Gerardo Chiricolo

Derivation of a pediatric growth curve for inferior vena caval diameter in healthy pediatric patients: brief report of initial curve development

BackgroundA validated tool has long been sought to provide clinicians with a uniform and accurate method to assess hydration status in the pediatric emergency medicine population. Outpatient clinicians use CDC height- and weight-based curves for the assessment of physical development. In hospital, daily weights provide objective data; however, these are usually not available at presentation.One of the most promising techniques for the rapid assessment of volume is ultrasound (US) to obtain an indexed inferior vena cava diameter (IVCDi); as previously described. Prior studies have focused on IVCDi in dehydrated patients and have shown that it provides accurate estimates of right atrial pressure and volume status. The objective of this study is to derive an IVC growth curve in healthy pediatric patients.MethodsProspective cohort design enrolled healthy children between the ages of 4 weeks and 20 years. Patients presenting with fever, illnesses, or diagnoses known to affect the volume will be excluded. All eligible patients under 21, who have provided self or parental written consent, will undergo a brief ultrasound to obtain transverse and long images of both the IVC and the aorta; all scans will be digitally saved. Image quality will be subjectively rated as poor, fair, or good based on wall clarity. Poor quality images will be recorded but may be omitted from our analysis. Five clinicians completed a 1-h introduction to IVC-US and ten supervised scans prior to enrollment. Still images will be measured in order to determine IVCDi in both transverse and longitudinal planes. To assess inter-rater reliability, in 10% of cases, two clinicians will complete scans. All study scans will be over-read by a fellowship-trained sonologist.IVCDi will be plotted independently as functions of age, gender, BMI, and aortic diameter. Within each group, means with means or medians with 95% CIs will be calculated. Following uni- and bivariate analyses and assessment for colinearity, a variety of parametric and nonparametric regression procedures will be conducted. The smoothed curves will be approximated using a modified LMS estimation procedure.ResultsData for the initial curve derivation includes 25 patients ranging from 13 months to 20 years (mean 102 months or 8.5 years). Sixty-five percent of patients were enrolled from the ED, while 35% were enrolled from well-child clinic visits. When evaluating the size of IVC as a function of time linear growth, increasing size was found to proportionately increase with age of patient in months.ConclusionsData suggest a linear correlation between IVC size and age. Such data, when plotted as a new growth curve, may allow clinicians to plot a patients sonographic measurements in order to assess hydration health.

Higher success rates and satisfaction in difficult venous access patients with a guide wire–associated peripheral venous catheter

STUDY OBJECTIVE This study compares first pass success rates and patient and physician satisfaction scores of using a guide wire-associated peripheral venous catheter (GAPIV) vs a traditional peripheral venous catheter in difficult to obtain venous access patients. METHODS A total of 200 patients were enrolled prospectively from a convenience sample in a large urban academic emergency department. Patients were included when they were deemed difficult access per study criteria. Patients were alternated to receiving either a traditional peripheral venous catheter or a GAPIV. The number of attempts, the number of catheters used, and patient and physician satisfaction scores were recorded. RESULTS A total of 100 patients were enrolled into each group. First attempt success was 85% with GAPIV vs 22% with the traditional peripheral venous catheter (P < .0001). Sixty-two percent of patients required a second stick with the conventional catheter compared to 15% with the GAPIV. The average number of attempts overall for the GAPIV product was 1.2 with an SD of 0.4 attempts vs 1.9 and an SD of 0.6 attempts with the traditional peripheral venous catheter; P < .0001. Using a 5-point Likert scale, the GAPIV had a median patient satisfaction score of 5 at insertion compared with the traditional peripheral venous catheter score of 2; P < .0001. Median physician satisfaction with the GAPIV study device was 5 at time of insertion, compared to 3 for the traditional peripheral venous catheter. CONCLUSION The GAPIV product demonstrated significantly higher first attempt success and patient satisfaction compared to a traditional peripheral venous catheter in difficult to obtain venous access patients. Physician satisfaction was also favorable due to ease of access, time, and efficiencies gained.

Ultrasound-guided drainage of peritonsillar abscess: shoot with your hockey-stick

Peritonsillar abscess (PTA) is a complication of pharyngitis and tonsillitis, and the most common deep space infection of the head and neck [1]. Often clinical examination alone cannot accurately distinguish between peritonsillar cellulitis and abscess. This can lead to inappropriate management, failed drainage attempts, and unnecessary complications. Some clinicians rely on computerized tomography (CT scans) or otolaryngologist consultation to confirm the diagnosis or assist in drainage. Point-of-care ultrasound is able to confirm the diagnosis of PTA, as well as differentiate PTA from cellulitis [1]. Ultrasound is also able to provide either static or dynamic guidance for drainage procedures [2]. Previous case studies report that intra-oral ultrasound has a sensitivity of 89 % and a specificity approaching 100 % for the diagnosis of PTA. A CT scan has a specificity of 75 % [3]. Typically, an endocavitary probe is used for the procedure [4]. Linear array probes have been used for transcutaneous imaging through the neck, but intraoral use has not been described [5]. This case report describes the diagnosis and drainage of PTA made with a linear array ‘‘hockeystick’’ probe intra-orally. This probe is unique in that it is shorter than typical endocavitary probes, and thinner than typical linear array probes, making it ideal for use within a confined space such as the oral cavity (Fig. 1a). We believe the novel use of this transducer provides better access to the oral cavity, is more comfortable for the patient, and provides superior imaging of the peritonsillar area compared with the endocavitary probe. A 23-year-old woman was presented to the Emergency Department (ED) complaining of severe throat pain for 2 days associated with fever, chills and odynophagia. The patient was tachycardiac and febrile on arrival. The head and neck examination revealed erythematous pharynx, swollen tonsils with bilateral white exudates, slight bulging of the right peritonsillar space without uvular deviation, some trismus, and right-sided anterior cervical lymphadenopathy. The patient was not drooling, had no audible stridor, and displayed no other signs of upper airway compromise. The remaining history and physical examinations were non-contributory. A PTA was suspected, and a focused ultrasound study of the painful area was performed to differentiate an abscess from simple pharyngitis or tonsillitis. After providing topical analgesia with Cetacaine spray, the patient’s pharyngeal cavity was examined via intra-oral ultrasound. It was determined that due to the patient’s trismus it would be difficult to insert an endocavitary transducer. Instead, we chose the L14-5sp linear array (aka ‘‘hockey-stick’’) transducer (ZONARE Medical Systems, Inc, Mountain View, CA). The probe was covered with a sterile barrier, and placed directly over the area of maximal swelling. A right-sided PTA was clearly visualized (Fig. 1b, c). The abscess was immediately drained at the bedside utilizing static ultrasound guidance. The patient was administered an initial dose of clindamycin in the ED, and was discharged home with oral antibiotic therapy and otolaryngology clinic follow-up. The diagnosis and drainage of PTA with an ultrasound study improves accuracy and decreases complications [1]. Not only is an ultrasound study able to identify the abscess & Adam Ash adamash4@hotmail.com

Credentialing for Emergency Ultrasonography

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