Farooqi Mariya, Seifert Steven, Kunkel Susan, Johnson Mary, Benson Blaine
New Mexico Poison and Drug Information Center and University of New Mexico College of Pharmacy, Albuquerque, NM, USA.
J Med Toxicol. 2009 Sep;5(3):130-3. doi: 10.1007/BF03161223.
Clonidine is frequently prescribed to children. Clonidine overdose in children has resulted in major clinical effects and deaths.
A 3.5-year-old male with a history of a seizure disorder and night terrors presented following difficulty walking, excessive sleeping, agitation when awake, and possible seizure activity. Chronic medications were valproic acid (VPA) and clonidine. On presentation, he alternated between poor responsiveness and agitation, with initial vitals: blood pressure, BP 144/76 mmHg; heart rate, 65 bpm; respiratory rate, 18 bpm; temperature 99.5 degrees F; and pulse oximetry 96% on room air. VPA level was 35 microg/mL. A toxicology consult the next day noted a dry mouth, 2-mm pupils, intermittent gasping, and central nervous system (CNS) depression, with a diagnostic impression of clonidine overdose. The caregiver had been giving 1 mL (0.1 mg) qd of a pharmacy-compounded clonidine suspension by a provided syringe. The pharmacy procedure record agreed with the physicians order. The amount dispensed was a 30-day supply but the bottle was empty on day 19, leading us to suspect a possible accelerated dosing error. The concentration in the bottle thus could not be confirmed. The child slowly returned to his baseline state over 48 hours. A serum clonidine level drawn approximately 18 hours after his last dose later returned at 300 ng/mL (reference range = 0.5-4.5 ng/mL).
Compounding and liquid dosing errors are common in children and may result in massive overdoses. There was an accelerated dosing error, but whether a compounding or suspension error or even an acute overdose occurred as well is unknown.
Particular care should be taken with medications that have low therapeutic indices, that are extemporaneously compounded, and are prepared as liquids, where medication errors are more likely.
可乐定常用于儿童。儿童可乐定过量已导致严重临床后果及死亡。
一名3.5岁男性，有癫痫和夜惊病史，因行走困难、过度嗜睡、清醒时烦躁不安及可能的癫痫发作前来就诊。长期服用的药物有丙戊酸（VPA）和可乐定。就诊时，他在反应迟钝和烦躁之间交替，初始生命体征为：血压144/76 mmHg；心率65次/分钟；呼吸频率18次/分钟；体温99.5华氏度；室内空气中脉搏血氧饱和度96%。VPA水平为35微克/毫升。次日的毒理学会诊发现口干、瞳孔2毫米、间歇性喘息及中枢神经系统（CNS）抑制，诊断为可乐定过量。护理人员一直通过提供的注射器每日给予1毫升（0.1毫克）药房配制的可乐定混悬液。药房程序记录与医生医嘱一致。配药量为30天的供应量，但在第19天瓶子就空了，这使我们怀疑可能存在加速给药错误。因此无法确认瓶中药物浓度。该患儿在48小时内缓慢恢复至基线状态。最后一剂后约18小时采集的血清可乐定水平后来回报为300纳克/毫升（参考范围 = 0.5 - 4.5纳克/毫升）。
配制和液体给药错误在儿童中很常见，可能导致大量药物过量。存在加速给药错误，但是否同时发生了配制错误、混悬液错误甚至急性过量尚不清楚。
对于治疗指数低、需临时配制且制成液体的药物，应格外小心，因为这些药物更容易出现用药错误。
