Reactions 1477, p13 - 9 Nov 2013 O S Clonidine overdose Prolonged hypertension in a child following a compounding error: case report A 7-year-old boy developed prolonged hypertension after receiving a 1000-fold overdose of clonidine due to a compounding error. The boy, who had a history of pervasive developmental disorder and attention deficit hyperactivity disorder, received his morning dose of clonidine 2.5mL of a 0.1mg/5mL suspension. Thirty minutes later, he was found unresponsive and apneic by his mother. On presentation to an emergency department, he was lethargic with pinpoint pupils; he had a BP of 136/90mm Hg, a pulse of 110/min and a RR of 5/min. The boy was intubated with etomidate and suxamethonium chloride [succinylcholine chloride], and he was transferred to a paediatric ICU with a BP of 140/115mm Hg. He remained hypertensive for 8 hours, and his BP subsequently decreased to 90/40mm Hg. He was intubated for 5 days due to a secondary infection, and he was later discharged without sequelae. A review of records found his pharmacist had unintentionally prepared the suspension with clonidine 4.5g instead of 4.5mg. Author comment: "[I]t is likely that the peripheral alpha2 adrenergic effects predominated over the central effects, leading to the prolonged hypertension. . . a compounding error, where 4.5 grams was inadvertently added instead of 4.5 milligrams, led to a 1,000-fold overdose." Biary R, et al. Prolonged Hypertension from a 1,000 fold clonidine compounding error. Clinical Toxicology 51: 596 abstr. 48, No. 7, Aug 2013. Available from: URL: http://dx.doi.org/10.3109/15563650.2013.817658 - USA 803095202 1 Reactions 9 Nov 2013 No. 1477 0114-9954/13/1477-0001/$14.95 Adis © 2013 Springer International Publishing AG. All rights reserved

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Reactions 1477, p13 - 9 Nov 2013

O SClonidine overdose

Prolonged hypertension in a child following acompounding error: case report

A 7-year-old boy developed prolonged hypertension afterreceiving a 1000-fold overdose of clonidine due to acompounding error.

The boy, who had a history of pervasive developmentaldisorder and attention deficit hyperactivity disorder, receivedhis morning dose of clonidine 2.5mL of a 0.1mg/5mLsuspension. Thirty minutes later, he was found unresponsiveand apneic by his mother. On presentation to an emergencydepartment, he was lethargic with pinpoint pupils; he had a BPof 136/90mm Hg, a pulse of 110/min and a RR of 5/min.

The boy was intubated with etomidate and suxamethoniumchloride [succinylcholine chloride], and he was transferred to apaediatric ICU with a BP of 140/115mm Hg. He remainedhypertensive for 8 hours, and his BP subsequently decreasedto 90/40mm Hg. He was intubated for 5 days due to asecondary infection, and he was later discharged withoutsequelae. A review of records found his pharmacist hadunintentionally prepared the suspension with clonidine 4.5ginstead of 4.5mg.

Author comment: "[I]t is likely that the peripheral alpha2adrenergic effects predominated over the central effects,leading to the prolonged hypertension. . . a compoundingerror, where 4.5 grams was inadvertently added instead of4.5 milligrams, led to a 1,000-fold overdose."Biary R, et al. Prolonged Hypertension from a 1,000 fold clonidine compoundingerror. Clinical Toxicology 51: 596 abstr. 48, No. 7, Aug 2013. Available from:URL: http://dx.doi.org/10.3109/15563650.2013.817658 - USA 803095202