The Cochrane Database of Systematic Review concluded that ketogenic diets (KDs), which are diets high in fat and low in carbohydrates, may reduce seizure frequency in those with refractory epilepsy. KDs may be especially helpful in pediatric patients with treatment-resistant seizure disorder.

A KD is recommended in patients who have not shown seizure control with two appropriately selected and adequately dosed antiseizure medications. Any substance, including drug therapy, that disrupts the balance between fats and carbohydrates has the potential to reduce seizure control. Unintentional medication errors can occur when a patient on a KD receives more than 300 mg/day of additional carbohydrates that is not calculated in the carbohydrate daily allowance.

Concern has been raised that commonly administered parenteral medications contain carbohydrates in either the drug formulation (e.g., propylene glycol [PG]) or in the diluent (e.g., dextrose).

It has been suggested that a standardized order set be developed and incorporated into the electronic health record to assist with the identification and selection order of medications that would not adversely affect a KD patient’s carbohydrate allowance.

As part of a quality initiative, investigators conducted a needs assessment to determine the extent of potential risk for accidental carbohydrate exposure in patients on a KD diet treated in the emergency department, ICU, or operating room at two academic medical centers.

After conducting a literature review, they examined 50 parenteral medications commonly used in the acute setting for their potential risk of carbohydrate exposure either from the undiluted drug or following reconstitution with a diluent.

Among the IV central nervous system drugs studied, dexamethasone, dexmedetomidine fentanyl, midazolam, rocuronium, and valproic acid had no carbohydrate content in the undiluted drug product but other drugs (e.g., acetaminophen [which contained mannitol], propofol [which contained glycerol], and diazepam, etomidate, lorazepam, pentobarbital, phenobarbital, and phenytoin [which contained PG]), did contain carbohydrates in the undiluted drug. Mannitol was also included in this list with 1 mg of mannitol containing 1 mg of carbohydrates. Vecuronium was listed as having 194 mg of carbohydrate content per 20-mL vial, but the carbohydrate included was not identified. Additionally, use of dextrose containing diluents varied between facilities and whether or not the drug required dilution.

Among IV cardiovascular drugs studied, calcium chloride, dobutamine, dopamine, epinephrine, hydrocortisone, nicardipine, nitroprusside, and norepinephrine did not contain carbohydrates in their undiluted form; however, digoxin, esmolol, hydralazine, some formulations of lidocaine, and nitroglycerin contained PG. Additionally, calcium gluconate, labetalol, and milrinone also contained carbohydrates. As mentioned previously, use/need for a dextrose-based diluent varied by product and facility.

All (except for one) of the IV antibiotics analyzed did not contain carbohydrates. The exception was sulfamethoxazole/trimethoprim, which contained PG. However, the use of dextrose-containing diluents varied by drug and facility.

The authors describe the development of an institutional protocol for those receiving a KD to inform prescribers about the unintentional carbohydrate exposure from parenteral medications. Collaboration between a pharmacist and a KD trained-registered dietician resulted in the development of an electronic medical record alert that would trigger during the drug-ordering process for patients who were on a KD and for whom a drug containing a clinically significant amount of carbohydrates was prescribed.

The investigators found that prior to the alert, pediatric patients on a KD were exposed to an average of 0.69 carbohydrate-containing medication orders per day. Following the implementation of the clinical decision support tool, this number dropped to 0.35 orders per patient per day. This represented a significant improvement in patient safety.

This quality improvement initiative is one that health-system pharmacists can implement in their facilities to improve unintentional medication errors that may compromise the seizure control of pediatric patients on a KD, and which may occur during transitions of care.

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