Gili Kadmon

Computerized Order Entry With Limited Decision Support to Prevent Prescription Errors in a PICU

OBJECTIVE: The value of computerized physician order entry (CPOE) and clinical decision support systems (CDSSs) in preventing prescription errors in pediatrics is unclear. We investigated the change in prescription error rates with the introduction of CPOE with and without a CDSS limited to weight-based dosing in a PICU. METHODS: In a PICU of a major tertiary-care pediatric medical center, 5000 orders were reviewed, that is, 1250 orders from each of 4 periods: period 1, before CPOE implementation; period 2, 1 year after CPOE implementation; period 3, after CDSS implementation; and period 4, after a change in prescription authorization. Prescription errors were identified and classified into: potential adverse drug events (ADEs), medication prescription errors (MPEs), and rule violations (RVs). RESULTS: We identified 273 errors (5.5%). The rate of potential ADEs decreased slightly between periods 1 and 2 (from 2.5% to 2.4%) and significantly in periods 3 and 4 (to 0.8% and 0.7%, respectively; P < .005). The rate of MPEs decreased slightly between periods 1 and 2 (from 5.5% to 5.3%), but new types of MPEs appeared. There was a significant decrease in period 3 (to 3.8%; P < .05) and a dramatically significant decrease in period 4 (to 0.7%; P < .0005). Only 3 RVs were found. Interrater agreement (κ statistic) was 0.788 between evaluators. CONCLUSIONS: CPOE implementation decreased prescription errors only to a small extent. However, the addition of a CDSS that limits doses by weight significantly reduced prescription error rates and, most importantly, potential ADEs. This finding emphasizes the major impact of weight-based calculation errors in pediatrics.

Computerized Scoring System for the Diagnosis of Foreign Body Aspiration in Children

Objectives: Foreign body aspiration (FBA) is a life-threatening event in children. The gold standard for diagnosis is bronchoscopy, but there is no consensus regarding indications for the procedure. The aim of this study was to formulate a predictive model for assessing the probability of FBA in suspected cases as an aid in the decision to perform diagnostic bronchoscopy. Methods: The files of 150 patients who underwent bronchoscopy for suspected FBA at our center between 1996 and 2004 were reviewed for medical history, physical examination, and radiologic studies. The findings were analyzed by logistic regression. Results: Using the file data, we formulated a predictive model wherein each parameter received a numeric coefficient representing its significance in evaluating suspected FBA. The most significant parameters were age 10 to 24 months, foreign body in the childs mouth and severe respiratory complaints during the choking episode, hypoxemia, dyspnea or stridor following the acute event, unilateral signs on lung auscultation, abnormal tracheal radiogram, unilateral infiltrate or atelectasis, and local hyperinflation or obstructive emphysema on chest radiogram. Conclusions: In our predictive model, every case of suspected FBA can be assigned a score based on the specific parameters present, which is then entered into a probability formula to determine the likelihood of a positive diagnosis. This model may serve as a useful tool for deciding on the use of bronchoscopy in all children with suspected FBA.

Bi-Level Positive Airway Pressure Ventilation in Pediatric Oncology Patients With Acute Respiratory Failure

The aim of the study was to describe our experience with bi-level positive airway pressure (BiPAP) ventilation in oncology children with acute respiratory failure, hospitalized in a single tertiary pediatric tertiary center. This was a retrospective cohort study of all pediatric oncology patients in our center admitted to the intensive care unit with acute hypoxemic or hypercarbic respiratory failure from January 1999 through May 2006, who required mechanical ventilation with BiPAP. Fourteen patients met the inclusion criteria with a total of 16 events of respiratory failure or impending failure: 12 events were hypoxemic, 1 was combined hypercarbic and hypoxemic, and 3 had severe respiratory distress. Shortly after BiPAP ventilation initiation, there was a statistically significant improvement in the respiratory rate (40.4 ± 9.3 to 32.5 ± 10.1, P < .05] and a trend toward improvement in arterial partial pressure of oxygen (PaO 2; 71.3 ± 32.7 to 104.6 ± 45.6, P = .055). The improvement in the respiratory status was sustained for at least 12 hours. In 12 (75%) events there was a need for sedation during ventilation; 12 children needed inotropic support during the BiPAP ventilation. Bi-level positive airway pressure ventilation failed in 3 (21%) children who were switched to conventional ventilation. All of them have died during the following days. One child was recategorized to receive palliative care while on BiPAP ventilator and was not intubated. In 12 of 16 BiPAP interventions (75%; 11 patients), the children survived to pediatric intensive care unit (PICU) discharge without invasive ventilation. No major complications were noted during BiPAP ventilation. Bi-level positive airway pressure ventilation is well tolerated in pediatric oncology patients suffering from acute respiratory failure and may offer noninferior outcomes compared with those previously described for conventional invasive ventilation. It appears to be a feasible initial option in children with malignancy experiencing acute respiratory failure.

Central apnoeas in infants with bronchiolitis admitted to the paediatric intensive care unit

Aim:  To further characterize apnoea(s) complicating bronchiolitis because of respiratory syncytial virus (RSV), to describe the incidence of this complication and identify possible risk factors for apnoea(s) and its development.

Validation of a pediatric obstructive sleep apnea screening tool

OBJECTIVE Pediatric obstructive sleep apnea (OSA) is a prevalent but under-diagnosed disease. The importance of screening for OSA in every child has been recently re-emphasized by the American Academy of Pediatrics Guidelines. Although several screening questionnaires are available for pediatric OSA, they are either complicated to use or not sensitive enough, and therefore OSA is seldom screened in primary care settings. Here, we validated a previously developed short (6-item) hierarchically-based screening questionnaire tool for pediatric OSA. METHODS Parents of 85 children referred for a sleep study at a pediatric community-based sleep clinic completed the questionnaire and their children underwent an overnight PSG. Receiver operator curve analyses and other predictive scales were assessed. RESULTS The 6-item questionnaire exhibited favorable sensitivity and fair specificity for diagnosis of OSA, which varied depending on the apnea-hypopnea index used for OSA definition. CONCLUSIONS A 6-item questionnaire is a sensitive and easy-to-use screening tool for pediatric OSA in a pediatric sleep clinic setting.

Nitric oxide for post-liver-transplantation hypoxemia in pediatric hepatopulmonary syndrome: Case report and review

Schiller O, Avitzur Y, Kadmon G, Nahum E, Steinberg RM, Nachmias V, Schonfeld T. Nitric oxide for post‐liver‐transplantation hypoxemia in pediatric hepatopulmonary syndrome: Case report and review.
Pediatr Transplantation 2011: 15: E130–E134.

Polymerase-chain-reaction-based diagnosis of viral pulmonary infections in immunocompromised children.

Viral pneumonia is a serious complication in immunocompromised children. Its aetiology is difficult to identify owing to the limitations of conventional microbiological tests. The aim of this study was to determine whether polymerase chain reaction (PCR) assays for respiratory viruses increase the diagnostic yield of bronchoalveolar lavage (BAL) in immunocompromised children.

Pulmonary hypertension specific treatment in infants with bronchopulmonary dysplasia.

When bronchopulmonary dysplasia (BPD) is complicated by pulmonary hypertension (PH), morbidity and mortality are significantly increased. BPD‐associated PH is not included in the current indications for PH medications. However, limited data demonstrate hemodynamic improvement and decreased mortality with PH‐specific treatment. This report describes our 6‐year experience treating BPD‐associated PH with PH medications, mainly sildenafil.

Postoperative thrombotic thrombocytopenic purpura in an infant: case report and literature review

Thrombotic thrombocytopenic purpura is caused by an imbalance of von Willebrand factor and its cleaving protease, which leads to the formation of microthrombi in end-organs. It rarely occurs in the pediatric population. Plasma exchange can significantly reduce mortality and morbidity. We present a 14-month-old infant in whom clinical and laboratory abnormalities compatible with thrombotic thrombocytopenic purpura were noted several days after resection of a large pelvic tumor. Treatment with double volume plasma exchange on postoperative day 5 led to complete resolution of the renal failure, thrombocytopenia, anemia, and neurological manifestations. ADAMTS13 inhibitors were negative and no mutations were found in factor H, factor I, membrane cofactor protein, and thrombomodulin to account for genetic predisposition to thrombotic thrombocytopenic purpura or atypical hemolytic uremic syndrome. Postoperative anemia, thrombocytopenia, fever, and neurological deficits in children should raise the suspicion of thrombotic thrombocytopenic purpura. Early diagnosis is important because the disorder is readily and efficiently treated with plasma exchange.

Polymerase‐chain‐reaction‐based diagnosis of invasive fungal pulmonary infections in immunocompromised children

Fungal pneumonia is a serious complication in immunocompromised children. It is difficult to diagnose because of the low sensitivity of clinical and standard laboratory tests. The aim of this study was to investigate the diagnostic impact of polymerase chain reaction (PCR) assays for fungal pathogens in bronchoalveolar lavage (BAL) fluid.