Rakesh D. Mistry

Reference Range for Cerebrospinal Fluid Opening Pressure in Children

To the Editor: A reference range for cerebrospinal fluid (CSF) opening pressure in children undergoing diagnostic lumbar puncture has not been established.1 The influence of age, body-mass index (B...

The Utility of Early Lactate Testing in Undifferentiated Pediatric Systemic Inflammatory Response Syndrome

OBJECTIVES Failure to recognize shock contributes to inadequate early resuscitation in many children with sepsis. Serum lactate levels are used to identify adult patients with septic shock, but physical examination diagnosis alone is recommended in pediatric sepsis. The authors sought to test the utility of lactate testing in pediatric emergency department (ED) patients with systemic inflammatory response syndrome (SIRS). The hypothesis was that early hyperlactatemia (serum lactate ≥ 4.0 mmol/L) would be associated with increased risk of organ dysfunction. METHODS This was a prospective cohort study of children younger than 19 years with SIRS presenting to a pediatric ED. The primary outcome was organ dysfunction within 24 hours of triage; secondary outcomes included disposition, serious bacterial infection (SBI), treatments, and mortality. Study personnel measured venous lactate level on a point-of-care meter, with clinicians blinded to results, and patients received usual care. RESULTS A total of 239 subjects were enrolled; 18 had hyperlactatemia. The hyperlactatemia group had a relative risk of 5.5 (95% confidence interval [CI] = 1.9 to 16.0) of developing 24-hour organ dysfunction. As a test for organ dysfunction, hyperlactatemia had a positive likelihood ratio of 5.0, a sensitivity of 31% (95% CI = 13% to 58%), and specificity of 94% (95% CI = 90% to 96%). Subjects with hyperlactatemia were significantly more likely to receive intravenous (IV) antibiotics and fluid boluses; despite increased therapy, they were at significantly increased risk for intensive care unit (ICU) admission and bacterial infection. CONCLUSIONS Among undifferentiated children with SIRS, early hyperlactatemia is significantly associated with increased risk of organ dysfunction, resuscitative therapies, and critical illness. The addition of serum lactate testing to the currently recommended clinical assessment may improve early identification of pediatric sepsis requiring resuscitation.

CSF opening pressure in children with optic nerve head edema.

Background: We previously reported that an abnormal CSF opening pressure (OP) in children was greater than 28 cm H2O. Since elevated intracranial pressure can cause optic nerve head edema (ONHE), we would expect that most patients with ONHE would have an OP greater than 28 cm H2O. This study describes the range of OP for children with ONHE and compared them to age-matched controls without ONHE. Methods: Case subjects were children (1–18 years of age) enrolled in a prospective study of CSF OP that demonstrated ONHE at time of lumbar puncture and that the ONHE later resolved. Patients with ONHE secondary to infectious, inflammatory, or ischemic conditions were excluded. Control subjects from the same study, but without ONHE, were matched to cases. Results: Of the 472 subjects enrolled in the study, 41 OP measurements were obtained from 33 patients with ONHE who did not have any exclusionary criteria and matched to 41 control subjects without ONHE. Case subjects had a significantly higher OP (mean, 41.4 cm H20; range, 22–56) than control subjects (mean, 18.9 cm H2O; range, 9–29; p < 0.01). Forty of 41 (97.6%) case subjects and 2 of 41 (4.8%) control subjects had OP measures >28 cm H2O. Conclusions: Children with ONHE not related to infectious, inflammatory, or ischemic causes typically have an OP >28 cm H2O, significantly higher than age-matched controls without ONHE. This study provides further support to our previously published findings that suggests an abnormal OP in children is typically above 28 cm H2O.

Association Between Parental and Childhood Emergency Department Utilization

Objective. To examine the association between parental emergency department (ED) utilization and child ED utilization for overall numbers of ED visits, as well as numbers of nonurgent ED visits. Methods This was a secondary data analysis of the 2000 Medical Expenditure Panel Survey, a nationally representative survey of health care utilization. The numbers of overall self-reported ED visits were collected for parents and a single child randomly selected from each family. Negative binomial linear regression, with clustering within families, was used to determine the association between parental ED and child ED use, controlling for potential confounders. The analysis was repeated for nonurgent ED visits, classified with standard and modified versions of previously published criteria. Results. The mean age of the 3182 children analyzed was 9.4 years; 51% were male, 18.1% were publicly insured, and 8.2% were uninsured. The mean number of overall ED visits in 2000 was 0.17 visits per year for the children (95% confidence interval [CI]: 0.15–0.19 visits per year), 0.18 visits per year for the mothers (95% CI; 0.15–0.21 visits per year), and 0.11 visits per year for the fathers (95% CI: 0.09–0.13 visits per year). Each maternal ED visit was associated with 1.30 additional child ED visits (95% CI: 1.07–1.59 visits); each paternal ED visit was associated with an additional 1.33 child ED visits (95% CI: 1.07–1.65 visits). The relationship between parental and child nonurgent ED visits was even more pronounced. Conclusions. Increased parental ED utilization is significantly associated with increased childhood ED utilization. Parental patterns of ED use may have implications for childhood ED use. Future interventions aimed at decreasing ED utilization should focus on parental or family utilization.

Blood culture contamination rates after skin antisepsis with chlorhexidine gluconate versus povidone-iodine in a pediatric emergency department.

OBJECTIVE To determine blood culture contamination rates after skin antisepsis with chlorhexidine, compared with povidone-iodine. DESIGN Retrospective, quasi-experimental study. SETTING Emergency department of a tertiary care childrens hospital. PATIENTS Children aged 2-36 months with peripheral blood culture results from February 2004 to June 2008. Control patients were children younger than 2 months with peripheral blood culture results. METHODS Blood culture contamination rates were compared using segmented regression analysis of time-series data among 3 patient groups: (1) patients aged 2-36 months during the 26-month preintervention period, in which 10% povidone-iodine was used for skin antisepsis before blood culture; (2) patients aged 2-36 months during the 26-month postintervention period, in which 3% chlorhexidine gluconate was used; and (3) patients younger than 2 months not exposed to the chlorhexidine intervention (ie, the control group). RESULTS Results from 11,595 eligible blood cultures were reviewed (4,942 from the preintervention group, 4,274 from the postintervention group, and 2,379 from the control group). For children aged 2-36 months, the blood culture contamination rate decreased from 24.81 to 17.19 contaminated cultures per 1,000 cultures (P < .05) after implementation of chlorhexidine. This decrease of 7.62 contaminated cultures per 1,000 cultures (95% confidence interval, -0.781 to -15.16) represented a 30% relative decrease from the preintervention period and was sustained over the entire postintervention period. No change in contamination rate was observed in the control group (P = .337). CONCLUSION Skin antisepsis with chlorhexidine significantly reduces the blood culture contamination rate among young children, as compared with povidone-iodine.

Characteristics of Recurrent Utilization in Pediatric Emergency Departments

BACKGROUND AND OBJECTIVE: Nationally, frequent utilizers of emergency departments (EDs) are targeted for quality improvement initiatives. The objective was to compare the characteristics and ED health services of children by their ED visit frequency. METHODS: A retrospective study in 1 896 547 children aged 0 to 18 years with 3 263 330 visits to 37 EDs in 2011. The number of ED visits per child within 365 days of their first visit was counted. Patient characteristics (age, chronic condition) and ED care (medications, testing [laboratory and radiographic], and hospital admission) were assessed. We evaluated the relationship between patient characteristics and ED health services received with multivariable regression. RESULTS: Children with ≥4 ED visits (8%) accounted for 24% of all visits and 31% (

Urgency classification methods for emergency department visits: do they measure up?

1.4 billion) of all costs. As visit frequency increased from 1 to ≥4, the percentage of children aged <1 year increased (12.1% to 33.2%) and the percentage of children without a chronic condition decreased (81.9% to 45.6%) (P < .001 for both). Children with ≥4 ED visits had a higher percentage of visits without medication administration (aside from acetaminophen or ibuprofen), testing, or hospital admission when compared with children with 1 visit (35.4% vs 29.0%; P < .001). Children with ≥4 ED visits who were aged <1 year (odds ratio: 3.8; 95% confidence interval: 3.7–3.9) and who were without a chronic condition (odds ratio: 3.1; 95% confidence interval: 3.0–3.1) had the highest likelihood of experiencing this type of visit. CONCLUSIONS: With a disproportionate share of pediatric ED cost and utilization, frequent utilizers, especially infants without a chronic condition, are the least likely to need medications, testing, and hospital admission.

Duration of Colonization and Determinants of Earlier Clearance of Colonization With Methicillin-Resistant Staphylococcus aureus

Across the United States, emergency departments (EDs) are plagued by overcrowding and its deleterious effects. Consequently, investigators have attempted to identify a subset of nonurgent patients who could potentially be managed in alternative settings to help alleviate the burden of overcrowding. Previous authors have used several methods to define ED visit urgency; however, the lack of a single valid method has resulted in widely variable estimates of nonurgent ED use. Accurate identification of nonurgent ED visits is necessary to compare nonurgent populations across health care settings and design safe, effective interventions aimed at reducing ED overcrowding. In this paper, we review the currently used methods for the classification of ED visit urgency, discuss the implications of measurement of ED urgency for health care stakeholders, and suggest future directions for the feasible, practical measurement of ED urgency.

Impact of Increasing Ondansetron Use on Clinical Outcomes in Children With Gastroenteritis

BACKGROUND The duration of colonization and factors associated with clearance of methicillin-resistant Staphylococcus aureus (MRSA) after community-onset MRSA skin and soft-tissue infection (SSTI) remain unclear. METHODS We conducted a prospective cohort study of patients with acute MRSA SSTI presenting to 5 adult and pediatric academic hospitals from 1 January 2010 through 31 December 2012. Index patients and household members performed self-sampling for MRSA colonization every 2 weeks for 6 months. Clearance of colonization was defined as negative MRSA surveillance cultures during 2 consecutive sampling periods. A Cox proportional hazards regression model was developed to identify determinants of clearance of colonization. RESULTS Two hundred forty-three index patients were included. The median duration of MRSA colonization after SSTI diagnosis was 21 days (95% confidence interval [CI], 19-24), and 19.8% never cleared colonization. Treatment of the SSTI with clindamycin was associated with earlier clearance (hazard ratio [HR], 1.72; 95% CI, 1.28-2.30; P < .001). Older age (HR, 0.99; 95% CI, .98-1.00; P = .01) was associated with longer duration of colonization. There was a borderline significant association between increased number of household members colonized with MRSA and later clearance of colonization in the index patient (HR, 0.85; 95% CI, .71-1.01; P = .06). CONCLUSIONS With a systematic, regular sampling protocol, duration of MRSA colonization was noted to be shorter than previously reported, although 19.8% of patients remained colonized at 6 months. The association between clindamycin and shorter duration of colonization after MRSA SSTI suggests a possible role for the antibiotic selected for treatment of MRSA infection.

Outcomes of children referred to an emergency department by an after-hours call center

IMPORTANCE Ondansetron hydrochloride use in children with gastroenteritis is increasing rapidly; however, little is known about its impact on outcomes. OBJECTIVE To determine whether increasing emergency department ondansetron use has resulted in a reduction in intravenous rehydration rates. DESIGN, SETTING, AND PARTICIPANTS Retrospective observational analysis of eligible visits included in the Pediatric Health Information System administrative database. Eligible institutions included 18 emergency departments geographically distributed across the United States, and participants included 804,000 patients aged 0 to 18 years who were diagnosed as having gastroenteritis in an emergency department at an eligible participating institution between January 1, 2002, and December 31, 2011. INTERVENTIONS The presence or absence of oral ondansetron administration was identified for each patient through database review. Visits were categorized based on institutional ondansetron use: low (<5% administered ondansetron), medium (5%-25%), or high (>25%). MAIN OUTCOMES AND MEASURES We conducted hospital-level analyses of the associations between ondansetron use and 3 outcomes: intravenous rehydration (primary), hospitalization, and emergency department revisits within 3 days. Time-series regression models were used, adjusting for demographic characteristics, laboratory testing, diagnostic imaging, and rotavirus infection. RESULTS A total of 804,000 eligible patient visits were identified. Oral ondansetron use increased from a median institutional rate of 0.11% (interquartile range, 0.04%-0.44%) of patient visits in 2002 to 42.2% (interquartile range, 37.5%-49.1%) in 2011 (P < .001). Intravenous rehydration was administered to 43,413 of 232,706 children (18.7%) during the low ondansetron period compared with 59,450 of 334,264 (17.8%) during the high ondansetron period (adjusted percentage change = -0.33%; 95% CI, -1.86% to 1.20%). During the transition from low to high ondansetron use, we observed no change in the hospitalization rate (adjusted percentage change = -0.33%; 95% CI, -0.95% to 0.29%), but emergency department revisits decreased (adjusted percentage change = -0.31%; 95% CI, -0.49% to -0.13%). The change in all 3 outcomes varied widely between low and high ondansetron use categories at an institutional level. Oral ondansetron was provided to 13.5% (95% CI, 13.3% to 13.7%) of children administered intravenous rehydration. CONCLUSIONS AND RELEVANCE Although ondansetron use increased during the study period, intravenous rehydration rates were unchanged. Most children administered intravenous fluids did not receive oral ondansetron. Our findings highlight the need to focus efforts to administer ondansetron to children at greatest risk for oral rehydration failure.