Aaron E. Chen

Implementation of a pediatric critical care focused bedside ultrasound training program in a large academic PICU.

Objectives: To determine the feasibility and describe the process of implementing a pediatric critical care bedside ultrasound program in a large academic PICU and to evaluate the impact of bedside ultrasound on clinical management. Design: Retrospective case series, description of program implementation. Setting: Single-center quaternary noncardiac PICU in a children’s hospital. Patients: Consecutive patients from January 22, 2012, to July 22, 2012, with bedside ultrasounds performed and interpreted by pediatric critical care practitioners. Interventions: A pediatric critical care bedside ultrasound program consisting of a 2-day immersive course followed by clinical performance with internal quality assurance review was implemented. Studies performed in the PICU following training were documented and reviewed against reference standards including subspecialist-performed ultrasound or clinical response. Measurements and Main Results: Seventeen critical care faculties and eight fellows recorded 201 bedside ultrasound studies over 6 months in defined core applications: 57 procedural (28%), 76 hemodynamic (38%), 35 thoracic (17%), and 33 abdominal (16%). A quality assurance review identified 23 studies (16% of all nonprocedural studies) as critical (affected clinical management or gave valuable information). Forty-eight percent of those studies (11/23) were within the hemodynamic core. The proportion of critical studies were not significantly different across the applications (hemodynamic, 11/76 [15%] vs thoracic and abdominal, 12/68 [18%]; p = 0.65). Examples of critical studies include evidence of tamponade secondary to pleural effusions, identification of pulmonary hypertension, hemodynamic assessment before tracheal intubation, recognition of hypovolemia and systemic vascular resistance abnormalities, determination of pneumothorax, location of chest tube and urinary catheter, and differentiation of pleural fluid from pulmonary consolidation. Conclusions: Implementation of a critical care bedside ultrasound program for critical care providers in a large academic PICU is feasible. Bedside ultrasound evaluation and interpretation by intensivists affected the management of critically ill children.

The Effect of Bedside Ultrasonographic Skin Marking on Infant Lumbar Puncture Success: A Randomized Controlled Trial

Study objective Lumbar puncture is a commonly performed procedure, although previous studies have documented low rates of successful completion in infants. Ultrasonography can visualize the anatomic landmarks for lumbar puncture and has been shown in some studies to reduce the failure rate of lumbar puncture in adults. We seek to determine whether ultrasonography‐assisted site marking increases success for infant lumbar punctures. Methods This was a prospective, randomized, controlled trial in an academic pediatric emergency department (ED). We enrolled a convenience sample of infants younger than 6 months between June 2014 and February 2016 and randomized them to either a traditional lumbar puncture arm or an ultrasonography‐assisted lumbar puncture arm. Infants in the ultrasonography arm received bedside ultrasonography of the spine by one of 3 study sonographers before lumbar puncture, during which the conus medullaris and most appropriate intervertebral space were identified and marked. The lumbar puncture was then performed by the predetermined ED provider. Our primary outcome was successful first‐attempt lumbar puncture. Subjects were considered to have a successful lumbar puncture if cerebrospinal fluid was obtained and RBC counts were less than 1,000/mm3. All outcomes were assessed by intention‐to‐treat analysis. Results One hundred twenty‐eight patients were enrolled, with 64 in each arm. No differences between the 2 arms were found in the baseline characteristics of the study subjects and providers, except for sex and first‐attempt position. The first‐attempt success rate was higher for the ultrasonography arm (58%) versus the traditional arm (31%) (absolute risk difference 27% [95% CI 10% to 43%]). Success within 3 attempts was also higher for the ultrasonography arm (75%) versus the traditional arm (44%) (absolute risk difference 31% [95% CI 15% to 47%]). On average, performing bedside ultrasonography on 4 patients (95% CI 2.1 to 6.6) resulted in 1 additional successful lumbar puncture. Conclusion Ultrasonography‐assisted site marking improved infant lumbar puncture success in a tertiary care pediatric teaching hospital. This method has the potential to reduce unnecessary hospitalizations and exposures to antibiotics in this vulnerable population.

Effect of Inhalational Anesthetics and Positive-pressure Ventilation on Ultrasound Assessment of the Great Vessels: A Prospective Study at a Children's Hospital.

Background:Bedside ultrasound has emerged as a rapid, noninvasive tool for assessment and monitoring of fluid status in children. The inferior vena cava (IVC) varies in size with changes in blood volume and intrathoracic pressure, but the magnitude of change to the IVC with inhalational anesthetic and positive-pressure ventilation (PPV) is unknown. Methods:Prospective observational study of 24 healthy children aged 1 to 12 yr scheduled for elective surgery. Ultrasound images of the IVC and aorta were recorded at five time points: awake; spontaneous ventilation with sevoflurane by mask; intubated with peak inspiratory pressure/positive end-expiratory pressure of 15/0, 20/5, and 25/10 cm H2O. A blinded investigator measured IVC/aorta ratios (IVC/Ao) and changes in IVC diameter due to respiratory variation (IVC-RV) from the recorded videos. Results:Inhalational anesthetic decreased IVC/Ao (1.1 ± 0.3 vs. 0.6 ± 0.2; P < 0.001) but did not change IVC-RV (median, 43%; interquartile range [IQR], 36 to 58% vs. 46%; IQR, 36 to 66%; P > 0.99). The initiation of PPV increased IVC/Ao (0.64 ± 0.21 vs. 1.16 ± 0.27; P < 0.001) and decreased IVC-RV (median, 46%; IQR, 36 to 66% vs. 9%; IQR, 4 to 14%; P < 0.001). There was no change in either IVC/Ao or IVC-RV with subsequent incremental increases in peak inspiratory pressure/positive end-expiratory pressure (P > 0.99 for both). Conclusions:Addition of inhalational anesthetic affects IVC/Ao but not IVC-RV, and significant changes in IVC/Ao and IVC-RV occur with initiation of PPV in healthy children. Clinicians should be aware of these expected vascular changes when managing patients. Establishing these IVC parameters will enable future studies to better evaluate these measurements as tools for diagnosing hypovolemia or predicting fluid responsiveness.

Identification of optic disc elevation and the crescent sign using point-of-care ocular ultrasound in children.

Abstract Point-of-care ocular ultrasound has been used to detect papilledema. In previous studies, investigators have evaluated only optic nerve sheath diameter as a screen for increased intracranial pressure. In this series of 4 children, we demonstrate 2 additional optic nerve abnormalities using point-of-care ocular ultrasound: optic disc elevation and the crescent sign. Assessing the optic nerve for each of these 3 findings may assist the examiner in detecting papilledema.

Management of Skin and Soft-Tissue Infections Before and After Clinical Pathway Implementation:

We evaluated if the introduction of a clinical pathway for skin and soft-tissue infections (SSTIs) would reduce methicillin-resistant Staphylococcus aureus (MRSA)-directed therapy for simple cellulitis and antibiotic use for simple abscess after drainage. We compared the treatment of SSTI during a 3-month prepathway and 11-month postpathway period. We included patients 57 days to 18 years old discharged from the emergency department (ED) with a diagnosis of cellulitis or abscess. Balancing measures included 72-hour revisit rate and ED length of stay (LOS). A total of 291 patients prepathway and 781 patients postpathway were included. The proportion of patients with simple cellulitis prescribed MRSA-directed therapy decreased from 81% to 54% postpathway. The proportion of patients with a drained abscess prescribed systemic antibiotics decreased from 88% to 75%. There was no increase in 72-hour revisit rates (3.8% vs 3.2%, P = .64) or ED LOS (2.8 vs 2.7 hours, P = .05).

Sonographically Occult Abscesses of the Buttock and Perineum in Children.

BACKGROUND Ultrasound (US) is used to differentiate abscess from cellulitis. At our institution, we observed children who had purulent fluid obtained after a negative abscess US. We sought to determine the incidence of sonographically occult abscess (SOA) of the buttock and perineum, and identify associated clinical and demographic characteristics. METHODS Retrospective chart review including children younger than 18 years old presenting to pediatric emergency department with soft tissue infection of the buttock or perineum and diagnostic radiology US read as negative for abscess. We defined SOA as wound culture growing pathogenic organism obtained within 48 hours of the US. Clinical and demographic characteristics included age, sex, race, ethnicity, fever, history of spontaneous drainage, duration of symptoms, previous methicillin resistant Staphylococcus aureus (MRSA) infection, or previous abscess. We used univariate and multivariate logistic regression to assess correlation between these characteristics and SOA. RESULTS A total of 217 children were included. Sixty-one (28%) children had SOA; 33 of 61 (54%) had incision and drainage within 4 hours of the US. Of children with SOA, 49 (80%) grew MRSA and 12 (20%) grew methicillin-sensitive S. aureus. In univariate analysis, a history of MRSA, symptom duration 4 days or less, age of younger than 4 years, and Hispanic ethnicity increased the odds of having SOA. In multivariate analysis, history of MRSA and duration of 4 days or less were associated with SOA. CONCLUSIONS Twenty-eight percent of children in our institution with US of the buttock and perineum negative for abscess had clinical abscess within 48 hours, most within 4 hours. History of MRSA and shorter symptom duration increased the odds of SOA.

An Uncommon Complication of Sinusitis in a Young Adolescent.

Abstract A young adolescent patient presented to the emergency department with forehead and eyelid swelling after a week of nasal discharge that was suspicious for Potts puffy tumor. Point-of-care ultrasound facilitated rapid diagnosis and initiation of treatment for a concerning and rare complication of sinusitis, confirmed by computed tomography scan.

Pulmonary emboli associated with isolated lower-extremity venous malformation: a case report.

Abstract Pulmonary thromboembolism is a relatively rare entity in the pediatric population; however, it should always be part of the differential diagnosis in patients with the appropriate clinical presentation. We report the case of a 13-year-old girl with a history of a lower-extremity venous malformation status post sclerotherapy 2 years prior but otherwise healthy who presented with painless hemoptysis. She was found to have multiple bilateral pulmonary emboli on computed tomographic angiography of the chest. Magnetic resonance venography of the lower extremities showed stable venous changes from prior studies and no obvious source of emboli. She was started on anticoagulation and was discharged home.

Point-of-care lung ultrasonography for pneumonia in children: does size really matter?

Lung ultrasonography for the diagnosis of pneumonia has been around since as early as 1970,1 although it is only in recent years with the growing interest in point-of-care ultrasound that more studies have been published with regard to its use in children. Even though pneumonia is one of the most common and potentially serious illnesses that affects children throughout the world, studies of pneumonia are often difficult to interpret in context with each other because of the variability in definitions used, as well as the lack of an easy gold standard. Many organisations, such as the World Health Organization (WHO) and British Thoracic Society, define pneumonia solely based on clinical findings, which can largely over-represent true cases of pneumonia (eg, children with bronchiolitis or viral-induced wheezing will often meet the case definition of pneumonia). Attempts to refine the definition of pneumonia by adding radiographic criteria (eg, parenchymal infiltrates on chest radiography) to the clinical criteria are also problematic given the variable test characteristics of chest radiography for pneumonia,2 variabilities in interpretation even among radiologists,3 problems with ionising radiation exposure and cost, and given that many clinical guidelines do not require the use of chest radiography for the management of suspected community-acquired pneumonia. Further complicating this issue is the fact that the causative pathogen of …