Mythili Srinivasan

Clinical Characterization of Children Presenting to the Hospital with Enterovirus D68 Infection During the 2014 Outbreak in St. Louis.

Background: The largest known outbreak of enterovirus D68 (EV-D68) infections occurred during 2014. The goal of our study is to characterize the illness severity and clinical presentation of children infected with EV-D68 in comparison to non-EV-D68-human rhinoviruses/enteroviruses (HRV/EV). Method: Our study is a retrospective analysis of severity level, charges and length of stay of children who presented to St. Louis Children’s Hospital from August 8, 2014 to October 31, 2014 and tested positive for EV-D68 in comparison to non-EV-D68-HRV/EV–infected patients. Chart review was performed for all EV-D68–infected patients and age and severity matched non-EV-D68-HRV/EV–infected patients. Result: There was a striking increase in hospital census in August of 2014 in our hospital with simultaneous increase in the number of patients with EV-D68 infection. There was no significant difference in severity of illness, length of stay or total charges between EV-D68–infected and non-EV-D68-HRV/EV–infected children. EV-D68 infection was characterized by presenting complaints of difficulty breathing (80%) and wheezing (67%) and by findings of tachypnea (65%), wheezing (71%) and retractions (65%) on examination. The most common interventions were albuterol (79%) and corticosteroid (68%) treatments, and the most common discharge diagnosis was asthma exacerbation (55%). Conclusion: EV-D68 caused a significant outbreak in 2014 with increased hospital admissions and associated increased charges. There was no significant difference in severity of illness caused by EV-D68 compared with non-EV-D68-HRV/EV infections suggesting that the impact from EV-D68 was because of increased number of infected children presenting to the hospital and not necessarily due to increased severity of illness.

Variation in Procedural Sedation Practices Among Children’s Hospitals

BACKGROUND AND OBJECTIVE Children often need procedural sedation for painful procedures. There are few data on type of provider, site of sedation, and agents used for procedural sedation in hospitals across the nation. The objective was to determine procedural sedation practices for hospitalized children outside the PICU and emergency department. METHODS Surveys were sent to 89 pediatric hospitalist (PH) leaders in hospitals belonging to the Child Health Corporation of America or the National Association of Childrens Hospitals and Related Institutions. RESULTS We received responses from 56 PHs (63%), of whom 49 (55%) completed the survey. PHs provided sedation in 18 hospitals. Provider, setting, and agents used for procedural sedation varied. The primary providers of procedural sedation for abscess incision and drainage, renal biopsy, joint aspiration, computed tomography, and MRI were anesthesiologists. A significantly greater percentage of hospitals where PHs did not provide procedural sedation used the operating room for abscess incision and drainage compared with hospitals where PHs provided procedural sedation (63% vs 28%, respectively). Postoperative/abscess dressing change, vesicocystourethrogram, and ≥1 painful procedure were performed without sedation in significantly greater percentage of hospitals where PHs did not provide procedural sedation compared with hospitals where PHs provided procedural sedation. CONCLUSIONS There is variability in sedation practices in hospitals across the nation, which affects patient care and use of resources such as the operating room. In hospitals where PHs provide procedural sedation, there is less operating room use and fewer painful procedures for which no sedation is provided.

Procedural sedation by pediatric hospitalists: analysis of the nature and incidence of complications during ketamine and nitrous oxide sedation.

OBJECTIVE The goal of this study was to determine the nature and rate of complications during procedural sedation by pediatric hospitalists (PH) using ketamine and nitrous oxide (N2O). METHODS This study was a retrospective review and analysis of a quality improvement database for sedations performed by PH at St Louis Childrens Hospital from February 2007 to February 2013. Information was obtained on sedations performed and reported in the quality improvement database by PH over this time period using ketamine and N2O. RESULTS PH performed 8870 sedations from 2007 to 2013, 60.2% using ketamine and 39.8% using N2O. Procedural completion rates were >99%; 0.12% of sedations were not completed due to inadequate sedation, and sedation level was not achieved in 1.71% of sedations. There were no occurrences of death, need for cardiopulmonary resuscitation, unplanned intubation, or emergency anesthesia consultation. The only major complications were 4 unplanned admissions, 2 each with ketamine and N2O. With ketamine, the 2 highest rates of complications were airway repositioning (3.99%) and nausea and/or vomiting (2.98%). With N2O, the 2 highest complication rates were nausea and/or vomiting (8.50%) and airway repositioning (1.10%). Respiratory and cardiovascular events were more frequently encountered with ketamine, whereas nausea/vomiting, sedation level not achieved, and inadequate sedation resulting in procedure not completed occurred more frequently with N2O. CONCLUSIONS PH at St Louis Childrens Hospital successfully provided sedation by using ketamine and N2O with low rates of complications for a variety of procedures.

Intravenous Versus Oral Antibiotics for the Prevention of Treatment Failure in Children With Complicated Appendicitis: Has the Abandonment of Peripherally Inserted Catheters Been Justified?

Objective: To compare treatment failure leading to hospital readmission in children with complicated appendicitis who received oral versus intravenous antibiotics after discharge. Background: Antibiotics are often employed after discharge to prevent treatment failure in children with complicated appendicitis, although existing studies comparing intravenous and oral antibiotics for this purpose are limited. Methods: We identified all patients aged 3 to 18 years undergoing appendectomy for complicated appendicitis, who received postdischarge antibiotics at 35 childrens hospitals from 2009 to 2012. Discharge codes were used to identify study subjects from the Pediatric Health Information System database, and chart review confirmed eligibility, treatment assignment, and outcomes. Exposure status was based on outpatient antibiotic therapy, and analysis used optimal and full matching methods to adjust for demographic and clinical characteristics. Treatment failure (defined as an organ-space infection) requiring inpatient readmission was the primary outcome. Secondary outcomes included revisits from any cause to either the inpatient or emergency department setting. Results: In all, 4579 patients were included (median: 99/hospital), and utilization of intravenous antibiotics after discharge ranged from 0% to 91.7% across hospitals. In the matched analysis, the rate of treatment failure was significantly higher for the intravenous group than the oral group [odds ratio (OR) 1.74, 95% confidence interval (CI) 1.05–2.88; risk difference: 4.0%, 95% CI 0.4–7.6%], as was the rate of all-cause revisits (OR 2.11, 95% CI 1.44–3.11; risk difference: 9.4%, 95% CI 4.7–14.2%). The rate of peripherally inserted central catheter line complications was 3.2% in the intravenous group, and drug reactions were rare in both groups (intravenous: 0.7%, oral: 0.5%). Conclusions: Compared with oral antibiotics, use of intravenous antibiotics after discharge in children with complicated appendicitis was associated with higher rates of both treatment failure and all-cause hospital revisits.

Quality Improvement Initiative to Increase the Use of Nasogastric Hydration in Infants With Bronchiolitis

BACKGROUND AND OBJECTIVES Intravenous (IV) hydration is used primarily in children with bronchiolitis at our institution. Because nasogastric (NG) hydration can provide better nutrition, the goal of our quality improvement (QI) initiative was to increase the rate of NG hydration in eligible children 1 to 23 months old with bronchiolitis by 20% over 6 months. METHODS We used Plan-Do-Study-Act cycles to increase the use of NG hydration in eligible children. Interventions included educational and system-based changes and sharing parental feedback with providers. Chart reviews were performed to identify the rates of NG hydration, which were plotted over time in a statistical process control p chart. The balancing measure was the rate of complications in children with NG versus IV hydration. RESULTS Two hundred and ninety-three children who were hospitalized with bronchiolitis needed supplemental hydration during the QI initiative (January 2016-April 2016). Ninety-one children were candidates for NG hydration, and 53 (58%) received NG hydration. The rates of NG hydration increased from a baseline of 0% pre-QI bronchiolitis season (January 2015-April 2015) to 58% during the initiative. There was no aspiration and no accidental placement of the NG tube into a childs airway. Nine patients (17%) in the NG group had a progression of disease requiring nil per os status, and 6 of these were transferred to the PICU whereas none of those in the IV group were transferred to the PICU. Post-QI initiative, the majority of nurses (63%) and physicians (95%) stated that they are more likely to consider NG hydration in children with bronchiolitis. CONCLUSIONS We successfully increased the rates of NG hydration in eligible children with bronchiolitis by using educational and system-based interventions.

Rates of Complications After Newborn Circumcision in a Well-Baby Nursery, Special Care Nursery, and Neonatal Intensive Care Unit

Objective/Method. To determine rates of complications after newborn circumcision by performing a retrospective chart review of patients circumcised at a well-baby nursery, neonatal intensive care units (NICU), and special care nursery (SCN) from 2007 to 2012. Result. A total of 5129 babies (73%) were circumcised at the well-baby nursery and 1909 babies (27%) at the NICU and SCN. Forty-seven patients (0.67%, 95% CI 0.49% to 0.89%) had circumcision-related complications: 5 (0.07%) patients with acute and 42 (0.6%) with late complications. Babies in the NICU/SCN had increased odds of complication (OR 4.00, 95% CI 2.23 to 7.19) compared with those in well-baby nursery. There were increased odds of complications in babies with Caucasian ethnicity (OR 2.60, 95% CI 1.48 to 4.89) compared with African American babies and in babies with private insurance (OR 4.0, 95% CI 2.1 to 7.5) compared with nonprivate insurance. Conclusions. The rates of complications after newborn circumcisions were low. Babies in the NICU/SCN had increased odds of complication.

A Proposed Mechanism to Assess Knowledge of Pediatric Hospitalists to Identify and Manage Rare Events During Procedural Sedation

OBJECTIVE The goal of this study was to assess the knowledge of pediatric hospitalists (PHs) in identifying and managing rare events during procedural sedation (PS) with ketamine and nitrous oxide (N2O). METHODS A Web-based survey with multiple choice questions and case scenarios was used to determine the knowledge of PHs in identifying infrequent contraindications and managing laryngospasm, a rare life-threatening complication during PS. The survey was sent to all PHs at St Louis Childrens Hospital. RESULTS Forty percent of experienced PHs (>50 sedation procedures performed) and 5% of inexperienced PHs (<50 sedation procedures performed) identified all 4 ketamine contraindications. Twenty-one percent of experienced PHs and 4% of inexperienced PHs identified all 6 N2O contraindications. Ninety-five percent of PHs identified presence of laryngospasm in a case scenario. As the patient in the case scenario progressed from partial to complete laryngospasm, 84% and 82% of PHs chose either the preferred or acceptable strategy to manage the patient. With further deterioration in the patients status in the scenario, 66% and 71% of PHs chose either the preferred or acceptable strategy to manage the patient. The preferred strategy at each step is one that attempted the least invasive maneuver to manage the patient. There was no significant difference between experienced and inexperienced PHs in the management of laryngospasm. CONCLUSIONS Knowledge gaps exist among PHs regarding contraindications for ketamine and N2O that are infrequently encountered in patients and for the management of laryngospasm, a rare adverse event with ketamine. Ongoing teaching tools are necessary to assess and maintain the knowledge of sedation providers regarding rare events during PS that can improve their proficiency.