Kenneth A. Michelson

Urinary Neutrophil Gelatinase-Associated Lipocalin Is a Promising Biomarker for Late Onset Culture-Positive Sepsis in Very Low Birth Weight Infants

Need for the early identification of sepsis in very low birth weight (VLBW) infants has led to the search for reliable biomarkers. This study aims to determine whether urinary neutrophil gelatinase-associated lipocalin (uNGAL) rises in culture-positive sepsis and, if so, is elevated at the time sepsis is suspected. This is a prospective study of 91 VLBW infants whose urine was collected daily for uNGAL analysis. In 65 episodes of suspected sepsis, four groups were identified: a) culture-positive sepsis; b) single culture positive for Staphylococcus epidermidis; c) and d) negative culture with antibiotic treatment for ≥7 d and <7 d, respectively. Daily means of uNGAL of each group were estimated for comparison. Mean uNGAL in group A (179 ng/mL) was significantly elevated on the day blood culture was drawn (day 0) compared with the mean of healthy VLBW infants (6.5 ng/mL), and to the means in groups B, C, and D (p < 0.05). In group A, mean uNGAL was significantly elevated on day 0 and daily for 5 days when compared with that of the day before culture (p < 0.05 to <0.005). uNGAL shows promise as an early marker for culture-positive sepsis in VLBW infants.

The impact of duration of labor induction on cesarean rate

OBJECTIVE We sought to determine maternal factors that influence success of labor induction and whether the probability of cesarean delivery changed with time during induction. STUDY DESIGN We performed a retrospective cohort study of 1650 singleton pregnancies induced at a gestation of 37 weeks or longer, with birthweights of 2500 g or greater, and without congenital anomalies. We used multivariate logistic regression to calculate odds ratios for cesarean. RESULTS Nulliparity (odds ratio [OR] 7.8, 95% confidence interval [CI] 5.7 to 11), hypertension (OR 1.4, 95% CI 1.1 to 1.8), diabetes (OR 2.2, 95% CI 1.6 to 3.1), maternal age 28.8 years old or older (OR 1.3, 95% CI 1.2 to 1.4), and birthweight of 3441 g or greater (OR 1.6, 95% CI 1.2 to 2.0) were significantly associated with cesarean. Cesarean risk increased linearly with time by an average of 3.8% per 6 hours. CONCLUSION Risk of cesarean increases over the duration of induction but does not reach clinical certainty. Cesarean probability is greater with nulliparity, hypertension, diabetes, older maternal age, or higher birthweight. Inductions without stated indications may not carry an increased risk of cesarean.

Pediatric Emergency Department Crowding Is Associated With a Lower Likelihood of Hospital Admission

OBJECTIVES Emergency department (ED) crowding may affect disposition decision-making. The objective was to measure the effect of ED crowding on probability of admission and return visit to the ED after discharge. METHODS The authors studied a historical cohort at a large pediatric ED over 40 months. Each patient was assigned a score on arrival based on the ED occupancy rate (the ratio of patients to beds). Patients were divided into quintiles by occupancy rate. The proportion admitted for each quintile was compared to the least crowded quintile adjusting for acuity, hospital occupancy, and time of arrival. The same analysis was performed for return visits to the ED within 48 hours. The analyses were repeated for the subsets of patients with asthma and with gastroenteritis and/or dehydration. RESULTS From the 40 months of historical data, 198,778 visits were analyzed. The adjusted odds ratio (aOR) for admission among the whole cohort was 0.85 (95% confidence interval [CI]=0.81 to 0.89) comparing the highest to the lowest crowding quintiles (occupancy rate >1.17 and <0.54, respectively). For asthma patients, aOR=0.93 (95% CI=0.72 to 1.20), and for gastroenteritis patients, aOR=0.87 (95% CI=0.65 to 1.17). The aOR of return visits comparing the highest to the lowest crowding quintiles for all patients was aOR=0.87 (95% CI=0.79 to 0.97), for asthma patients was aOR=1.52 (95% CI=0.95 to 2.46), and for gastroenteritis patients was aOR=0.83 (95% CI=0.54 to 1.28). CONCLUSIONS Increasing ED crowding is associated with a lower likelihood of hospital admission and lower frequency of return visits within 48 hours.

Glucocorticoids and Hospital Length of Stay for Children with Anaphylaxis: A Retrospective Study.

OBJECTIVE To evaluate whether glucocorticoid administration is associated with improved outcomes in children with anaphylaxis. STUDY DESIGN We included children from the Pediatric Health Information System database who were diagnosed with anaphylaxis at 35 US childrens hospitals between 2009 and 2013. Patients were stratified by disposition from the emergency department (ED), either hospitalized or discharged. We evaluated the association between glucocorticoid administration and prolonged length of stay (LOS), defined as hospital stay ≥ 2 days, and subsequent epinephrine administration among hospitalized children. Among discharged children, we assessed the association between glucocorticoid administration and ED revisits within 3 days. Analyses were adjusted for illness severity using ordering of laboratory tests, medications, oxygen, intravenous fluids, and admission to the intensive care unit. RESULTS Among 5203 children hospitalized with anaphylaxis, 424 (8.2%) had prolonged LOS. Glucocorticoid administration was inversely associated with prolonged LOS (aOR, 0.61; 95% CI, 0.41-0.93) and with subsequent epinephrine use (aOR, 0.63; 95% CI, 0.43-0.84) among hospitalized children. Glucocorticoid administration was not associated with the odds of a 3-day revisit (aOR, 1.01; 95% CI, 0.50-2.05) among discharged patients. CONCLUSION The use of glucocorticoids was inversely associated with prolonged LOS among children hospitalized with anaphylaxis, but was not associated with 3-day ED revisits among discharged children. These findings support the use of glucocorticoids in children hospitalized with anaphylaxis.

Variation and Trends in Anaphylaxis Care in United States Children's Hospitals.

OBJECTIVES We sought to determine the extent of variation in treatment of children with anaphylaxis. METHODS We identified children 1 month to 18 years of age presenting with a primary diagnosis of anaphylaxis to one of the 35 pediatric hospitals included in the Pediatric Health Information System between January 1, 2009, and September 30, 2013. We evaluated the variation in use of β2 agonists, glucocorticoids, histamine-1 (H1) antagonists, histamine-2 (H2) antagonists, inhaled epinephrine, intravenous fluids, and oxygen. We assessed whether variation exists in the rates of hospitalization and 3-day emergency department (ED) revisits and whether a temporal trend exists in the ED visit rate for anaphylaxis. RESULTS Among 10,351 children with anaphylaxis, the hospital-level median use of common anaphylaxis therapies varied for β2 agonists (22%, interquartile range [IQR] = 16%-26%), glucocorticoids (71%, IQR = 65%-76%), H1 blockers (60%, IQR = 57%-65%), H2 blockers (53%, IQR = 36%-64%), inhaled epinephrine (2.2%, IQR = 1.3%-3.5%), intravenous fluids (26%, IQR = 13%-41%), and oxygen (2.6%, IQR = 0.8%-4.1%). Hospitalization rates ranged from 12% to 95%, with a median rate of 41%. Anaphylaxis diagnoses rose from 5.7 to 11.7 patients per 10,000 ED visits between 2009 and 2013 (p < 0.001 for trend). CONCLUSIONS There is substantial variability in the use of common therapies and hospitalization rates for children cared for in U.S. childrens hospitals. Additionally, ED visits for children with anaphylaxis are increasing at U.S. childrens hospitals. These findings highlight the need for research defining optimal care for anaphylaxis.

Yield of emergent neuroimaging in children with new-onset seizure and status epilepticus

PURPOSE To determine the yield of emergent neuroimaging among children with new-onset seizures presenting with status epilepticus. METHOD We performed a cross-sectional study of children seen at a single ED between 1995 and 2012 with new-onset seizure presenting with status epilepticus. We defined status epilepticus as a single seizure or multiple seizures without regaining consciousness lasting 30 min or longer. Our primary outcome was urgent or emergent intracranial pathology identified on neuroimaging. We categorized neuroimaging results as emergent if they would have changed acute management as assessed by a blinded neuroradiologist and neurologist. To ensure abnormalities were not missed, we review neuroimaging results for 30 days following the initial episode of SE. RESULTS We included 177 children presenting with new-onset seizure with status epilepticus, of whom 170 (96%) had neuroimaging performed. Abnormal findings were identified on neuroimaging in 64/177 (36%, 95% confidence interval 29-43%) children with 15 (8.5%, 95% confidence interval 5.2-14%) children having urgent or emergent pathology. Four (27%) of the 15 children with urgent or emergent findings had a normal non-contrast computed tomography scan and a subsequently abnormal magnetic resonance image. Longer seizure duration and older age were associated with urgent or emergent intracranial pathology. CONCLUSION A substantial minority of children with new-onset seizures presenting with status epilepticus have urgent or emergent intracranial pathology identified on neuroimaging. Clinicians should strongly consider emergent neuroimaging in these children. Magnetic resonance imaging is the preferred imaging modality when available and safe.

Anaphylaxis in children.

Purpose of review Anaphylaxis is a serious allergic reaction that can be life threatening. We will review the most recent evidence regarding the diagnosis, treatment, monitoring, and prevention of anaphylaxis in children. Recent findings Histamine and tryptase are not sufficiently accurate for the routine diagnosis of anaphylaxis, so providers should continue to rely on clinical signs. Platelet-activating factor shows some promise in the diagnosis of anaphylaxis. Intramuscular is the best route for epinephrine administration for children of all weights. Glucocorticoids may reduce prolonged hospitalizations for anaphylaxis. Children with anaphylaxis who have resolving symptoms and no history of asthma or previous biphasic reactions may be observed for as few as 3–4 h before emergency department discharge. Early peanut introduction reduces the risk of peanut allergy. Summary Epinephrine remains the mainstay of anaphylaxis treatment, and adjuvant medications should not be used in its place. All patients with anaphylaxis should be prescribed and trained to use an epinephrine autoinjector. Clinically important biphasic reactions are rare. Observation in the emergency department for most anaphylaxis patients is recommended, with the duration determined by risk factors. Admission is reserved for patients with unimproved or worsening symptoms, or prior biphasic reaction.

Pediatric status epilepticus: How common is cerebrospinal fluid pleocytosis in the absence of infection?

PURPOSE To determine the rate of cerebrospinal fluid (CSF) pleocytosis among children presenting with status epilepticus (SE) without proven central nervous system infection. METHOD We performed a retrospective cross-sectional study of all patients aged one month to 21 years of age who were evaluated in a single pediatric emergency department (ED) for SE between 1995 and 2012. We limited our study to those children who had a CSF culture obtained and excluded those children with proven viral or bacterial infection. We defined SE in a patient who had a single seizure or a cluster of seizures without regaining consciousness which lasted 30 min or longer. We defined CSF pleocytosis as a CSF white blood cells (WBC)>10 cells/mm(3) and a peripheral leukocytosis as WBC ≥ 15,000 cells/mm(3). We compared the rate of CSF pleocytosis between children with and without peripheral leukocytosis using the Fishers exact test. RESULTS We identified 289 ED visits for SE, of which 178 (62%) met study inclusion criteria. Seven children (4%, 95% confidence interval 1.7-8.2%) had CSF pleocytosis. More children with peripheral leukocytosis had CSF pleocytosis: (8.6% with peripheral leukocytosis vs. 0.9% without leukocytosis, p=0.01). CONCLUSION CSF pleocytosis is relatively uncommon among children with prolonged seizures, even in the presence of peripheral leukocytosis. Therefore, all children with CSF pleocytosis after status epilepticus need comprehensive evaluation for central nervous system infection.

Cardiac Arrest Survival in Pediatric and General Emergency Departments

Survival in OHCA is higher in pediatric EDs than general EDs. BACKGROUND AND OBJECTIVES: Pediatric out-of-hospital cardiac arrest (OHCA) has a low rate of survival to hospital discharge. Understanding whether pediatric emergency departments (EDs) have higher survival than general EDs may help identify ways to improve care for all patients with OHCA. We sought to determine if OHCA survival differs between pediatric and general EDs. METHODS: We used the 2009–2014 Nationwide Emergency Department Sample to study children under 18 with cardiac arrest. We compared pediatric EDs (those with >75% pediatric visits) to general EDs on the outcome of survival to hospital discharge or transfer. We determined unadjusted and adjusted survival, accounting for age, region, and injury severity. Analyses were stratified by nontraumatic versus traumatic cause. RESULTS: The incidences of nontraumatic and traumatic OHCA were 7.91 (95% confidence interval [CI]: 7.52–8.30) and 2.67 (95% CI: 2.49–2.85) per 100 000 person years. In nontraumatic OHCA, unadjusted survival was higher in pediatric EDs than general EDs (33.8% vs 18.9%, P < .001). The adjusted odds ratio of survival in pediatric versus general EDs was 2.2 (95% CI: 1.7–2.8). Children with traumatic OHCA had similar survival in pediatric and general EDs (31.7% vs 26.1%, P = .14; adjusted odds ratio = 1.3 [95% CI: 0.8–2.1]). CONCLUSIONS: In a nationally representative sample, survival from nontraumatic OHCA was higher in pediatric EDs than general EDs. Survival did not differ in traumatic OHCA. Identifying the features of pediatric ED OHCA care leading to higher survival could be translated into improved survival for children nationally.

Reducing Hospitalization Rates for Children With Anaphylaxis

Implementing an EBG and a QI initiative led to a successful reduction in hospitalization rates for patients with anaphylaxis. BACKGROUND AND OBJECTIVES: Most children with anaphylaxis in the emergency department (ED) are hospitalized. Opportunities exist to safely reduce the hospitalization rate for children with anaphylaxis by decreasing unnecessary hospitalizations. A quality improvement (QI) intervention was conducted to improve care and reduce hospitalization rates for children with anaphylaxis. METHODS: We used the Model for Improvement and began with development and implementation in 2011 of a locally developed evidence-based guideline based on national recommendations for the management of anaphylaxis. Guideline adoption and adherence were supported by interval reminders and feedback to providers. Patients from 2008 to 2014 diagnosed with anaphylaxis were identified, and statistical process control methods were used to evaluate change in hospitalization rates over time. The balancing measure was any return visit to the ED within 72 hours. To control for secular trends, hospitalization rates for anaphylaxis at 34 US children’s hospitals over the same time period were analyzed. RESULTS: Over the study period, there were 1169 visits for children with anaphylaxis, of which 731 (62%) occurred after the QI implementation. The proportion of children hospitalized decreased from 54% to 36%, with no increase in the 72-hour ED revisit rate. The hospitalization rate across 34 other US pediatric hospitals remained static at 52% over the study period. CONCLUSIONS: We safely reduced unnecessary hospitalizations for children with anaphylaxis and sustained the change over 3 years by using a QI initiative that included evidence-based guideline development and implementation, reinforced by provider reminders and structured feedback.