Polypharmacy is common in critically ill children and causes adverse events, including death. Identifying and understanding how specific drug combinations contribute to adverse events is challenging in critically ill children, requiring knowledge of drug levels and their relationships to adverse events. Although such information could be obtained from clinical trials, the execution of these trials for every drug combination is virtually impossible. Dr. Zimmerman aims to develop and evaluate an approach that combines electronic health records and simulated drug levels to identify and characterize polypharmacy-related adverse events in critically ill children. She hypothesizes that the combined approach will describe a relationship between drug levels and a specific adverse event similar to that identified through a clinical trial. This approach could then be used as a platform for evaluating safety in drug combinations frequently used in children. Dr. Zimmerman will conduct a pilot clinical trial to evaluate relationships between delirium scores and drug levels of fentanyl and dexmedetomidine in mechanically-ventilated children. She will then identify a single-center cohort from Duke electronic health records and apply PK models to predict drug levels in this population. Using advanced pharmacoepidemiologic methods, she will create statistical models to describe relationships between simulated drug levels and delirium scores. She will compare results to those obtained in the clinical trial. Finally, she will evaluate the broader applicability of the combined approach in a multicenter electronic health record cohort. Dr. Zimmerman is a pediatric intensivist with a proven commitment to patient-oriented research and a desire to acquire sophisticated skills in pharmacoepidemiologic methods. The skills achieved as a result of this proposal will facilitate the candidate's long-term career goal to advance public health by developing new methods to leverage information from large databases to increase the safety of drugs administered to critically ill children. The candidate's short-term career goals for the K23 program are to: 1) acquire knowledge and skills in optimal clinical trial design and pharmacoepidemiology; 2) develop the professional skills to successfully lead a clinical trial research team; and 3) produce preliminary data and publications to support an R01 grant application and establish a program of independent research in pediatric pharmacoepidemiology. This proposal will capitalize on unique opportunities provided by the Duke Clinical Research Institute (Smith, mentor) and the UNC epidemiology PhD program (Strmer, PhD advisor). The mentorship team assembled is uniquely qualified, and strengths include extensive clinical research experience, internationally recognized thought leadership in trial design, clinical pharmacology, and pharmacoepidemiology; and a successful history of mentorship of junior faculty. At the conclusion of this program, Dr. Zimmerman will be well positioned to be an independent physician-scientist leading a research team.

Public Health Relevance

Although common and potentially deadly, polypharmacy and its related adverse events have been understudied in critically ill children. Reasons for limited study are largely related to the lack of rigorous, efficient, and well-validated methods that account for the unique physiology of drug administration in pediatric critical illness. This proposal will use advanced pharmacoepidemiologic methods, electronic health records, and simulated drug levels to develop and evaluate a rigorous and efficient method for studying polypharmacy- related adverse events in critically ill children.

National Institute of Health (NIH)
Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD)
Mentored Patient-Oriented Research Career Development Award (K23)
Project #
Application #
Study Section
National Institute of Child Health and Human Development Initial Review Group (CHHD)
Program Officer
Taylor-Zapata, Perdita
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
Duke University
Schools of Medicine
United States
Zip Code
Wang, Laura A; Smith, P Brian; Laughon, Matthew et al. (2018) Prolonged furosemide exposure and risk of abnormal newborn hearing screen in premature infants. Early Hum Dev 125:26-30
Ge, Shufan; Beechinor, Ryan J; Hornik, Christoph P et al. (2018) External Evaluation of a Gentamicin Infant Population Pharmacokinetic Model Using Data from a National Electronic Health Record Database. Antimicrob Agents Chemother 62:
Heath, Travis S; Greenberg, Rachel G; Hupp, Susan R et al. (2018) Effects of Methadone on Corrected Q-T Interval Prolongation in Critically Ill Children. J Pediatr Pharmacol Ther 23:119-124
Greenberg, Rachel G; Wu, Huali; Laughon, Matthew et al. (2017) Population Pharmacokinetics of Dexmedetomidine in Infants. J Clin Pharmacol 57:1174-1182
Dallefeld, Samantha H; Spears, Tracy G; Zimmerman, Kanecia O (2017) The Challenges of Identifying an Oxygenation Index Threshold for Increased Mortality in Pediatric Acute Respiratory Failure. Respir Care 62:1375-1376