Graham C. Thompson

Outcomes of Children With Suspected Appendicitis and Incompletely Visualized Appendix on Ultrasound

OBJECTIVES The objective was to review the clinical outcomes of children with suspected appendicitis after an ultrasound (US) examination fails to fully visualize the appendix, the diagnostic characteristics of US in children with suspected appendicitis, and the predictive value of secondary signs of appendicitis when the appendix is not fully visualized. METHODS This was a retrospective health record review of children aged 3 to 17 years presenting to a tertiary pediatric emergency department (ED) with suspected appendicitis. Descriptive statistics and diagnostic test characteristics are reported. RESULTS Overall, 968 children had US. The appendix was fully visualized in 442 cases (45.7%), and 526 (54.3%) children had incompletely visualized appendices. The disposition of those with incompletely visualized appendices were as follows: 59.1% were discharged home, 10.5% went directly to the operating room, and 30.4% were admitted to the hospital for further observation. Of those discharged home based on clinical findings after incompletely visualized appendices, fewer than 0.3% ended up having appendicitis. Ultimately 15.6% of children with incompletely visualized appendices had pathology-confirmed appendicitis. The sensitivity and specificity of US for children with fully visualized appendices were 99.5% (95% confidence interval [CI] = 96.7% to 100%) and 81.3% (95% CI = 75.2% to 86.2%), respectively. The sensitivity and specificity for the presence of any secondary sign in diagnosing appendicitis were 40.2% (95% CI = 29.6% to 51.7%) and 90.6% (95% CI = 87.5% to 93.2%), respectively. CONCLUSIONS Children with incompletely visualized appendices on US can be safely discharged home based on clinical findings with an acceptable rate of missed appendicitis. Children with nonreassuring clinical examinations following incompletely visualized appendices on US may benefit from further imaging studies prior to appendectomy, to reduce the rate of negative appendectomy. While the presence of secondary signs of inflammation can be used to rule in appendicitis, statistical strength to rule out appendicitis in the absence of secondary signs is insufficient.

Development of metabolic and inflammatory mediator biomarker phenotyping for early diagnosis and triage of pediatric sepsis.

IntroductionThe first steps in goal-directed therapy for sepsis are early diagnosis followed by appropriate triage. These steps are usually left to the physician’s judgment, as there is no accepted biomarker available. We aimed to determine biomarker phenotypes that differentiate children with sepsis who require intensive care from those who do not.MethodsWe conducted a prospective, observational nested cohort study at two pediatric intensive care units (PICUs) and one pediatric emergency department (ED). Children ages 2–17 years presenting to the PICU or ED with sepsis or presenting for procedural sedation to the ED were enrolled. We used the judgment of regional pediatric ED and PICU attending physicians as the standard to determine triage location (PICU or ED). We performed metabolic and inflammatory protein mediator profiling with serum and plasma samples, respectively, collected upon presentation, followed by multivariate statistical analysis.ResultsNinety-four PICU sepsis, 81 ED sepsis, and 63 ED control patients were included. Metabolomic profiling revealed clear separation of groups, differentiating PICU sepsis from ED sepsis with accuracy of 0.89, area under the receiver operating characteristic curve (AUROC) of 0.96 (standard deviation [SD] 0.01), and predictive ability (Q2) of 0.60. Protein mediator profiling also showed clear separation of the groups, differentiating PICU sepsis from ED sepsis with accuracy of 0.78 and AUROC of 0.88 (SD 0.03). Combining metabolomic and protein mediator profiling improved the model (Q2 =0.62), differentiating PICU sepsis from ED sepsis with accuracy of 0.87 and AUROC of 0.95 (SD 0.01). Separation of PICU sepsis or ED sepsis from ED controls was even more accurate. Prespecified age subgroups (2–5 years old and 6–17 years old) improved model accuracy minimally. Seventeen metabolites or protein mediators accounted for separation of PICU sepsis and ED sepsis with 95 % confidence.ConclusionsIn children ages 2–17 years, combining metabolomic and inflammatory protein mediator profiling early after presentation may differentiate children with sepsis requiring care in a PICU from children with or without sepsis safely cared for outside a PICU. This may aid in making triage decisions, particularly in an ED without pediatric expertise. This finding requires validation in an independent cohort.

Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals

OBJECTIVES The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments (EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies. METHODS Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with after-hours surgery were determined using generalized estimating equations logistic regression. RESULTS Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014). CONCLUSIONS Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes.

RECOGNITION AND MANAGEMENT OF SEPSIS IN CHILDREN: PRACTICE PATTERNS IN THE EMERGENCY DEPARTMENT

BACKGROUND Pediatric sepsis remains a leading cause of morbidity and mortality. Understanding current practice patterns and challenges is essential to inform future research and education strategies. OBJECTIVE Our aim was to describe the practice patterns of pediatric emergency physicians (PEPs) in the recognition and management of sepsis in children and to identify perceived priorities for future research and education. METHODS We conducted a cross-sectional, internet-based survey of members of the American Academy of Pediatrics, Section on Emergency Medicine and Pediatric Emergency Research Canada. The survey was internally derived, externally validated, and distributed using a modified Dillman methodology. Rank scores (RS) were calculated for responses using Likert-assigned frequency values. RESULTS Tachycardia, mental-status changes, and abnormal temperature (RS = 83.7, 80.6, and 79.6) were the highest ranked clinical measures for diagnosing sepsis; white blood cell count, lactate, and band count (RS = 73.5, 70.9, and 69.1) were the highest ranked laboratory investigations. The resuscitation fluid of choice (85.5%) was normal saline. Dopamine was the first-line vasoactive medication (VAM) for cold (57.1%) and warm (42.2%) shock with epinephrine (18.5%) and norepinephrine (25.1%) as second-line VAMs (cold and warm, respectively). Steroid administration increased with complexity of presentation (all-comers 3.8%, VAM-resistant shock 54.5%, chronic steroid users 72.0%). Local ED-specific clinical pathways, national emergency department (ED)-specific guidelines, and identification of clinical biomarkers were described as future priorities. CONCLUSIONS While practice variability exists among clinicians, PEPs continue to rely heavily on clinical metrics for recognizing sepsis. Improved recognition through clinical biomarkers and standardization of care were perceived as priorities. Our results provide a strong framework to guide future research and education strategies in pediatric sepsis.

Implementation of an Advanced Nursing Directive for Suspected Appendicitis to Empower Pediatric Emergency Nurses

In response to a clinical safety review, we have implemented an AND to empower our pediatric emergency nurses to identify and initiate care directives for children with suspected appendicitis. Future quality assessment and research studies will focus on the accuracy of the AND in predicting which children will have imaging studies or an appendectomy as well as the impact of the AND on key pediatric ED flow measures.

Pain management of acute appendicitis in Canadian pediatric emergency departments

OBJECTIVES Children with suspected appendicitis are at risk for suboptimal pain management. We sought to describe pain management patterns for suspected appendicitis across Canadian pediatric emergency departments (PEDs). METHODS A retrospective medical record review was undertaken at 12 Canadian PEDs. Children ages 3 to 17 years who were admitted to the hospital in February or October 2010 with suspected appendicitis were included. Patients were excluded if partially assessed or treated at another hospital. Data were abstracted using a study-specific, standardized electronic data extraction tool. The primary outcome was the proportion of children who received analgesia while in the emergency department (ED). Secondary outcomes included the proportion of children receiving intravenous (IV) morphine and the timing of analgesic provision. RESULTS A total of 619 health records were abstracted; mean (SD) patient age was 11.4 (3.5) years. Sixty-one percent (381/616) of patients received analgesia in the ED; 42.8% (264/616) received IV morphine. Other analgesic agents provided included oral acetaminophen (23.5% [145/616]) and oral ibuprofen (5.8% [36/616]). The median (IQR) initial dose of IV morphine was 0.06 (0.04, 0.09) mg/kg. The median (IQR) time from triage to the initial dose of analgesia was 196 (101, 309.5) minutes. Forty-three percent (117/269) of children receiving analgesia received the initial dose following surgical consultation; 43.7% (121/277) received their first analgesic after abdominal ultrasound was performed. CONCLUSIONS Suboptimal and delayed analgesia remains a significant issue for children with suspected appendicitis in Canadian PEDs. This suggests a role for multidimensional knowledge translation interventions and care protocols to improve timely access to analgesia.

Reported provision of analgesia to patients with acute abdominal pain in Canadian paediatric emergency departments.

OBJECTIVES Evidence exists that analgesics are underutilized, delayed, and insufficiently dosed for emergency department (ED) patients with acute abdominal pain. For physicians practicing in a Canadian paediatric ED setting, we (1) explored theoretical practice variation in the provision of analgesia to children with acute abdominal pain; (2) identified reasons for withholding analgesia; and (3) evaluated the relationship between providing analgesia and surgical consultation. METHODS Physician members of Paediatric Emergency Research Canada (PERC) were prospectively surveyed and presented with three scenarios of undifferentiated acute abdominal pain to assess management. A modified Dillmans Tailored Design method was used to distribute the survey from June to July 2014. RESULTS Overall response rate was 74.5% (149/200); 51.7% of respondents were female and mean age was 44 (SD 8.4) years. The reported rates of providing analgesia for case scenarios representative of renal colic, appendicitis, and intussusception, were 100%, 92.1%, and 83.4%, respectively, while rates of providing intravenous opioids were 85.2%, 58.6%, and 12.4%, respectively. In all 60 responses where the respondent indicated they would obtain a surgical consultation, analgesia would be provided. In the 35 responses where analgesia would be withheld, 21 (60%) believed pain was not severe enough, while 5 (14.3%) indicated it would obscure a surgical condition. CONCLUSIONS Pediatric emergency physicians self-reported rates of providing analgesia for acute abdominal pain scenarios were higher than previously reported, and appeared unrelated to request for surgical consultation. However, an unwillingness to provide opioid analgesia, belief that analgesia can obscure a surgical condition, and failure to take self-reported pain at face value remain, suggesting that the need exists for further knowledge translation efforts.

Advanced Nursing Directives: Integrating Validated Clinical Scoring Systems into Nursing Care in the Pediatric Emergency Department

In an effort to improve the quality and flow of care provided to children presenting to the emergency department the implementation of nurse-initiated protocols is on the rise. We review the current literature on nurse-initiated protocols, validated emergency department clinical scoring systems, and the merging of the two to create Advanced Nursing Directives (ANDs). The process of developing a clinical pathway for children presenting to our pediatric emergency department (PED) with suspected appendicitis will be used to demonstrate the successful integration of validated clinical scoring systems into practice through the use of Advanced Nursing Directives. Finally, examples of 2 other Advanced Nursing Directives for common clinical PED presentations will be provided.

Is Pelvic Ultrasound Associated with an Increased Time to Appendectomy in Pediatric Appendicitis

BACKGROUND Appendicitis is a common pediatric condition requiring urgent surgical intervention to prevent complications. Pelvic ultrasound (US) as a diagnostic aid has become increasingly common. Despite its advantages, evidence suggests US can lead to delayed definitive management. OBJECTIVE The objective was to test the hypothesis that US is associated with an increased time to appendectomy in children with acute appendicitis. METHODS A chart review was conducted of all children aged 0-17 years who presented to the pediatric emergency department (ED) with a discharge diagnosis of appendicitis. The primary outcome variable was the interval between initial evaluation to appendectomy between patients who received an US and those who did not. RESULTS Of 662 cases included, 424 patients (64%) underwent a pelvic US and 238 patients underwent an appendectomy without US. Median time interval from initial evaluation in the ED by a physician to appendectomy among patients who received an US was 9.7 h (interquartile range [IQR]: 6.8-15.0 h) compared with 5.5 h (IQR: 3.8-8.6 h) among patients who did not receive an US (Mann-Whitney, p < 0.001). The increased time to appendectomy in patients who received an US was dependent on the patient being female and presenting to the ED after hours (univariate analysis of variance test for interaction, p < 0.05). CONCLUSIONS Female pediatric patients and those presenting after hours that undergo an US have a significantly increased time to appendectomy compared with those who do not undergo diagnostic imaging.

Sex-hormone-driven innate antibodies protect females and infants against EPEC infection

Females have an overall advantage over males in resisting Gram-negative bacteremias, thus hinting at sexual dimorphism of immunity during infections. Here, through intravital microscopy, we observed a sex-biased difference in the capture of blood-borne bacteria by liver macrophages, a process that is critical for the clearance of systemic infections. Complement opsonization was indispensable for the capture of enteropathogenic Escherichia coli (EPEC) in male mice; however, a faster complement component 3–independent process involving abundant preexisting antibodies to EPEC was detected in female mice. These antibodies were elicited predominantly in female mice at puberty in response to estrogen regardless of microbiota-colonization conditions. Estrogen-driven antibodies were maternally transferrable to offspring and conferred protection during infancy. These antibodies were conserved in humans and recognized specialized oligosaccharides integrated into the bacterial lipopolysaccharide and capsule. Thus, an estrogen-driven, innate antibody-mediated immunological strategy conferred protection to females and their offspring.Kubes and colleagues describe the presence in females of estrogen-driven, innate antibodies against specific oligosaccharides in EPEC that are maternally transferrable to offspring in mice and humans.