Dennis Scolnik

Liposomal lidocaine to improve procedural success rates and reduce procedural pain among children: a randomized controlled trial

Background: Historically, children have been undertreated for their pain, and they continue to undergo painful cutaneous procedures without analgesics. A new topical anesthetic, liposomal lidocaine 4% cream (Maxilene, RGR Pharma, Windsor, Ont.), has become available. It has pharmacologic properties that are superior to other topical anesthetics, including an onset of action of only 30 minutes. We sought to determine the success rate of cannulation, analgesic effectiveness, procedure duration and rate of adverse skin reactions when liposomal lidocaine is used before intravenous cannulation of children. Methods: In this double-blind randomized controlled trial, children aged 1 month to 17 years received liposomal lidocaine or placebo before cannulation. Success on first cannulation attempt was recorded, and, among children 5 years and older, pain was evaluated before and after the attempt by the child, parents and research assistant using a validated measure (Faces Pain Scale-Revised). For children younger than 5 years, pain was evaluated by the parents and research assistant only. The total duration of the procedure and adverse skin reactions were also recorded. Results: Baseline characteristics did not differ (p > 0.05) between children who received liposomal lidocaine (n = 69) and those who received placebo (n = 73). Cannulation on the first attempt was achieved in 74% of children who received liposomal lidocaine compared with 55% of those who received placebo (p = 0.03). Among children 5 years of age and older (n = 67), lower mean pain scores during cannulation were reported by those receiving liposomal lidocaine (p = 0.01). Similarly, lower mean pain scores during cannulation were reported by the parents and research assistant for all children who received liposomal lidocaine than for all those who received placebo (p < 0.001). The mean total procedure duration was shorter with liposomal lidocaine (6.7 v. 8.5 minutes; p = 0.04). The incidence of transient dermal changes was 23% in both groups (p = 1.0). Conclusions: Use of liposomal lidocaine was associated with a higher intravenous cannulation success rate, less pain, shorter total procedure time and minor dermal changes among children undergoing cannulation. Its routine use for painful cutaneous procedures should be considered whenever feasible.

Gastric-outlet obstruction induced by prostaglandin therapy in neonates

BACKGROUND An infusion of prostaglandin E1 is widely used to maintain patency of the ductus arteriosus in neonates with congenital heart disease. After gastric-outlet obstruction was recognized in several infants who received prostaglandin E1, we studied the association between the drug and this complication. METHODS We evaluated all neonates who received prostaglandin E1 in our hospital between October 1, 1989, and September 30, 1991, for clinical, radiologic, or pathological evidence of acute gastric-outlet obstruction. RESULTS Of the 74 neonates evaluated, 65 had no signs of gastric obstruction and were considered normal; 5 had clinical and radiologic or pathological evidence of gastric obstruction consistent with the presence of antral mucosal hyperplasia. The remaining four neonates had clinical signs of gastric obstruction, but no radiologic or pathological examinations were performed. The 5 neonates with antral hyperplasia had received prostaglandin E1 for longer periods (mean [+/- SD] duration, 569 +/- 341 hours) than the 65 normal neonates (54 +/- 58 hours, P less than 0.001) or the 4 neonates with clinical signs of gastric obstruction (119 +/- 60 hours, P less than 0.05). The cumulative dose of prostaglandin E1 was higher in the neonates with antral hyperplasia (2982 +/- 1392 micrograms per kilogram of body weight) than in the normal neonates (279 +/- 270 micrograms per kilogram, P less than 0.001) or the neonates with signs of gastric obstruction (528 +/- 306 micrograms per kilogram, P less than 0.01). In two neonates with antral hyperplasia, the cessation of therapy lessened the gastric-outlet obstruction. CONCLUSIONS The administration of prostaglandin E1 to neonates can cause gastric-outlet obstruction due to antral hyperplasia. Neonates who receive prostaglandin E1 at recommended doses for more than 120 hours should be closely monitored for evidence of antral hyperplasia.

Practice Variations in the Treatment of Febrile Infants Among Pediatric Emergency Physicians

OBJECTIVES: The objectives of this study were to characterize variations in treatment decisions for young febrile infants in pediatric emergency departments across Canada and to document the extent of practice variations among pediatric emergency department practitioners. METHODS: This was a prospective, concurrent, cohort study of consecutive infants up to 90 days of age who presented to 6 pediatric emergency departments in Canada with fever (rectal temperature of ≥38.0°C). We recorded information in the emergency department and contacted the families by telephone to confirm the final disposition. RESULTS: A total of 257 infants were recruited over 2 to 4 months. Patients were similar across centers in terms of gestational age and weight, chronologic age at arrival, weight, and gender. Temperatures measured at home and during triage and durations of fever also were similar among centers. In one center, significantly more children arrived with cough; in another center, fewer parents reported sick contacts at home. Rates of blood and urine testing were not significantly different across sites, but rates of lumbar puncture, respiratory virus testing, and chest radiography were different. A total of 55% of infants received antibiotics, and significant practice variations in the numbers and types of antibiotics used were documented. CONCLUSIONS: Practices in the evaluation of young infants with fever in tertiary pediatric emergency departments varied substantially. Blood and urine tests were ordered in the majority of centers, but rates of cerebrospinal fluid testing and antibiotic treatment differed across centers.

Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: a randomized, controlled trial.

Objective. Medication errors are common among pediatric patients and in emergency departments (EDs). Such errors may lead to prolonged hospitalization, unnecessary diagnostic tests and treatments, and death. The objective of this study was to determine whether the use of a structured order sheet reduces the incidence of medication errors in a pediatric ED. Methods. The study was a randomized, controlled study that was conducted in a tertiary care pediatric hospital. Eighteen days were randomized into 2 study groups: days during which the regular blank order sheets were used and days during which preprinted, formatted, order sheets were used. All patients’ charts from these days were reviewed by 2 medical students, who extracted demographic, clinical, and therapeutic data into a database. Two pediatric emergency physicians, blinded to the form used, reviewed the database and independently decided whether an error had occurred and the severity of the error. Results. Within the study period, there were 2157 visits to the ED. A total of 2058 (95.4%) charts were available for review. A total of 411 (52.2%) orders for drugs in the ED were ordered on the regular form, and 376 (47.8%) were given on the new form. Drug errors were identified in 68 (16.6%) orders when the regular form was used and in 37 (9.8%) of the orders on the new form. Using the new form was associated with a significant reduction in the risk for an error (odds ratio: 0.55; 95% confidence interval: 0.34–0.90). Conclusions. The use of a preprinted structured order form significantly reduces medication errors among pediatric patients in the ED.

The Effect of Detection Approaches on the Reported Incidence of Tenfold Errors

AbstractBackground: Tenfold errors in calculation of paediatric drug doses are often life threatening. The magnitude and characteristics of this phenomenon have not been fully described. Objectives: The objective of this study was to describe the incidence and nature of paediatric tenfold errors and to describe the effect of different detection approaches on the detection of such errors. Methods: To evaluate the incidence of tenfold errors, data were collected from three different studies on medication errors all conducted at a large tertiary care paediatric hospital: (i) a study investigating medication event reports to the hospital’s Medication Incident Committee; (ii) a study auditing the charts of 1532 patients in the emergency department (ED) and; (iii) a prospective study of medication errors occurring during mock code resuscitations in the ED. Results: In the first study, 20 tenfold errors were reported during the surveyed period. Almost all errors were prescribing errors. The calculated incidence was 1 per 22 500 doses prescribed. In chart auditing study in the ED, two tenfold errors where found in 1678 orders. In the prospective study, four tenfold errors were identified in eight mock resuscitations (125 orders for drugs). Conclusion: The incidence of tenfold errors in paediatrics varies dramatically when different detection approaches are used. The rate of tenfold errors may be especially high in resuscitation situations and is underestimated by spontaneous reporting.

Incidence of Traumatic Lumbar Puncture: Experience of a Large, Tertiary Care Pediatric Hospital

The objective of this study was to establish the incidence of traumatic or unsuccessful lumbar punctures (LPs) in the authors’ institution. This is a prospective study. Traumatic LP was defined as >400 red blood cells (RBCs) and unsuccessful LP as failure to obtain cerebrospinal fluid (CSF) after the first LP attempt. A total of 127 CSF were recorded over 1 year. The incidence of a traumatic LP was 27/103 (26.2%) using the sitting position and 3/24 (12.5%) in infants and children using the lying position. In total, 33 (26%) CSF samples had 0 RBCs. The incidence of traumatic LP was 24% when the procedure involved one LP and 50% when more than one attempt was required. RBC count was significantly lower in cases requiring only one attempt (P = .0074). Incidence of traumatic LP was independent of physicians’ experience, sedation use or time of procedure, suggesting an intrinsic factor as the cause of traumatic LPs.

The Changing Clinical Presentation of Hypertrophic Pyloric Stenosis: The Experience of a Large, Tertiary Care Pediatric Hospital

The authors reviewed the clinical and laboratory data from cases of hypertrophic pyloric stenosis (HPS) diagnosed at their institution from 2006 to 2008. They assessed and compared presentation of patients with HPS over time at their institution. A total of 118 patients were included in this study. An “olive” was palpated in only 13.6% of cases. This is in contrast to older studies, where more than 50% of the patients were reported to have a palpable “olive” depending on when the study was conducted. In patients from this institution, hypochloremia was present in 23% and alkalosis in 14.4%, which are less frequent than the incidence of these abnormalities in older studies. There was a change in the additional “classical” symptoms, represented by the lower percentage of infants in whom an “olive” was palpated and the lower numbers of patients with severe electrolyte imbalances. The reason for this change appears to be the frequent use of ultrasound.

The Effect of a Medical Clown on Pain During Intravenous Access in the Pediatric Emergency Department A Randomized Prospective Pilot Study

Background. We report the effect of the presence of a medical clown during insertion of an intravenous catheter during their emergency department visit. Methods. Prospectively randomized to either the presence or absence of a male medical clown during the procedure. Pain was assessed using the Faces Pain Scale–Revised in children 4 to 7 years old, and visual analog scales in children 8 years and older. Parental situational anxiety was recorded using the State-Trait Anxiety Inventory after the procedure. Results. The presence of a medical clown during a painful procedure in the pediatric emergency department tended to improve pain scores in children younger than 7 years. Parental situational anxiety was significantly reduced in parents of children older than 8 years (P = .02). Conclusion. Therapeutic clowns are useful for diminishing pain and anxiety during painful procedures being performed on children in the emergency department.

Accidental methadone ingestion in an infant: case report and review of the literature.

INTRODUCTION We discuss accidental methadone intoxication in an 11-month-old female infant, review the literature, and stress the potential for child abuse among methadone-maintained caregivers. CASE An 11-month-old female infant presented with lethargy. Vital signs were normal, and pupils were constricted. Sepsis workup revealed no evidence of bacterial infection. High venous pCO2 suggested respiratory acidosis. Urine toxicology revealed high concentrations of methadone and its metabolites, and the diagnosis of methadone intoxication was confirmed when 0.1 mg/kg intravenous naloxone normalized the childs behavior. Social service agency inquiries found that the childs grandfather had been prescribed methadone for acquired morphine addiction. He carried 5-mg methadone tablets in his pocket and had recently babysat the infant. The patient was subsequently discharged home with pediatric and community services follow-up. DISCUSSION Methadone intoxication should be considered in children presenting with lethargy, miosis, and respiratory depression. Seventy-two percent of reported methadone poisoning patients are symptomatic, and unintentional poisoning is a real danger to children because small amounts can be fatal. There are also several case reports where the cause of intoxication was homicide by the parents. Initial management consists of establishing an airway, and naloxone may be indicated, before urine toxicology results are obtained, to help establish the diagnosis. However, if 2 doses do not reverse the childs symptoms, the diagnosis should be questioned. When repeated bolus doses of naloxone are indicated, a continuous infusion may be preferable.

Antimalarial Therapy Selection for Quinolone Resistance among Escherichia coli in the Absence of Quinolone Exposure, in Tropical South America

Background Bacterial resistance to antibiotics is thought to develop only in the presence of antibiotic pressure. Here we show evidence to suggest that fluoroquinolone resistance in Escherichia coli has developed in the absence of fluoroquinolone use. Methods Over 4 years, outreach clinic attendees in one moderately remote and five very remote villages in rural Guyana were surveyed for the presence of rectal carriage of ciprofloxacin-resistant Gram-negative bacilli (GNB). Drinking water was tested for the presence of resistant GNB by culture, and the presence of antibacterial agents and chloroquine by HPLC. The development of ciprofloxacin resistance in E. coli was examined after serial exposure to chloroquine. Patient and laboratory isolates of E. coli resistant to ciprofloxacin were assessed by PCR-sequencing for quinolone-resistance-determining-region (QRDR) mutations. Results In the very remote villages, 4.8% of patients carried ciprofloxacin-resistant E. coli with QRDR mutations despite no local availability of quinolones. However, there had been extensive local use of chloroquine, with higher prevalence of resistance seen in the villages shortly after a Plasmodium vivax epidemic (p<0.01). Antibacterial agents were not found in the drinking water, but chloroquine was demonstrated to be present. Chloroquine was found to inhibit the growth of E. coli in vitro. Replica plating demonstrated that 2-step QRDR mutations could be induced in E. coli in response to chloroquine. Conclusions In these remote communities, the heavy use of chloroquine to treat malaria likely selected for ciprofloxacin resistance in E. coli. This may be an important public health problem in malarious areas.