Ahmad Farooqi

Optimal dosing of intravenous ketamine for procedural sedation in children in the ED—a randomized controlled trial

OBJECTIVE The objective of the study is to compare need for redosing, sedation efficacy, duration, and adverse events between 3 commonly administered doses of parenteral ketamine in the emergency department (ED). METHODS We conducted a prospective, double-blind, randomized controlled trial on a convenience sample of children 3 to 18years who received intravenous ketamine for procedural sedation. Children from each age group (3-6, 7-12, and 13-18years) were assigned in equal numbers to 3 dosing groups (1, 1.5, and 2mg/kg) using random permuted blocks. The primary outcome measure was need for ketamine redosing to ensure adequate sedation. Secondary outcome measures were sedation efficacy, sedation duration, and sedation-related adverse events. RESULTS A total of 171 children were enrolled of whom 125 (1mg/kg, 50; 1.5mg/kg, 35; 2mg/kg, 40) received the randomized dose and were analyzed. The need for ketamine redosing was higher in the 1mg/kg group (8/50; 16.0% vs 1/35; 2.9% vs 2/40; 5.0%). There was no significant difference in the median Ramsay sedation scores (5.5 [interquartile range {IQR}, 4-6] vs 6 [IQR, 4-6] vs 6 [IQR, 5-6]), FACES-R score (0 [IQR, 0-4] vs 0 [IQR, 0-0] vs 0 [IQR, 0-0]), sedation duration in minutes (23 [IQR, 19-38] vs 24.5 [IQR, 17.5-34.5] vs 23 [IQR, 19-29]), and adverse events (10.0% vs 14.3% vs 10.0%) between the 3 dosing groups. Physician satisfaction was lower in the 1mg/kg group (79.6% vs 94.1% vs 97.3%). CONCLUSIONS Adequate sedation was achieved with all 3 doses of ketamine. Higher doses did not increase the risk of adverse events or prolong sedation. Ketamine administered at 1.5 or 2.0mg/kg intravenous required less redosing and resulted in greater physician satisfaction.

Is Shunt Evaluation Useful in Children with Intraventricular Shunts with Seizures

BACKGROUND Seizures are a common presenting symptom to the emergency department (ED) in children with intraventricular shunts (IVS). The incidence of shunt malfunction and the yield of imaging studies in children with IVS presenting with seizures is unknown. OBJECTIVES We assessed the utility and diagnostic yield of evaluation for shunt malfunction in patients with IVS with seizure and identified clinical predictors for shunt malfunction in these children. METHODS We performed a retrospective review of children aged zero to 21 years of age with IVS who presented to the ED with seizure between 2011 and 2015. Demographic, clinical, laboratory and radiological data were collected. Shunt malfunction was diagnosed based on whether a shunt revision was performed during the hospitalization. RESULTS We evaluated 408 ED visits (median age: six years [IQR: 3, 11], males 61.5%) for IVS with seizures. Few visits were for first seizure (37; 9.1%) or for status epilepticus (46 visits; 11.3%). Computerized tomography head was performed in 318 patients (95.2%), of which 32 scans (10.6%) were suggestive of shunt malfunction. A shunt series was performed in 302 (90.4%) and was suggestive of shunt malfunction in eight (2.6%) patients. Shunt malfunction was diagnosed in 40 of 408 visits (9.8%). Only a history of multiple (≥3) shunt revisions was significantly associated with shunt malfunction. There was no association between number, type, or prior history of seizures and shunt malfunction. CONCLUSION Our study demonstrates a low yield of imaging studies for the evaluation of shunt malfunction in children with IVS with seizures, and shunt malfunction is an uncommon cause of seizures in these children.

Procedural sedation in children with autism spectrum disorders in the emergency department

BACKGROUND AND OBJECTIVES Children with autism spectrum disorder (ASD) present more frequently to the emergency department (ED) than children with normal development, and frequently have injuries requiring procedural sedation. Our objective was to describe sedation practice and outcomes in children with ASD in the ED. METHODS We performed a retrospective chart review of children with ASD who underwent sedation at two tertiary care EDs between January 2009-December 2016. Data were collected on children 1-18 years of age with ASD who were sedated in the ED. RESULTS There were 6020 ED visits by children with ASD, 126 (2.1%) of whom received sedation. The most frequent indications for sedation were laceration repair (24.6%), incision and drainage (17.5%), diagnostic imaging (14.3%), and physical examination (11.9%). The most common sedatives used were ketamine (50.8%) and midazolam (50.8%). Ketamine was most commonly given intravenously (71.9%), while midazolam was usually given intranasally (71.9%). Procedures could not be completed in 4 (3.2%) patients, and adverse events were noted in 23 (18.3%) patients. Only four (3.2%) patients required supplemental oxygenation, and one received positive pressure ventilation. CONCLUSIONS Children with autism in the ED commonly received sedation; one in four of which were for non-painful diagnostic procedures or physical examination. Over one-third received sedation via a non-parenteral route for intended minimal sedation. Sedative medication dosing and observed adverse events were similar to those reported previously in children without ASD. Emergency providers must be prepared to meet the unique sedation needs of children with ASD.

Association of vitamin D with cathelicidin and vitamin D binding protein in pediatric sepsis

a Childrens Emergency Services, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, 1540 East Hospital Drive, CW 2-737, SPC 4260, Ann Arbor, MI 48109-4260, United States Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine and Atlanta VA Medical Center, Atlanta, GA, United States c Division of Pediatric Critical Care Medicine, Carman and Ann Adams Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, United States d Childrens Research Center of Michigan at Childrens Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, United States e Division of Pediatric Emergency Medicine, Carman and Ann Adams Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, United States

The Utility of Real-Time Quantitative Polymerase Chain Reaction Genotype Detection in the Diagnosis of Urinary Tract Infections in Children:

Urinary tract infections (UTIs) are the most common serious bacterial infection in children with significant morbidity with delayed diagnosis. Polymerase chain reaction (PCR) is very accurate in detecting bacteria and widely available, but has never been evaluated to detect UTIs in children. To assess the utility of PCR as a rapid diagnostic tool, we conducted a prospective cohort study of 193 urine samples from children younger than 36 months undergoing evaluation for UTI in the emergency department over a 10-month period. A quantification cycle (Cq) threshold of 26.15 identified all Escherichia coli positive samples with sensitivity and specificity of 100% and 99.5%, respectively (95% CI = 71.5%-100% and 97.9%-99.5%, respectively). A Cq threshold of 19.03 identified E coli infections >100 000 colony forming units/mL with sensitivity and specificity of 100% (95% CI = 72.2%-100% and 98.6%-100%, respectively). PCR is very accurate in diagnosing E coli UTIs in young children and could be useful as a rapid diagnostic tool.