Kathleen M. Adelgais, MD, MPH et. al.

A Randomized Double Blind Trial of a Needle-free Injection System to Topical Anesthesia for Infant Lumbar Puncture

  • LPs are more likely to be successful if you use local anesthetic
  • The J-Tip – needle free injection – has onset of 1-2 minutes and doesn’t hurt. They compared this to topical anesthetic (EMLA)
  • Primary outcome was a neonatal pain score – LP success was a secondary outcome
  • Randomized controlled trial showed no difference between groups at 5 minutes
  • J-Tip had higher success rate OR = 2.9 (95% CI = 1-9.2)

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LETEMLALMX

How to succeed on your next Lumbar Puncture

Why we do what we do: Early stylet removal in lumbar puncture

Paul C. Mullan, MD, MPH et. al.

A quality improvement project to decrease blood culture contaminants in a pediatric emergency department: an interrupted time series analysis

  • The national blood culture contaminant rate benchmark is <2%
  • The group used PDSA cycles to reduce contaminant rates from 3% that they were seeing locally to 1.51%
  • Secondary aim reduce blood culture ordering rare by 10% over 24 months
  • They excluded patients with cancer, central lines, VP shunts, neutropenia or transplant history
  • Key Drivers were  – increase venipuncture sterility
    • Nurse education initiatives including annual reviews, educational
  • …and reduce number of blood culture orders
    • With educational initiatives and guidelines as well as shared accountability
  • They are currently measuring ED bounce back rates – they have saved up to $290,000+
  • This study was nurse initiated!

Jay Pershad, MD, MMM, FAAP et. al.

Optimal Imaging Strategy for Suspected Acute Cranial Shunt Failure: A Cost-Effectiveness Analysis

  • The team did a cost effectiveness analysis (a model – not an actual comparative trial) of 4 modalities – note that all got plain X-Ray shunt series
    • CT
    • fast MRI
    • POCUS (point of care ultrasound) followed by CT
    • POCUS screening of optic nerve sheath diameter (ONSD) followed by MRI
  • If the rate of shunt failure is 30%, then POCUS + normal shunt series was the most cost effective
  • If there was an abnormal shunt series or ONSD on U/S then fast MRI was more cost effective when compared with CT
  • If they did fast MRI on all patients it would cost ~$270,000 to gain one additional QALY for a child with a shunt
  • In conclusion – children with low pre-test probability benefit most from U/S measurement of ONSD as the preferred initial test.
  • In children with high-pre-test probability the fast MRI is the most cost effective

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A podcast on CSF shunt complications

Jianling Xie et. al.

Relationship between Enteric Pathogen and Acute Gastroenteritis Disease Severity: A Prospective Cohort Study

  • Does it really matter which pathogen causes acute gastroenteritis?
  • They performed a perspective cohort of children with AGE and tested for 28 pathogens
  • They used the Total Modified Vesikari Scale
  • 36% had isolated vomiting in their cohort
  • Rotavirus, Norovirus and Adenovirus were the most common pathogens
  • Predictors of severe disease included
    • Rotavirus OR = 8
    • Salmonella OR = 5.4
    • Adenovirus OR = 2.1
    • Norovirus G2 OR = 1.8

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Validation of the Total Modified Vesikari Scale – Schnadower et al.J Pediatrician’s Gastroenterol Nutr, 2014

Fran Balamuth, MD, PhD, MSCE et. al.

Predictive Modeling for Organ Dysfunction in Children with Suspected Sepsis in the Emergency Department

  • A single-center prospective study where patients were treated with a sepsis protocol in the ED
  • They assessed for organ dysfunction by international consensus criteria – within the first 3 days of hospitalization
  • Their final model – bolstered by machine learning – showed that the following were associated with organ dysfunction
    • WBC
    • Procalcitonin
    • Time to initial IV antibiotics
    • Time to initial IV fluids
  • Their machine learning algorithm had the following test characteristics – in the validation set. Note that these values were higher in the “Training” set, where they actually built the model.
    • Sensitivity 83%
    • Specificity 63.%
    • Positive Likelihood Ratio 90%
    • Negative Predictive Value 49.4%

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Are you pro Procalcitonin?

David Piechota, MD et. al.

Refinement of Appendix Ultrasound Interpretation to Limit Equivocal Results

  • The team begun using a standardized assessment tool for appendicitis ultrasound
  • Most common secondary signs associated with appendicitis when the appendix was not seen include
    • Non-compressible appendix
    • Echogenic fat
    • RLQ tenderness
  • If >1 secondary sign was seen rate of apps was 30.2% versus 6.5% if none were seen
  • Though rate of actually finding the appendix didn’t change they were better able to attend to the nuances of  ultrasound interpretation

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2017 Starter Pack: Appendicitis

Rohit P. Shenoi, MD et. al.

The Pediatric Submersion Score Predicts Children at Low Risk for Injury Following Submersions

  • A single center cross-sectional derivation and validation study to predict children at low risk for injury after a submersion event
  • To predict safe discharge at 8 hours the score identified 5 factors – a higher score is better
    • Normal mental status
    • Normal respiratory rate
    • Absence of dyspnea
    • Absence of need for respiratory support (intubation, bag valve mask, CPAP)
    • Absence of hypotension
  • The overall discriminate ability peaks at 75% (score 3.5)
  • A score >4 predicts safe discharge home from the ED at 8 hours