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.
Guests
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 of Little Big Med, host Jason Woods talked with Mark Piehl, pediatric intensivist and founder and CMO of 410 Medical Innovation, about his journey with taking an idea for a medical innovation from concept the entire way to commercial production. Mark is co-inventor of the LifeFlow device and has specific interest in improving resuscitation in pediatric shock, sepsis, and trauma.
Key Points:
Guest: Mark Piehl MD, MPH – Founder and CMO of 410 Medical Innovation, Medical Director WakeMed Mobile Pediatric Critical Care Transport Team, pediatric intensivist at WakeMed in Raleigh, NC
Retrospective study, data from Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project, 2013
Included 20483 patients from 426 hospitals in Florida, Iowa, Massachusetts, Nebraska, and New York
Mortality decreased with increasing readiness score
Adjusted OR also showed that the highest “readiness” hospitals had the lowest mortality in this cohort
Some concern remains that the difference is at least partially related to case definition – ICU admission was included as an inclusion criteria, which may have falsely lowered the overall level of illness of patients admitted to an institution with a PICU. HOWEVER –
Cases were also followed through time – so patients that were transferred to a hospital with an ICU from a hospital without one had their data linked together.
In that case the presence or absence of an ICU at the index hospital would not have “counted against” the index hospital, unless that hospital were inappropriately admitting critical ill patients to a general ward instead of transferring to a facility with a PICU
The authors feel they addressed this by also considering PECARN illness severity scores, most of which were 4 or 5 (most severe illness)
Most deaths in this cohort occurred in the ED rather than in the ICU/floor, arguing that the ICU admission criteria itself did not drive mortality rates.
This is part 1 of a 2 part series. Please be sure to listen to part 2!
In this episode, host Jason Woods speaks with Dr. Daniel Tsze and Child Life Specialist Hilary Woodward about how to approach pain in the pediatric patient. This could be pain from the presenting complaint or from the procedure being performed. The discussion focusses primarily on the non-pharmacologic techniques that have been shown to improve the experience for patients, caregivers, and care providers.
Hilary Woodward MS, CCLS -New York-Presbyterian Morgan Stanley Children’s Hospital at Columbia University Medical Center
Daniel Tsze MD, MPH – Associate Professor of Pediatrics (Emergency Medicine), New York-Presbyterian Morgan Stanley Children’s Hospital at Columbia University Medical Center
Show Notes
Techniques – non pharmacologic
Environment – Remember that the environment can have a huge impact not he patient! (I.e. colors on the walls, pictures/posters, cartoons). The attitude and approach from the caregivers and clinical providers also contributes.
Before procedure
Opportunities for patient to interact (safely) with procedure materials. Can use either (or both) of the techniques below:
Medical play – free play with safe procedure materials, possibly with some child-centered narration as patient manipulates what is provided (i.e. “you’re putting that on the doll’s arm”); helps with desensitization & child-directed understanding (figuring out organically how the materials work) and increases patient’s opportunities for control.
Developmentally appropriate teaching – practice procedure on stuffed animal/doll etc., while explaining what will happen and clarifying patient’s questions/misconceptions as needed. May consider hand-over-hand techniques to give patients some knowledge/experience with sharps (if caregiver consent provided, safety guidelines in place, patient assessed by clinician to be an appropriate candidate developmentally and in regards to temperament)
Explanation of what you are going to do. How much do you tell a child and how does this change based on
Can start with “small spoonfuls” of info, focusing on what the patient’s sensory experience will likely be (i.e. how will it feel, what will they see/smell/taste; “some kids say it’s like _______”). Monitor verbal/non-verbal cues to guide when/if/how to share more
Patient and caregiver input is vital – ask what they would like to know more about, and offer choices of coping techniques (consider needs of self-identified “attenders” vs. “distractors”)
Don’t forget the basis like splinting, ice packs, which also have analgesic effects
Positioning for comfort
Chest to chest in a chair for scalp lacs, procedures on extremities
Parent sitting in a chair works well – make sure that patient’s feet are dangling so that they don’t have leverage to push up
Make sure to brace the extremity you are working with (rest extremity on the bed or on a bedside table, ideally at close to a 90 degree angle)
Consider asking a “helper” to hold head or extremity steady
Patient’s back against parent’s chest for facial lacs, procedures on extremities
Have parent lay on stretcher with their whole body (feet included) on the bed; child lays or sits between parent’s legs, with their bottom on the stretcher (NOT on parent’s lap) – then parent can cross their legs over child’s legs
As with chest-to-chest, make sure to use appropriate bracing and a “helper” as needed for steadying
Do you talk with parents about their role in comforting their child, not showing distress etc?
Strengths-based approach: Reinforce helpful caregiver behaviors, while validating the stress of the situation. “The way you let your child know you will be there for him, and the way you engaged him in telling his favorite story – that was so helpful! It really makes a positive difference when parents show calm and help engage their child. I know you might not be feeling as calm on the inside, but you’re really helping us create a better experience for your son. Thank you!”
If it’s a more challenging scenario, and you are having difficulty identifying a strength, step into the conversation piece by piece. Start with validating: “I can see how upsetting this is for you, and it makes complete sense to feel upset in this situation.” Then read the verbal & non-verbal cues – are you building effective rapport? If so, you might be able to very gently make your big ask (and it can help to label it as such): “I’ve been thinking about how we can help make this experience as smooth as possible for your daughter. I have some ideas, and I know this might be a big ask, but I’m hoping you can help me?” If receptive: “I’m noticing that your daughter seems more tearful & distressed when she sees you get upset. Maybe you could help us distract her? Sometimes, helping distract their child helps parents feel a little better, too.” And when the procedure is over, make sure to validate the parent’s effort and be specific about what went well to both parent & child.
During Procedure
Distraction
Both “techy” (iPad, virtual reality) and “non-techy” (toys, games, songs, conversation, deep breathing, etc.)
“Blinder” and other visual barriers
Any specific dos and dont’s with these?
Generally not worthwhile for kids who become more agitated by the blinder/barrier itself (may include toddlers, patients with sensory challengers, patients who are “attenders” and better able to cope/feel in control when they can see everything that is going on). Patient choice & caregiver input are key.
Parent/family presence? Helpful or harmful?
From Hilary – I would say 98% of the time helpful, but it can be important to give parents the choice whether to be present and/or involved. (This discussion might connect well with the point above about whether or not to talk with parents/caregivers about their role in comforting their child.)
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.
Take-Home Points
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.
Pathophysiology
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
Management
Prehospital
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.
ED
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.
References:
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.
Guests
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 Sarah Mojarad, lecturer at USC with appoints in the schools of Medicine and Engineering. Professor Mojarad is an expert in online professionalism, social media use in STEMM (science, technology, engineering, mathematics, medicine), and science communication. This episode is all about how and why social media can be used in medicine (also the how not and why not!), strategies for successful communication to colleagues and patients, and mistakes to avoid.
Sarah has a number of online resources on these topics (listed below) and is a fantastic person to follow on social media. Her insights, topic highlights, and approach are invaluable to any health care practitioner looking to be involved on social media.
Guest
Sarah Mojarad, Lecturer of Engineering Writing, Viterbi School of Engineering and Keck School of Medicine, University of Southern California
On this episode, host Jason Woods speaks with Dr. Nancy Spector, Professor of Pediatrics at Drexel University College of Medicine, and Executive Director of the Executive Leadership in Academic Medicine program, about gender equity issues in medicine. Dr. Spector is a frequent speaker on this issue and was the lead author on an article last year outlining the progress, barriers, and opportunities for women in pediatrics (see reference below).
This is part one of a two-part discussion. In part one, Dr. Spector focuses on outlining the scope of the issues and provides strategies for decreasing the equity gap and increasing opportunities for women at all levels of academic medicine.
I want to send out a big thanks to Kellen Vu, who serve as audio producer for this episode!
Guest
Nancy Spector MD, Professor of Pediatrics, Associated Dean for Faculty Development, Drexel University College of Medicine
