James M. Gerard

Sleep Apnea in Patients Receiving Growth Hormone

Among 145 patients treated with recombinant human growth hormone (GH), four devel oped sleep apnea (two obstructive, two mixed) associated with tonsillar and adenoidal hypertrophy in three. These four patients had no local risk factors predisposing to upper airway obstruction (i.e., frequent pharyngitis or sinusitis). Clinical and/or polysomnographic features of sleep apnea improved following cessation of GH therapy in one patient, and following tonsillectomy and adenoidectomy in all patients. The present observations indicate that, albeit rarely, obstructive and/or central sleep apnea may occur in children treated with GH. Polysomnography should be considered if symptoms of snoring, interrupted sleep, daytime somnolence—particularly if associated with tonsillar hypertrophy—appear in children during GH therapy.

Impact of Just-in-Time and Just-in-Place Simulation on Intern Success With Infant Lumbar Puncture.

BACKGROUND AND OBJECTIVE: Simulation-based skill trainings are common; however, optimal instructional designs that improve outcomes are not well specified. We explored the impact of just-in-time and just-in-place training (JIPT) on interns’ infant lumbar puncture (LP) success. METHODS: This prospective study enrolled pediatric and emergency medicine interns from 2009 to 2012 at 34 centers. Two distinct instructional design strategies were compared. Cohort A (2009–2010) completed simulation-based training at commencement of internship, receiving individually coached practice on the LP simulator until achieving a predefined mastery performance standard. Cohort B (2010–2012) had the same training plus JIPT sessions immediately before their first clinical LP. Main outcome was LP success, defined as obtaining fluid with first needle insertion and <1000 red blood cells per high-power field. Process measures included use of analgesia, early stylet removal, and overall attempts. RESULTS: A total of 436 first infant LPs were analyzed. The LP success rate in cohort A was 35% (13/37), compared with 38% (152/399) in cohort B (95% confidence interval for difference [CI diff], −15% to +18%). Cohort B exhibited greater analgesia use (68% vs 19%; 95% CI diff, 33% to 59%), early stylet removal (69% vs 54%; 95% CI diff, 0% to 32%), and lower mean number of attempts (1.4 ± 0.6 vs 2.1 ± 1.6, P < .01) compared with cohort A. CONCLUSIONS: Across multiple institutions, intern success rates with infant LP are poor. Despite improving process measures, adding JIPT to training bundles did not improve success rate. More research is needed on optimal instructional design strategies for infant LP.

Validation of global rating scale and checklist instruments for the infant lumbar puncture procedure.

Introduction The Patient Outcomes in Simulation Education network has developed tools for the assessment of competency to perform the infant lumbar puncture (ILP) procedure. The objective of this study was to evaluate the validity and reliability of these tools in a simulated setting. Methods We developed a 4-point anchored global rating scale (GRS) and 15-item dichotomous checklist instrument to assess ILP performance in a simulated environment. Video recordings of 60 subjects performing an unsupervised lumbar puncture on an infant bench top simulator were collected prospectively; 20 performed by subjects in each of 3 categories (beginner, intermediate experienced, or expert). Three blinded, expert raters independently scored each subject’s video recording using the GRS and checklist instruments. Results The final version of the scoring instruments is presented. Across all subject groups, higher GRS scores were found with advancing level of experience (P < 0.01). Total checklist scores were similar between the expert and intermediate experienced groups (P = 0.54). Both groups scored higher than the beginner group on the checklist instrument (P < 0.01). For each rater, a significant positive correlation was found between GRS scores and total checklist scores (median &rgr; = 0.75, P < 0.01). Cronbach &agr; coefficient for the checklist was 0.77. The intraclass correlation coefficients between raters for the GRS and total checklist scores were 0.71 and 0.52, respectively. Conclusions This study provides some initial evidence to support the validity and reliability of the ILP-anchored GRS. Acceptable internal consistency was found for the checklist instrument. The GRS instrument outperformed the checklist in its discriminant ability and interrater agreement.

Simulation training for pediatric residents on central venous catheter placement: a pilot study.

Objective: To assess the effect of simulation training on pediatric residents’ acquisition and retention of central venous catheter insertion skills. A secondary objective was to assess the effect of simulation training on self-confidence to perform the procedure. Design: Prospective observational pilot study. Setting: Single university clinical simulation center. Subjects: Pediatric residents, postgraduate years 1–3. Interventions: Residents participated in a 60- to 90-minute ultrasound-guided central venous catheter simulation training session. Video recordings of residents performing simulated femoral central venous catheter insertions were made before (baseline), after, and at 3-month following training. Three blinded expert raters independently scored the performances using a 24-item checklist and 100-mm global rating scale. At each time point, residents rated their confidence to perform the procedure on a 100-mm scale. Measurements and Main Results: Twenty-six residents completed the study. Compared with baseline, immediately following training, median checklist score (54.2% [interquartile range, 40.8–68.8%] vs 83.3% [interquartile range, 70.0–91.7%]), global rating score (8.0 mm [interquartile range, 0.0–64.3 mm] vs 79.5 mm [interquartile range, 16.3–91.7 mm]), success rate (38.5% vs 80.8%), and self-confidence (8.0 mm [interquartile range, 3.8–19.0 mm] vs 52.0 mm [interquartile range, 43.5–66.5 mm]) all improved (p < 0.05 for all variables). Compared with baseline, median checklist score (54.2% [interquartile range, 40.8–68.8%] vs 54.2% [interquartile range, 45.8–80.4%], p = 0.47), global rating score (8.0 mm [interquartile range, 0.0–64.3 mm] vs 35.5 mm [interquartile range, 5.3–77.0], p = 0.62), and success rate (38.5% vs 65.4%, p = 0.35) were similar at 3-month follow-up. Self-confidence, however, remained above baseline at 3-month follow-up (8.0 mm [interquartile range, 3.8–19.0 mm] vs 61.0 mm [interquartile range, 31.5–71.8 mm], p < 0.01). Conclusions: Simulation training improved pediatric residents’ central venous catheter insertion procedural skills. Decay in skills was found at 3-month follow-up. This suggests that simulation training for this procedure should occur in close temporal proximity to times when these skills would most likely be used clinically and that frequent refresher training might be beneficial to prevent skills decay.

Are pediatric interns prepared to perform infant lumbar punctures? A multi-institutional descriptive study.

Background There are few data describing pediatric interns’ experiences, knowledge, attitudes, and skills related to common procedures. This information would help guide supervisors’ decisions about interns’ preparedness and training needs. Objectives This study aimed to describe pediatric interns’ medical school experiences, knowledge, attitudes, and skills with regard to infant lumbar punctures (LPs) and to describe the impact of these factors on interns’ infant LP skills. Methods This prospective cross-sectional descriptive study was conducted at 21 academic medical centers participating during 2010. Participants answered 8 knowledge questions, 3 attitude questions, and 6 experience questions online. Skills were assessed on an infant LP simulator using a 15-item subcomponent checklist and a 4-point global assessment. Results Eligible interns numbered 493, with 422 (86%) completing surveys and 362 (73%) completing skills assessments. The majority 287/422 (68%) had never performed an infant LP; however, 306 (73%) had observed an infant LP during school. The mean (SD) knowledge score was 63% (±21%). The mean (SD) subcomponent skills checklist score was 73% (±21%). On the global skills assessment, 225 (62%) interns were rated as beginner, and 137 (38%) were rated as competent, proficient, or expert. Independent predictors of an above-beginner simulator performance included infant LP experience on a patient (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.4–3.5), a knowledge score greater than 65% (OR, 2.4; 95% CI, 1.5–3.7), or self-reported confidence (OR, 3.5; 95% CI, 1.9–6.4). Conclusions At the start of residency, the majority of pediatric interns have little experience, poor knowledge, and low confidence and are not prepared to perform infant LPs.

A Fatal Overdose of Arginine Hydrochloride

CASE REPORT Arginine hydrochloride is used both diagnostically to test for growth hormone deficiency and therapeutically for treatment of metabolic alkalosis. We describe a 21-month-old girl who developed cardiopulmonary arrest following an accidental overdose of arginine hydrochloride. The patient developed acute metabolic acidosis and transient, but severe, hyponatremia. Thirty-six hours after successful resuscitation, she developed fatal central pontine and extrapontine myelinolysis. Unlike previous reports of arginine-toxicity, our patient showed no evidence of hyperkalemia. This case illustrates a previously unreported mechanism of arginine hydrochloride toxicity.

An Analysis of Morning Report at a Pediatric Hospital

The purpose of this study was to determine the types of cases residents select for morning report discussion and the educational value of postdischarge follow-up of unknown cases. Between April and December of 1994, at Cardinal Glennon Childrens Hospital in St. Louis, Missouri, random, resident, and group-selected patients listed at morning report were followed up throughout hospitalization. Patients were categorized based upon whether or not their morning report and discharge diagnoses were the same or different. Patients discharged without a diagnosis were followed up by chart review at 6 months to determine whether a diagnosis had been made. Data were analyzed by Chi-square analysis with Bonfferoni adjustment factor for multiple comparisons. Residents were more than two times more likely to select cases for discussion in which the diagnosis changed during hospitalization (P<O.O1). The 6-month follow-up yielded new diagnoses in only 21% of previously unknown cases. We concluded that residents do an exceptional job of selecting difficult diagnostic cases for discussion at morning report. Postdischarge follow up of unknown cases adds little new information for discussion at morning report.

The Correlation of Workplace Simulation-Based Assessments With Interns' Infant Lumbar Puncture Success: A Prospective, Multicenter, Observational Study.

Introduction Little data are available to guide supervisors’ decisions regarding when trainees are prepared to safely perform their first procedure on a patient. We aimed to describe the correlation of simulation-based assessments, in the workplace, with interns’ first clinical infant lumbar puncture (ILP) success. Methods This is a prospective, observational subcomponent of a larger study of incoming interns at 33 academic medical centers (July 2010 to June 2012) assessing the impact of just-in-time training. When an intern’s patient required an ILP, a just-in-time simulation-based skills refresher was conducted with his or her supervisor. At the end of the refresher, supervisors assessed interns’ ILP skills on a simulator in the workplace before clinical performance using a four point anchored scale. The primary outcome was the correlation of supervisors’ assessment and interns’ procedural success. The number needed to assess for this instrument (1 / absolute risk reduction) was calculated. Results A total of 1600 interns were eligible to participate, and 1215 were enrolled. A total of 297 completed an assessment and a subsequent clinical ILP. Success rates for each scale rating were 29% (18/63) for novice, 39% (51/130) for beginner, 55% (46/83) for competent, and 43% (9/21) for proficient. The correlation coefficient was 0.161 (95% confidence interval, 0.057–0.265), indicating a weak correlation between supervisor rating and success. Success rate was 53% for the ratings of competent or proficient compared with 35% for the ratings of novice or beginner. Using the global rating scale for the summative assessment to determine procedural readiness could lead to 1 fewer patient experiencing a failed ILP for every 6 interns tested (6.2; 95% confidence interval, 4.0–8.5). Conclusions A simulation-based assessment of interns conducted in the workplace before their first ILP has some value in predicting clinical ILP success.

Comparison of cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations.

Objective We sought to compare cosmetic outcomes, complication rates, and patient/caregiver satisfaction of absorbable versus nonabsorbable sutures in children. Methods Healthy patients, 1 to 18 years old, with facial lacerations 1 to 5 cm, were randomized to repair with fast-absorbing catgut (FAC) or nylon (NYL) sutures. Patients returned in 4 to 7 days and in 3 to 4 months, at which time photographs and caregiver surveys were completed. Unlike part I, all FAC sutures were permitted to absorb rather than be removed. Using a 100-mm visual analog scale (VAS), a noninferiority (NI) design was applied, with a difference of less than 15 mm considered clinically equivalent. Caregivers and 3 blinded physicians independently rated the scars via photographs. Results Ninety-eight patients were enrolled, 76 caregiver surveys were completed, and 61 (29 FAC, 32 NYL) had photographs scored by physicians. The mean physician VAS scores for FAC and NYL were 57.6 and 67.6, respectively (difference, −10.0; 95% confidence interval, −19.1 to −0.4); thus, NI could not be established. The mean caregiver VAS scores for the FAC and NYL groups were 93.8 and 86.6, respectively (difference, 7.2; 95% confidence interval, −4.9 to 13.9); thus, NI of FAC was established. There were no significant differences in rates of infection, wound dehiscence, or keloid formation. In terms of future preference, caregivers favored FAC (33/33) over NYL (26/36) (P < 0.01). Conclusions Caregiver VAS scores showed NI of FAC, which were also preferred by the caregivers. However, NI for FAC could not be demonstrated by blinded physicians with respect to cosmetic outcomes.

Do children with high body mass indices have a higher incidence of emesis when undergoing ketamine sedation

Objectives The objective of this study was to determine if overweight children are more likely than normal-weight children to require ondansetron when undergoing ketamine sedation in a pediatric emergency department. Methods Patients between the ages of 2 and 18 years with an American Society of Anesthesiologists classification of I or II who underwent intravenous procedural sedation with ketamine with or without midazolam for uncomplicated forearm fracture reduction in an urban pediatric emergency department during the year 2007 were included. A review of sedation records was conducted for each visit. Data collected included demographics, sedation time, and doses of medications administered. Body mass index (BMI) was calculated using an estimated height for the 50th percentile for age and sex. In 2007, all patients underwent procedural sedation per protocol. Per protocol, patients did not prophylactically receive ondansetron during procedural sedations. Results During the study period, 141 patients were identified who met inclusion criteria. Of these, 110 had an estimated BMI less than 25 kg/m2; 31 had an estimated BMI of 25 kg/m2 or greater. Ten patients (7.1%) received ondansetron. Patients in the high-BMI group were more likely to have received ondansetron than those in the normal-BMI group (16.1% vs 4.5%, P = 0.04). Conclusions Our data suggest that pediatric patients with high BMIs are at greater risk for nausea or emesis during ketamine sedation. Clinicians should consider prophylactic administration of ondansetron to this group of patients before performing ketamine sedation.