In this episode host Jason Woods talks with Corrie Chumpitazi and Pradip Kamat about the general trends in pediatric sedation (outside of the operating room) over the last decade, centered on a paper they co-authored. The discussion focuses on changing distribution of WHO is doing sedations, medications used, and safety measures.
Highlighted paper: Kamat PP, McCracken CE, Simon HK, et al. Trends in Outpatient Procedural Sedation: 2007-2018. Pediatrics. 2020;145(5):e20193559. doi:10.1542/peds.2019-3559
DISCLOSURE: We will be discussing sedation medications, which are commonly used but not FDA approved for children for this indication.
Corrie E. Chumpitazi MD, MS, Associate Professor of Pediatrics, Baylor College of Medicine/Texas Children’s Hospital
Director of Sedation, Associate Chief of Research, Sedation Oversight Committee Chair, Section of Emergency Medicine, Baylor College of Medicine/Texas Children’s Hospital
Site Principal Investigator, National EMS for Children Innovation and Improvement Center
Society for Pediatric Sedation Provider Course Chair
Pradip P. Kamat MD, MBA Associate Professor of Pediatrics/Pediatric Critical Care Medicine Children’s Heathcare of Atlanta/Emory University School of Medicine
Director Children’s Sedation Services At Egleston, Children’s Healthcare of Atlanta/Emory University School of Medicine
Society for Pediatric Sedation, Chair of Membership Committee, President-Elect
Kamat PP, McCracken CE, Simon HK, et al. Trends in Outpatient Procedural Sedation: 2007-2018. Pediatrics. 2020;145(5):e20193559. doi:10.1542/peds.2019-3559
Bhatt M, Kennedy RM, Osmond MH, Krauss B, McAllister JD, Ansermino JM, Evered LM, Roback MG; Consensus Panel on Sedation Research of Pediatric Emergency Research Canada (PERC) and the Pediatric Emergency Care Applied Research Network (PECARN). Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children. Ann Emerg Med. 2009 Apr;53(4):426-435.e4. doi: 10.1016/j.annemergmed.2008.09.030. Epub 2008 Nov 20. PMID: 19026467.
Roback MG, Green SM, Andolfatto G, Leroy PL, Mason KP. Tracking and Reporting Outcomes Of Procedural Sedation (TROOPS): Standardized Quality Improvement and Research Tools from the International Committee for the Advancement of Procedural Sedation. Br J Anaesth. 2018 Jan;120(1):164-172. doi: 10.1016/j.bja.2017.08.004. Epub 2017 Nov 23. PMID: 29397125.
Mallory MD, Baxter AL, Yanosky DJ, Cravero JP; Pediatric Sedation Research Consortium. Emergency physician-administered propofol sedation: a report on 25,433 sedations from the pediatric sedation research consortium. Ann Emerg Med. 2011;57(5):462-8.e1.
Jenkins E, Hebbar KB, Karaga KK, et al. Experience with the use of propofol for radiologic imaging in infants younger than 6 months of age. Pediatr Radiol. 2017;47(8):974-983. doi:10.1007/s00247-017-3844-7
Biber JL, Allareddy V, Allareddy V, et al. Prevalence and Predictors of Adverse Events during Procedural Sedation Anesthesia-Outside the Operating Room for Esophagogastroduodenoscopy and Colonoscopy in Children: Age Is an Independent Predictor of Outcomes. Pediatr Crit Care Med. 2015;16(8):e251-e259. doi:10.1097/PCC.0000000000000504
In this episode, host Jason Woods speaks with Emma Harding and Laura Bricklin about drowning in children. The discussion covers prevention (specifically parental and patient education) and management, as well as the current terminology and existing data.
This episode is produced in conjunction with Drs. Emma Harding and Laura Bricklin as part of their worth on an AAP CATCH grant.
The following show notes were authored by Drs. Bricklin and Harding and provide a fantastic review.
Drowning is the #1 cause of preventable death in children age 1-4
You can’t drown-proof a child – multiple layers of protection help prevent drowning
Providers are a major source of water-safety education for most families
Major Data Points
Drowning claimed the lives of nearly 1,000 children (under 20 years old) in 2017, and an estimated 8,700 children visited a hospital emergency department for a drowning.
Two age groups have the highest risk of drowning – toddlers, and teens. Teens of color are at especially high risk.
The highest rate of drowning is among children under age 4, with children 12 to 36 months of age being at the highest risk.
Most infants drown in bathtubs and buckets.
Most preschool-aged children drown in swimming pools.
CPSC found that 69% of children under 5 who drowned were not expected to be at or near a pool when the drowned.
Teens ages 15-19 years have the second-highest fatal drowning rate. Every year, about 370 children ages 10-19 drown.
Among teens, half of all drownings occur in natural water settings like lakes, rivers or oceans.
Among teens, drowning is due to a variety of factors, but alcohol is often involved.
Layers of Protection
All children and adults should learn to swim. If swim lessons are suspended in your area due to coronavirus, it is important to add other layers of protection until your child can access lessons.
Close, constant, attentive supervision around water is important. Assign an adult ‘water watcher,’ who should not be distracted by work, socializing, or chores.
Around the house, empty all buckets, bathtubs, and wading pools immediately after use. If you have young children, keep the bathroom door closed, and use toilet locks to prevent access.
Pools should be surrounded by a four-sided fence, with a self-closing and self-latching gate. Research shows pool fencing can reduce drowning risk by 50%. Additional barriers can include door locks, window locks, pool covers, and pool alarms.
Adults and older children should learn CPR.
Everyone, children and adults, should wear US Coast Guard-approved life jackets whenever they are in open water, or on watercraft.
Parents and teens should understand how using alcohol and drugs increase the risk of drowning while swimming or boating.
Fatal and nonfatal drowning typically begins with a period of panic, loss of the normal breathing pattern, breath-holding, air hunger, and a struggle by the victim to stay above the water.
Reflex inspiratory efforts eventually occur, leading to hypoxemia by means of either aspiration or reflex laryngospasm that occurs when water contacts the lower respiratory tract
Results in decreased lung compliance, ventilation-perfusion mismatching, and intrapulmonary shunting, leading to hypoxemia that causes diffuse organ dysfunction
Rescue and immediate resuscitation by bystanders improves the outcome of drowning victims
Ventilation is generally considered the most important initial treatment for victims of submersion injury. Rescue breathing should begin as soon as the rescuer reaches shallow water or a stable surface. Note that the priorities of CPR in the drowning victim differ from those in the typical adult cardiac arrest patient, which emphasizes immediate uninterrupted chest compressions. If the patient does not respond to the delivery of two rescue breaths that make the chest rise, the rescuer should immediately begin performing high-quality chest compressions.
In a large, population-based, observational study using a Japanese government registry, no significant difference in neurologic outcome at one month was found between drowning victims treated initially with compression-only CPR and conventional CPR with rescue breathing
According to the AHA Guidelines for Advanced Cardiac Life Support (ACLS), routine cervical spine immobilization can interfere with essential airway management and is not recommended
unless there are clinical signs of injury or a concerning mechanism (eg, dive into shallow water)
Pulses may be very weak and difficult to palpate in the hypothermic patient with sinus bradycardia or atrial fibrillation; a careful search for pulses should be performed for at least one minute before initiating chest compressions in the hypothermic patient because these arrhythmias require no immediate treatment.
Attempts at rewarming hypothermic patients with a core temperature <33ºC should be initiated, either by passive or active means as available.
If tracheal intubation is performed, an orogastric tube should be placed to relieve gastric distension, which occurs from passive passage of fluid and is common in nonfatal drowning patients.
A bedside glucose measurement should be obtained soon upon arrival.
Wet clothing should be removed and rewarming initiated in hypothermic patients.
Methods include passive and active external rewarming (eg, application of warm blankets, plumbed garments, heating pads, radiant heat, forced warm air), and active internal core rewarming (eg, warmed humidified oxygen via tracheal tube, heated irrigation of peritoneal and pleural cavities).
In addition, endovascular and several extracorporeal rewarming options are available in some centers.
Possibly because of the neuroprotective effects of hypothermia, complete recovery of some patients with accidental hypothermia and cardiac arrest, despite prolonged resuscitation, has been well documented
Therefore, prolonged resuscitative efforts may be effective (in rare instances, even if continued for several hours) and should be continued until the patient’s core temperature reaches 32 to 35ºC (90 to 95ºF)
Most non-fatal drowning victims are hospitalized because of the severity of illness or concern for clinical deterioration.
However, a review of 75 pediatric patients found that all who ultimately developed symptoms did so within seven hours of immersion
Asymptomatic patients should be closely observed for approximately eight hours and admitted if any deterioration occurs.
If vital signs, pulse oximetry, and all studies, including a chest radiograph obtained close to the end of the observation period, are normal and no clinical deterioration develops during this period, the patient may be discharged with appropriate follow-up.
Clear verbal and written instructions to return to the emergency department immediately for any respiratory or other problems must be given, and the patient must be accompanied by a responsible adult.
Brenner, R. A., Taneja, G. S., Haynie, D. L., Trumble, A. C., Qian, C., Klinger, R. M., & Klebanoff, M. A. (2009). Association Between Swimming Lessons and Drowning in Childhood. Archives of Pediatrics & Adolescent Medicine,163(3), 203. doi:10.1001/archpediatrics.2008.563
Causey, A. L., Tilelli, J. A., & Swanson, M. E. (2000). Predicting discharge in uncomplicated near-drowning. The American Journal of Emergency Medicine,18(1), 9-11. doi:10.1016/s0735-6757(00)90039-1
Chandy, D., MD, & Weinhouse, G. L., MD. (2020). Drowning (submersion injuries). Retrieved August 01, 2020, from https://www.uptodate.com/contents/drowning-submersion-injuries
Denny, S. A., Quan, L., Gilchrist, J., Mccallin, T., Shenoi, R., Yusuf, S., . . . Weiss, J. (2019). Prevention of Drowning. Pediatrics,143(5). doi:10.1542/peds.2019-0850
Hoek, T. L., Morrison, L. J., Shuster, M., Donnino, M., Sinz, E., Lavonas, E. J., . . . Gabrielli, A. (2010). Part 12: Cardiac Arrest in Special Situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation,122(18_suppl_3). doi:10.1161/circulationaha.110.971069
Lavonas, E. J., Drennan, I. R., Gabrielli, A., Heffner, A. C., Hoyte, C. O., Orkin, A. M., . . . Donnino, M. W. (2015). Part 10: Special Circumstances of Resuscitation. Circulation,132(18 suppl 2). doi:10.1161/cir.0000000000000264
Pratt, F. D., & Haynes, B. E. (1986). Incidence of “Secondary Drowning” after saltwater submersion. Annals of Emergency Medicine,15(9), 1084-1087. doi:10.1016/s0196-0644(86)80133-0
Schmidt, A. C., Sempsrott, J. R., Hawkins, S. C., Arastu, A. S., Cushing, T. A., & Auerbach, P. S. (2016). Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning. Wilderness & Environmental Medicine,27(2), 236-251. doi:10.1016/j.wem.2015.12.019
Tobin, J. M., Ramos, W. D., Pu, Y., Wernicki, P. G., Quan, L., & Rossano, J. W. (2017). Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning. Resuscitation,115, 39-43. doi:10.1016/j.resuscitation.2017.04.004
Venema, A. M., Groothoff, J. W., & Bierens, J. J. (2010). The role of bystanders during rescue and resuscitation of drowning victims. Resuscitation,81(4), 434-439. doi:10.1016/j.resuscitation.2010.01.005
On this episode, host Jason Woods talks with Dr. Megan Barry, pediatric neurologist and stroke specialist, about pediatric stroke. This episode serves as a primer to pediatric stroke and a foundation for future discussion. We talk about diagnosis and initial management, risk factors, and places that can trip you if you aren’t careful
Of note, since recording, the International Pediatric Stroke Organization has been founded and has a number of great resources. Guests
Megan Barry, DO. Assistant professor, Pediatric Neurohospitalist, Adult Vascular Neurologist, University of Colorado and Children’s Hospital Colorado
On this episode, host Jason Woods talks with Alexis Topjian about the 2019 “AHA Pediatric Post–Cardiac Arrest Care Scientific Statement.” Dr. Topjian is the first author on the statement, which is the first pediatric post arrest care statement from the AHA (previously children had primarily been discussed as a special population within a primarily adult guideline). The document itself is long, but contains a large amount of useful information for bedside providers, health care administrators, and researchers.
Alexis Topjian MD, Associate Professor of Anesthesia and Critical Care Medicine, University of Pennsylvania School of Medicine, Children’s Hospital of Philadelphia
On this episode, host Jason Woods speaks with Dr Heather Hoch DeKeyser, pediatric pulmonologist, about EVALI (e-cigarette or vaping product use-associated lung injury). This recently recognized condition has caused numerous people to suffer severe lung disease. We discuss the definition, current approach, remaining mysteries, and potential causes.
All treatment discussed is based on the most recent CDC EVALI guideline at the time of recording – available here
Heather Hoch DeKeyser MD – Assistant Professor, Dept. of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado
On this episode, host Jason Woods speaks with Dr Nelson Sanchez-Pinto, pediatric intensivist, about an article he co-authored that was just e-published in the last week! The article concerns a retrospective analysis of the use of HAT therapy (hydrocortisone, ascorbic acid, thiamine) at a single center PICU for the treatment of pediatric septic shock. The e-pub link is below and this post will update when it is published in print. This topic has caused significant controversy and strong emotions for the last several years, and I expect that to continue. Please take a look at the additional resources below, as well as Dr. Sanchez-Pinto’s twitter feed (@nelsonspinto), for even more information.
Single center, retrospective, propensity score matched
557 septic shock patients in the PICU
43 received HAT, 181 hydrocortisone alone, 333 neither
HAT patients matched 1:1 with the other groups
HAT patients had lower mortality at 30-days (9 vs 28%, P=0.03) and 90-days (14 vs 37%, P=0.01) compared to no HAT or hydrocortisone
Similar results comparing mortality in HAT to those with hydrocortisone alone – 30-day (9 vs 30%, p=0.01) and 90 day (14 vs 37%, p=0.01)
No difference at 30 days in vasoactive free days or hospital free days
Nelson Sanchez-Pinto MD, Assistant Professor of Pediatrics and Preventative Medicine, Northwestern University, Feinburg School of Medicine
Pediatric Intensivist, Anne and Robert H. Lurie Children’s Hospital of Chicago
1. Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2017;151(6):1229-1238.
2. Wilson JX. Mechanism of action of vitamin C in sepsis: ascorbate modulates redox signaling in endothelium. Biofactors. 2009;35(1):5-13.
3. Fowler AA, 3rd, Syed AA, Knowlson S, Sculthorpe R, Farthing D, DeWilde C, et al. Phase I safety trial of intravenous ascorbic acid in patients with severe sepsis. J Transl Med. 2014;12:32.
4. Spoelstra-de Man AME, Elbers PWG, Oudemans-van Straaten HM. Making sense of early high-dose intravenous vitamin C in ischemia/reperfusion injury. Crit Care. 2018;22(1):70.
5. Zabet MH, Mohammadi M, Ramezani M, Khalili H. Effect of high-dose Ascorbic acid on vasopressor’s requirement in septic shock. J Res Pharm Pract. 2016;5(2):94-100.
6. Wald EL, Sanchez-Pinto LN, Smith CM, Moran T, Badke CM, Barhight MF, Malakooti MR. Hydrocortisone-Ascorbic Acid-Thiamine Use Associated with Lower Mortality in Pediatric Septic Shock. Am Journal Respr and Crit Care Med. E-pub ahead of print. PMID: 31916841. DOI: https://doi.org/10.1164/rccm.201908-1543LE
7. Fowler AA, Trust JD, Hite RD. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure – The CITRIS-ALI Randomized Clinical Trial. JAMA. 2019;322(13):1261-1270. doi:10.1011/jama.2019.11825
On this episode, host Jason Woods speaks with Dr. Danielle Soranno, pediatric nephrologist, about nephritis in children. What is it, why are the terms so confusing, how do we diagnosis it, and when should we involve a nephrologist? Did the nephrologists invent terminology just to confuse us?
Danielle Soranno MD, Assistant Professor, Pediatrics, Bioengineering & Medicine University of Colorado and Children’s Hospital Colorado
On this episode, host Jason Woods speaks with Dr. Gabrielle Freire about her work with PERN (Pediatric Emergency Research Network) and evaluation of predictive risk factors for escalation of care in bronchiolitis.
THE BOTTOM LINE:
Multiple risk factors were found that predicted escalated care in infants. Infants aged < 12 months old with bronchiolitis but without predictors have a low risk of receiving escalated care (<1%) and may be candidates for outpatient management. Infants with increasing numbers of predictors are at a increasing risk of requiring escalated care and need consideration for in patient care with expertise in paediatric airway support.
Bronchiolitis is responsible for ~ 16% of all hospitalizations in the first year of life
The cost incurred from bronchiolitis admissions is thought to be ~ $1.78 billion every year in the US and Canada
Retrospective cohort study of a previously collected database of infants aged < 12 months with clinical diagnosis of bronchiolitis
Bronchiolitis defined as viral respiratory infection with respiratory distress
Age 12 months or younger
Visits from Jan – Dec 2013 collected as part of PERN
First episode of bronchiolitis only
Comorbidities such as chronic lung disease, congenital heart disease, immunodeficiency, renal or liver insufficiency, neuromuscular disorders
Prior episode of diagnosed bronchiolitis
2722 patients included
261 (9.6%) required escalated care
Predictors included in the final model
O2 sats < 90 (OR 8.9)
Nasal flaring/grunting (OR 3.76)
Apnea (OR 3.01)
Retractions (OR 3.02)
Age < 2 months (OR 2.1)
Concomitant dehydration (OR 2.13)
Poor feeding (OR 1.85)
Discussion points (detailed in the audio)
Respiratory rate and retractions were co-linear, so RR was not included in the final model
The risk score “points” were assigned by diving the OR by 2 to give a total score of 14
Duration of illness was not found to be a significant predictor – this may be due to the lack of granularity of the data (only available in days rather than hours)
Oxygen saturation had the highest OR by a substantial margin
Gabrielle Freire MD, Paediatric Emergency Physician, The Hospital for Sick Children, Department of Paediatrics University of Toronto, Toronto, Ontario, CA.
On this episode, host Jason Woods speaks with Dr. Amy Grover about HIV screening in the pediatric emergency department. Dr. Grover works in both the section of emergency medicine and hospital medicine and has an interest in HIV screening.
An estimated 50% of adolescents with HIV do not know they have contracted HIV
Acute retroviral syndrome has many non specific symptoms and can be difficult to diagnosis but includes the following
Nausea, vomiting, and/or diarrhea
Rash that can involve the hands and feed
Pharyngitis is typically not as exudative as EBV
CDC guidelines recommend that EVERY person ages 13-64 who is sexually active be screened for HIV at least once in their lives, and yearly if ongoing risk for exposure
One of the difficult aspects of setting up a screening program is deciding who is responsible for follow up of the results. Each institution will have to discuss what is appropriate for their setting
Do not forget to evaluate for risk of other STI, including Syphilis (prevalence is rising in the US)
Most rapid screening tests that do not use whole blood can not detect HIV infection until there is an antibody response (3 weeks – 3 months)
The 4th generation HIV test can detect infection starting as early as 15 days after infection. Note that there is still a latent period when detection is not possible.
One of the important reasons to screen patients is that there is evidence that knowledge of HIV infection decreases high-risk behavior.
The benefit and effect of HIV screening may depend on the regional HIV rates
Amy Grover MD – University of Colorado School of Medicine, Sections of Emergency Medicine and Hospital Medicine, Children’s Hospital Colorado