Kenneth Yen

Derivation of the DIVA score: a clinical prediction rule for the identification of children with difficult intravenous access.

Objective: To develop a clinical prediction rule that would be easy to apply and be useful for predicting success or failure of peripheral intravenous line insertion in children. Methods: This was a prospective cohort study of children aged 0 to 21 years undergoing peripheral intravenous placement by staff nurses in a pediatric emergency department. Information on candidate predictor variables was obtained before attempting intravenous placement, and the outcome was successful on first attempt. Backward stepwise logistic regression was used to identify factors independently predictive of success. Those factors remaining in the model were used in a set of linear scores. Receiver operating characteristic curves were constructed for each model, and the areas under the curve were calculated. Results: Six hundred fifteen subjects were enrolled. Success rate for intravenous insertion on first attempt was 75%. A 4-variable proportionally weighted rule (known as the difficult intravenous access [DIVA] score) was created (3 points for prematurity, 3 for younger than 1 year, 1 for 1-2 years of age, 2 for vein not palpable, and 2 for vein not visible). The area under the receiver operating characteristic curve was 0.67. Subjects with a DIVA score of 4 or more were more than 50% likely to have failed intravenous placement on first attempt. Conclusions: A clinical prediction rule that is easy to apply and is useful for predicting success or failure of peripheral intravenous insertion has been created. If externally validated, this DIVA score can be used to predict which children will have difficult intravenous access.

Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries

STUDY OBJECTIVE We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. METHODS We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. RESULTS We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). CONCLUSION A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.

Store-and-forward teledermatology versus in-person visits: A comparison in pediatric teledermatology clinic

BACKGROUND The role of teledermatology in the diagnosis of pediatric skin conditions has not been studied exclusively. OBJECTIVE To determine the ability of a pediatric dermatologist to correctly diagnose rashes by history and digital images. METHODS Consecutive, new referrals to the pediatric dermatology clinic with a rash were enrolled in the study. A history, demographic data, and digital photographs were obtained from each patient. The data were reviewed by a pediatric dermatologist who made a preliminary diagnosis. The child was then seen in person and a final diagnosis was made. Concordance and kappa values were calculated. Cases of diagnostic disagreement were analyzed for their effect on management. RESULTS One hundred thirty-five patients were enrolled. Diagnostic concordance was 82% (95% confidence interval [CI], 73%-88%), and the kappa value was 0.80. Clinically relevant disagreement occurred in 12% of cases. LIMITATIONS The study was performed at a single site, theoretically limiting generalizability. CONCLUSION Teledermatology appears to have a useful role in the care of children with rashes.

Validation and Refinement of the Difficult Intravenous Access Score: A Clinical Prediction Rule for Identifying Children With Difficult Intravenous Access

OBJECTIVES The difficult intravenous access (DIVA) score, a proportionally weighted four-variable (vein palpability, vein visibility, patient age, and history of prematurity) clinical rule, has been developed to predict failure of intravenous (IV) placement in children. This study sought to externally validate and refine the DIVA score. METHODS Patients undergoing peripheral IV placement by pediatric emergency department (ED) nurses were enrolled. The outcome of interest was defined as failure of cannulation on first attempt. Proposed refinement predictor variables include history of newborn intensive care unit (NICU) stay, operator experience characteristics (years since graduation, years of pediatric nursing experience, and IVs started per month), and skin shade. Adjusted multivariate models were constructed using logistic regression. Receiver operating characteristic (ROC) curves were constructed and areas under the curve (AUC) calculated for each model. RESULTS A total of 366 subjects were enrolled (mean age = 5.4 years, SD ± 5.6 years) and of them, 118 (32.2%) subjects failed the first IV attempt. The original four-variable model tested in this data set resulted in an AUC of 0.72 (95% confidence interval [CI] = 0.67 to 0.78). Patients with a DIVA score of 4 or greater had more than 50% likelihood of failed first IV attempt. A three-variable rule (vein palpability, vein visibility, and patient age) was evaluated and found to possess similar discriminating ability (AUC = 0.72, 95% CI = 0.67 to 0.78). CONCLUSIONS This study validated the previously derived four-variable DIVA score. A simpler three-variable rule was as predictive of failed IV placement on first attempt as the four-variable rule. Validation in nonpediatric EDs is needed to thoroughly evaluate generalizability.

Peripheral Difficult Venous Access in Children

Early identification of DVA is the first step in optimizing patient care. The consensus panel described DVA as a clinical condition in which multiple attempts and/or special interventions are anticipated or required to achieve and maintain peripheral venous access. Special interventions are defined as the use of any technique or hospital resource with the potential to improve peripheral IV insertion success rates. These include traditional methods of enhancing the visibility and palpability of peripheral veins (eg, warming the catheter site to induce vasodilation); advanced visualization technologies such as ultrasound, transillumination, and nearinfrared lighting; and enlisting designated IV specialists and/or hospital staff with extensive experience in starting pediatric IVs. Some children may need more invasive interventions such as intraosseous (IO) infusion, a peripherally inserted central catheter, or a central venous catheter (CVC) to achieve parenteral access. There is a dearth of clinical evidence on the incidence of DVA in pediatric patients. Studies of IV insertion success rates indicate that 5% to 33% of children require more than 2 needle sticks to achieve IV access. Even when interventions such as transillumination and ultrasound are used, up to 15% of children still require more than 2 attempts to establish venous access. A recent prospective analysis of 593 insertion attempts in centers with pediatric hospitalist services showed that successful placement Establishing peripheral intravenous (IV) access in pediatric patients can be challenging. Clinical studies show that only 53% to 76% of children are successfully cannulated on the first attempt. Multiple failed attempts are painful and upsetting for the child and distressing for family members and caregivers, yet there are no guidelines or consensus statements on the recognition and management of this problem. In January 2008, a panel of physicians and nurses specializing in emergency medicine, anesthesia, critical care, and hospital medicine convened to discuss peripheral difficult venous access (DVA) in children. Daniel Rauch, MD, FAAP, and Laura L. Kuensting, MSN(R), RN, CPNP, cochaired the roundtable discussion, which was made possible by a grant from Baxter Healthcare, Inc. The main objectives of the meeting were to estimate the frequency of DVA in pediatric patients; describe its clinical and emotional impact on the patient, the patient’s family, and clinicians; develop terminology that accurately describes the condition; review the factors that help identify children with DVA; and

Strategies to improve flow in the pediatric emergency department

As emergency departments (EDs) experience overcrowding, there is ever-growing pressure to improve patient flow. We present a review of strategies to increase efficiency of patient inflow, throughput, and output in the ED, with an emphasis on approaches that are under greater control of the ED itself and therefore more amenable to implementation without major institutional changes.

Evaluation of Temporal Artery Thermometry in Children 3–36 Months Old

PURPOSE This study aims to determine whether temporal artery (TA) thermometer readings are accurate and better tolerated than rectal readings in young children. DESIGN AND METHODS Paired rectal and TA temperature readings and Face Legs Activity Cry and Consolability (FLACC) scores were obtained. RESULTS TA thermometry failed to detect rectal fever (38 degrees C or greater) in approximately 20% of paired temperature readings. FLACC scores were significantly lower after TA readings than after rectal readings. PRACTICE IMPLICATIONS This study questions TA readings as an accurate substitute for rectal thermometry.

Management of children with solid organ injuries after blunt torso trauma

BACKGROUND Management of children with intra-abdominal solid organ injuries has evolved markedly. We describe the current management of children with intra-abdominal solid organ injuries after blunt trauma in a large multicenter network. METHODS We performed a planned secondary analysis of a prospective, multicenter observational study of children (<18 years) with blunt torso trauma. We included children with spleen, liver, or kidney injuries identified by computed tomography, laparotomy/laparoscopy, or autopsy. Outcomes included disposition and interventions (blood transfusion for intra-abdominal hemorrhage, angiography, laparotomy/laparoscopy). We performed subanalyses of children with isolated injuries. RESULTS A total of 12,044 children were enrolled; 605 (5.0%) had intra-abdominal solid organ injuries. The mean (SD) age was 10.7 (5.1) years, and injured organs included spleen 299 (49.4%), liver 282 (46.6%), and kidney 147 (24.3%). Intraperitoneal fluid was identified on computed tomography in 461 (76%; 95% confidence interval [CI], 73–80%), and isolated solid organ injuries were present in 418 (69%; 95% CI, 65–73%). Treatment included therapeutic laparotomy in 17 (4.1%), angiographic embolization in 6 (1.4%), and blood transfusion in 46 (11%) patients. Laparotomy rates for isolated injury were 11 (5.4%) of 205 (95% CI, 2.7–9.4%) at non-freestanding children’s hospitals and 6 (2.8%) of 213 (95% CI, 1.0–6.0%) at freestanding children’s hospitals (difference, 2.6%; 95% CI, −7.1% to 12.2%). Dispositions of the 212 children with isolated Grade I or II organ injuries were home in 6 (3%), emergency department observation in 9 (4%), ward in 114 (54%), intensive care unit in 73 (34%), operating suite in 7 (3%), and transferred in 3 (1%) patients. Intensive care unit admission for isolated Grade I or II injuries varied by center from 9% to 73%. CONCLUSION Most children with solid organ injuries are managed with observation. Blood transfusion, while uncommon, is the most frequent therapeutic intervention; angiographic embolization and laparotomy are uncommon. Emergency department disposition of children with isolated Grade I to II solid organ injuries is highly variable and often differs from published guidelines. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Interobserver Agreement in the Clinical Assessment of Children With Blunt Abdominal Trauma

OBJECTIVES The objective was to determine the interobserver agreement of historical and physical examination findings assessed during the emergency department (ED) evaluation of children with blunt abdominal trauma. METHODS This was a planned substudy of a multicenter, prospective cohort study of children younger than 18 years of age evaluated for blunt abdominal trauma. Patients were excluded if injury occurred more than 24 hours prior to evaluation or if computed tomography (CT) imaging was obtained at another hospital prior to transfer to a study site. Two clinicians independently recorded their clinical assessments of a convenience sample of patients onto data collection forms within 60 minutes of each other and prior to CT imaging (if obtained) or knowledge of laboratory results. The authors categorized variables as either subjective symptoms (i.e., patient history) or objective findings (i.e., physical examination). For each variable recorded by the two observers, the agreement beyond that expected by chance was estimated, using the kappa (κ) statistic for categorical variables and weighted κ for ordinal variables. Variables with 95% lower confidence limits (LCLs) κ ≥ 0.4 (moderate agreement or better) were considered to have acceptable agreement. RESULTS A total of 632 pairs of physician observations were obtained on 23 candidate variables. Acceptable agreement was achieved in 16 (70%) of the 23 variables tested. For six subjective symptoms, κ ranged from 0.48 (complaint of shortness of breath) to 0.90 (mechanism of injury), and only the complaint of shortness of breath had a 95% LCL κ < 0.4. For the 17 objective findings, κ ranged from -0.01 (pelvis instability) to 0.82 (seat belt sign present). The 95% LCL for κ was <0.4 for flank tenderness, abnormal chest auscultation, suspicion of alcohol or drug intoxication, pelvis instability, absence of bowel sounds, and peritoneal irritation. CONCLUSIONS Observers can achieve at least acceptable agreement on the majority of historical and physical examination variables in children with blunt abdominal trauma evaluated in the ED. Those variables are candidates for consideration for development of a clinical prediction rule for intra-abdominal injury in children with blunt trauma.

Vomiting of liquid corticosteroids in children with asthma.

Background: Oral corticosteroids are an essential part of the management of children with acute asthma exacerbations. Vomiting is a frequently cited problem attributed to oral corticosteroids. A new formulation of prednisolone, Orapred, claims to have improved palatability that may decrease the incidence of vomiting. Objective: To compare the incidence of vomiting and taste between patients who are given the generic preparation of prednisolone with those given Orapred. Design/Methods: A randomized, double blind clinical trial was conducted at a tertiary care children s hospital emergency department. Children age 2 to 10 years presenting with acute asthma exacerbation were eligible. Patients with allergy to prednisolone, corticosteroid use within 2 weeks, history of vomiting in the last 24 hours, requirement for vascular access, and preference for other forms of corticosteroid were excluded. Enrolled patients were randomized and given either generic prednisolone (15 mg/5 ml) or Orapred (15 mg/5 ml). In children 6 years or older, a taste score was obtained using a 5 point hedonic face scale (1 = bad to 5 = great). After the administration, patients were observed for 30 minutes for vomiting. The Mann-Whitney U test was used to compare the median taste score between the two study groups. Relative risk (RR) of vomiting was calculated. Other confidence intervals were calculated when appropriate. Results: During the study period, 211 eligible children were enrolled, of whom 23 were excluded. Of the remaining 188 subjects, 96 received generic prednisolone and 92 received Orapred. All baseline characteristics were similar in both groups. In the generic prednisolone group, 17 (17.7%) children vomited compared with 5 (5.4%) in the Orapred group (RR = 3.26, 95% CI, 1.25, 8.47). Taste scores were obtained from 18 children in the generic prednisolone group and from 19 children in the Orapred group. The median taste score was 2 for the generic prednisolone group and 4 for the Orapred group (&Dgr; = -2.0, 95% CI, -3.0, -1.0) (P = 0.0001). Conclusions: In our study population, Orapred was associated with a significant less incidence of vomiting and better taste score compared to the generic prednisolone.