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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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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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