Barbara M. Garcia Peña

Predictors of Airway and Respiratory Adverse Events With Ketamine Sedation in the Emergency Department: An Individual-Patient Data Meta-analysis of 8,282 Children

STUDY OBJECTIVEnAlthough ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events.nnnMETHODSnWe pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events.nnnRESULTSnIn 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route.nnnCONCLUSIONnRisk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

Effect of Computed Tomography on Patient Management and Costs in Children With Suspected Appendicitis

Objective. Children evaluated in the emergency department for possible appendicitis are often admitted for observation, despite the widespread availability of accurate diagnostic studies, particularly computed tomography (CT). We sought to establish effective and efficient strategies for using CT to diagnose and manage children with possible appendicitis. Design. Retrospective chart review and decision analysis. Setting. Emergency department of a large, urban tertiary care pediatric teaching hospital. Patients. All patients admitted from January 1996 to August 1997 for suspected appendicitis. Method of Analysis. Three modeled strategies were empirically applied to the retrospective cohort of patients admitted for observation. Outcomes and costs under the modeled strategies were compared with those under current practice. The three strategies were: 1) to obtain CT scans on all patients and discharge those with normal findings; 2) to obtain CT scans and admit all patients; 3) to selectively obtain CT scans on those patients with a peripheral white blood cell count >10u2009000/mm3 (10 × 109/L) and admit all. The sensitivity and specificity of CT for diagnosing appendicitis were determined empirically from the data. A sensitivity analysis was performed. Main Outcome Measures. The number of preoperative inpatient observation days, total hospital costs, and the rates of both missed appendicitis and negative laparotomies. Results. Of 609 patients hospitalized for possible appendicitis, 287 went directly to the operating room and 14 patients had known perforation and abscess. Three hundred eight children were observed and comprised the study cohort. Of the cohort, 112 (36.4%) underwent appendectomy and 26 (23.2%) of these had a normal appendix at pathology. Three patients were discharged from the hospital after observation and were subsequently readmitted with appendicitis (missed appendicitis). Among the 75 patients who had CT performed, the sensitivity and specificity of CT were both 97%. Under the current practice strategy, the cohort collectively accumulated 487 inpatient observation days and incurred a per patient cost of

Predictors of Emesis and Recovery Agitation With Emergency Department Ketamine Sedation: An Individual-Patient Data Meta-Analysis of 8,282 Children

5831. All three CT strategies would have reduced the total number of inpatient observation days, operations, negative laparotomies, as well as the per patient cost. The strategy of obtaining CT scans on all patients and then admitting them had the lowest rate of missed appendicitis. The additional cost of preventing each case of missed appendicitis under this strategy compared with the strategy of obtaining CT scans and sending home those with negative findings was

Costs and effectiveness of ultrasonography and limited computed tomography for diagnosing appendicitis in children.

150u2009304. Even at the lowest reported sensitivity and specificity of CT in the literature, the ordering of the three strategies remained constant and continued to reduce total cost per patient. Conclusion. Compared with current practice, diagnostic strategies using CT could reduce costs and improve diagnosis, management, and outcomes for children with appendicitis.

Neurotoxicities in Infants Seen With the Consumption of Star Anise Tea

STUDY OBJECTIVEnKetamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies.nnnMETHODSnWe pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events.nnnRESULTSnIn 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of > or =2.5 mg/kg or a total dose of > or =5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation.nnnCONCLUSIONnEarly adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.

Occult Bacteremia With Group B Streptococci in an Outpatient Setting

Background. A protocol of ultrasonography (US) followed by computed tomography with rectal contrast (CTRC) has been shown to be 94% accurate in the diagnosis of acute appendicitis in children. Objective. To evaluate the changes in patient management and costs of a protocol using US and CTRC in the evaluation of appendicitis in children. Design, Setting, and Subjects. Prospective cohort study of 139 children between 3 and 21 years of age who had equivocal clinical findings for acute appendicitis seen in the emergency department of a large, urban pediatric teaching hospital between July 1998 and December 1998. Protocol. Children with equivocal clinical presentations for acute appendicitis were prospectively evaluated with US. Patients with positive findings for acute appendicitis went directly to the operating room. Patients with negative or equivocal findings on US underwent CTRC. Surgical management plans were recorded before imaging, after US, and after CTRC. Main Outcome Measures. Surgical management plans before and after the imaging protocol as well as total hospital direct and indirect costs incurred or saved by each change in management were determined. Costs were obtained through the hospitals cost database and by ratios of costs to charges. Results. Of the 139 children, the protocol resulted in a beneficial change in management in 86 children (61.9%), no change in management in 50 children (36.0%) and an incorrect change in management in 3 children (2.1%). US alone resulted in a beneficial change in management decision in 12/31 children (38.7%), while US followed by CTRC resulted in a beneficial change in management in 74/108 children (68.5%). The protocol resulted in a total cost savings of

Simple febrile seizures: are the AAP guidelines regarding lumbar puncture being followed?

78u2009503.99 or

Use of a Metronome in Cardiopulmonary Resuscitation: A Simulation Study

565/patient. Conclusion. A protocol of US followed by CTRC in children with negative or equivocal US examinations results in a high rate of beneficial change in management as well as in total cost savings in children with equivocal clinical presentations for suspected appendicitis.

Heelys injuries: a review of the National Electronic Injury Surveillance System Data.

Chinese star anise (Illicium verum Hook f.) is a well-known spice used in many cultures. Many populations use it as a treatment for infant colic. Japanese star anise (Illicium anisatum L), however, has been documented to have both neurologic and gastrointestinal toxicities. Recently, concern has been raised regarding the adulteration of Chinese star anise with Japanese star anise. We report 7 cases of adverse neurologic reactions in infants seen with the home administration of star anise tea. In addition, we have found evidence that Chinese star anise has been contaminated with Japanese star anise. More strict federal regulation of the import of star anise into the United States is warranted. Star anise tea should no longer be administered to infants because of its potential danger in this population.

Evaluation of Ultrasonography and Focused Computed Tomography in the Diagnosis and Management of Appendicitis in Children

Objectives.u2003We undertook this study to determine the relative frequency of occult bacteremia with group B streptococci (GBS) and to define the clinical features of infants with occult bacteremia attributable to GBS at the time of initial clinical contact. Design.u2003The logs of the microbiology laboratory were reviewed for blood and cerebrospinal fluid isolates of GBS from 1982 to 1996. Records of patients identified with GBS were abstracted. Patients were classified as having occult bacteremia if GBS were isolated from their blood and they seemed nontoxic and had no apparent clinical or laboratory evidence of focal infection. All other patients were diagnosed with sepsis, meningitis, or nonmeningeal foci. Results.u2003We reviewed the medical records of 147 children with GBS and identified 108 outpatients, including 47 (44%) with occult bacteremia, 42 (39%) with meningitis, 11 (10%) with nonmeningeal foci, and 8 (7%) with sepsis. Compared with patients with sepsis or focal infections, those with occult bacteremia were older (61.1 vs 39.1 days) and had slightly, although not significantly, higher white blood cell (WBC) counts (13u2009280 ± 6854 vs 10u2009688 ± 8574), but similar degrees of fever. Among the 47 patients with occult bacteremia, none died, as compared with 2 of 61 with serious infections, and fewer had neurologic sequelae (0/47 vs 11/61). Patients with occult bacteremia >90 days of age generally had temperatures >39°C (9/11, mean 39.3°C) and WBC counts >15u2009000/mm3 (7/10, mean 19u2009070/mm3), both of which differed significantly compared with those who were <90 days of age. Thirty of the 47 patients with occult bacteremia received intravenous antibiotics and recovered. One of 8 patients discharged without antibiotics and none of 8 with antibiotics developed a focal complication; 1 discharged patient was lost to follow-up. Conclusions.u2003Almost one-half of the children with GBS disease beyond the immediate neonatal period had occult bacteremia. Among 8 untreated patients with bacteremia, 1 developed a focal complication. Although the small proportion of children with GBS occult bacteremia who were >90 days of age usually had the risk factors of temperature >39°C and WBC >15u2009000/mm3, as seen with occult bacteremia attributable to other organisms, the majority of the patients who were younger did not have a characteristic clinical syndrome. Prevention of sequelae in these young infants will require a low threshold for diagnosis and treatment.