such as optimizing medical order audit system, increasing the monitoring rate of digoxin blood concentration, and strengthening training were put forward, and an expert consensus in the hospital was reached. After implementation of the improvement measures, a total of 47 children were prescribed digoxin in the whole hospital from January to June, 2020, none of them were given overdose of digoxin, and the monitoring rate of digoxin blood concentration was increased to 40.4% (19/47).
