Sandy M Hopper

Topical Lidocaine to Improve Oral Intake in Children With Painful Infectious Mouth Ulcers: A Blinded, Randomized, Placebo-Controlled Trial

STUDY OBJECTIVE We establish the efficacy of 2% viscous lidocaine in increasing oral intake in children with painful infectious mouth conditions compared with placebo. METHODS This was a randomized placebo-controlled trial of viscous lidocaine versus placebo at a single pediatric emergency department. Study staff, clinicians, nurses, caregivers, and participants were blinded to the group assignment. Children with acute infectious ulcerative mouth conditions (gingivostomatitis, ulcerative pharyngitis, or hand, foot, and mouth disease) and poor oral fluid intake were randomized to receive 0.15 mL/kg of either 2% viscous lidocaine or placebo with identical appearance and flavor. The primary outcome was the amount of fluid ingested in the 60 minutes after administration of the intervention, with a difference in intake of 4 mL/kg considered clinically important. Secondary outcomes were specific milliliter per kilogram fluid targets and incidence of adverse events. RESULTS One hundred participants were recruited (50 per treatment group), all of whom completed the 60-minute fluid trial period. Oral intake 1 hour after drug administration was similar in both groups: lidocaine median 8.49 mL/kg (interquartile range 4.07, 13.84 mL/kg) versus placebo 9.31 mL/kg (interquartile range 3.06, 15.18 mL/kg); difference in medians 0.82 mL/kg (95% confidence interval -2.52 to 3.26); Mann-Whitney P=.90. Likewise, short-term secondary outcomes were similar between the groups and there were no adverse events in either group. CONCLUSION Viscous lidocaine is not superior to a flavored gel placebo in improving oral intake in children with painful infectious mouth ulcers.

Paediatric procedural sedation based on nitrous oxide and ketamine: sedation registry data from Australia

Objective Large, mainly North American, series has shown the safety of paediatric procedural sedation in the emergency department (ED). However, sedation practices elsewhere differ. This study set out to investigate the sedation practice and the associated adverse events profile at the largest Australian paediatric ED. Method Review of a prospective single centre procedural sedation registry database at an urban tertiary childrens hospital ED in Australia with an annual census of 67 000 patients over a 4-year period (2004–8). Sedation records were supplemented with medical record review. Patients 18 years and older were excluded. Demographics, agents used, adverse events and complications were analysed descriptively. Results Over the 4-year period, 2002 patients underwent procedural sedation. The median age was 5.7 years. Nitrous oxide was used in 1625 (81%), ketamine in 335 (17%) and midazolam in 39 (2%). Propofol and chloral hydrate were used in two and one patient, respectively. Most sedations were for laceration repair (38%) and orthopaedic procedures (33%); 89% had no adverse events. Most adverse events were mild, mainly vomiting (8%). Serious adverse events were desaturation in 12 patients, seizures in two patients and chest pain in one patient. The maximum required airway support was bag mask ventilation. No patients aspirated or required intubation. Conclusion In variation to reported practice elsewhere, almost all procedures in this Australian series were undertaken using nitrous oxide and ketamine. The serious adverse events rate was low.

Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial.

Objective To determine if a simple stimulation method increases the rate of infant voiding for clean catch urine within five minutes. Design Randomised controlled trial. Setting Emergency department of a tertiary paediatric hospital, Australia. Participants 354 infants (aged 1-12 months) requiring urine sample collection as determined by the treating clinician. 10 infants were subsequently excluded. Interventions Infants were randomised to either gentle suprapubic cutaneous stimulation (n=174) using gauze soaked in cold fluid (the Quick-Wee method) or standard clean catch urine with no additional stimulation (n=170), for five minutes. Main outcome measures The primary outcome was voiding of urine within five minutes. Secondary outcomes were successful collection of a urine sample, contamination rate, and parental and clinician satisfaction with the method. Results The Quick-Wee method resulted in a significantly higher rate of voiding within five minutes compared with standard clean catch urine (31% v 12%, P<0.001), difference in proportions 19% favouring Quick-Wee (95% confidence interval for difference 11% to 28%). Quick-Wee had a higher rate of successful urine sample collection (30% v 9%, P<0.001) and greater parental and clinician satisfaction (median 2 v 3 on a 5 point Likert scale, P<0.001). The difference in contamination between Quick-Wee and standard clean catch urine was not significant (27% v 45%, P=0.29). The number needed to treat was 4.7 (95% confidence interval 3.4 to 7.7) to successfully collect one additional urine sample within five minutes using Quick-Wee compared with standard clean catch urine. Conclusions Quick-Wee is a simple cutaneous stimulation method that significantly increases the five minute voiding and success rate of clean catch urine collection. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12615000754549.

Aggression management in a children’s hospital setting

Objectives: To describe the development, structure and implementation of a formal system of aggression management, and to document its utilisation during the first year of operation.

Who Can Have Parenteral Antibiotics at Home?: A Prospective Observational Study in Children with Moderate/Severe Cellulitis.

Background: The benefits of treating children at home or in an ambulatory setting have been well documented. We aimed to describe the characteristics and evaluate the outcomes of children with moderate/severe cellulitis treated at home with intravenous (IV) ceftriaxone via direct referral from the Emergency Department to a hospital-in-the-home (HITH) program. Methods: Patients aged 3 months to 18 years with moderate/severe cellulitis referred from a tertiary pediatric Emergency Department to HITH from September 2012 to January 2014 were prospectively identified. Data collection included demographics, clinical features, microbiological characteristics and outcomes. To ensure home treatment did not result in inferior outcomes, these patients were retrospectively compared with patients who were hospitalized for IV flucloxacillin, the standard-of-care over the same period. The primary outcome was home treatment failure necessitating hospital admission. Secondary outcomes included antibiotic changes, complications, length of stay and cost. Results: Forty-one (28%) patients were treated on HITH and 103 (72%) were hospitalized. Compared with hospitalized patients, HITH patients were older (P < 0.01) and less likely to have periorbital cellulitis (P = 0.01) or fever (P = 0.04). There were no treatment failures under HITH care. The rate of antibiotic changes was similar in both groups (5% vs. 7%, P = 0.67), as was IV antibiotic duration (2.3 vs. 2.5 days, P = 0.23). Conclusion: Older children with moderate/severe limb cellulitis without systemic symptoms can be treated at home. To ascertain if this practice can be applied more widely, a comparative prospective, ideally randomized, study is needed.

Quick-Wee: a novel non-invasive urine collection method

Background Clean catch urine (CCU) collection in precontinent children is often time-consuming, with associated collection failure. We hypothesise that stimulating cutaneous reflexes hastens voiding for CCU. Methods 40 children aged 1–24 months in the ED. Standard CCU was augmented with gentle suprapubic cutaneous stimulation using saline-soaked gauze (Quick-Wee method). Results 12/40 (30%) children voided within 5 min for successful CCU. Parental and clinician satisfaction was high. Conclusions Quick-Wee appears to be a simple method to speed CCU in young children.

PS-374 A Comparison Of Treatment At Home Or In Hospital For Moderate/severe Cellulitis In Children

Background and aims Adults with cellulitis are commonly receive IV antibiotics via hospital-in-the-home (HITH). Children are usually admitted to hospital. Royal Children’s Hospital (RCH) HITH and offers once daily IV ceftriaxone for cellulitis. Concerns remain for some physicians about its anti-staphylococcal activity. We aim to compare the clinical features and outcomes of patients with cellulitis admitted to hospital with IV flucloxacillin to those treated via HITH with IV ceftriaxone. Methods A retrospective chart review of patients with cellulitis treated with IV antibiotics. Exclusions- complicated cellulitis (abscess, orbital cellulitis, post-operative cellulitis, bites and immunosuppression). Demographics, clinical and microbiological features, antibiotic management and outcomes are related to two groups: inpatients treated with IV flucloxacillin and HITH patients treated with IV ceftriaxone. Results Over 17 months (2012–2014), 745 children presented to ED with cellulitis: 353 (47%) received IV antibiotics; 169 were excluded (complicated cellulitis, comorbidities, misdiagnosis or miscoding), leaving 184. 47 (26%) were admitted to HITH and 137 (74%) were admitted as inpatients. Initial treatment was IV ceftriaxone in 41 (87%) of HITH patients and IV flucloxacillin in 103 (75%) of inpatients. HITH patients were older, more likely to have failed prior oral antibiotics, less likely to have periorbital rather than limb cellulitis. Inpatients required longer IV treatment. Readmission rates, adverse events and rates of change of treatment were similar. Conclusion Some children with moderate/severe cellulitis can be treated via HITH with IV ceftriaxone in this non-randomised study however further prospective work is required to define the most appropriate sub-group.

A double blind, randomised placebo controlled trial of topical 2% viscous lidocaine in improving oral intake in children with painful infectious mouth conditions

BackgroundPainful infectious mouth conditions are a common presentation to emergency departments. Although self limiting, painful ulcerative lesions and inflamed mucosa can decrease oral intake and can lead to dehydration. Oral analgesia is of limited efficacy and is often refused by the patient. Despite widespread use of oral 2% viscous lidocaine for many years, there is little evidence for its efficacy as an analgesic and in aiding oral intake in children with painful infectious mouth conditions. This study aims to establish the effectiveness of 2% viscous lidocaine in increasing oral intake in these children by comparing it with placebo.Methods/DesignThis study is a randomised double-blind placebo controlled trial of children between 6 months and 8 years of age with painful infectious mouth conditions defined as gingivostomatitis (herpetic or non herpetic), ulcerative pharyngitis, herpangina and hand foot and mouth disease as assessed by the treating clinician in association with a history of poor oral fluid intake. It will be conducted at a single tertiary paediatric emergency department in Melbourne Australia.20 patients have already been randomised to receive 2% lidocaine or placebo in a pilot study to determine the sample size in a preplanned adaptive design. A further 80 patients will be randomised to receive either 2% lidocaine or placebo. The placebo agent is identical to lidocaine in terms of appearance, flavour and smell. All clinical and research staff involved, patients and their parents will be blinded to treatment allocation.The primary endpoint is the amount of fluid ingested by each child, expressed in ml/kg, within 60 minutes from the time of administration of the study mixture. Secondary endpoints are the proportion of patients ingesting 5 ml/kg and 10 ml/kg at 30 and 60 minutes after drug administration and the incidence of adverse events. Longer term outcomes will include the proportion of patients requiring hospital admission and length of emergency department stay.DiscussionThis trial will define the role of 2% lidocaine in the treatment of painful infectious mouth conditionsTrial registrationThe trial is registered with the Australian and New Zealand Clinical Trials Registry - ACTRN12609000566235.

Paediatric short stay unit in a community hospital: Effective, efficient and popular

Objectives:  Short stay medicine is a cost‐effective and efficient way to manage patients with suitable conditions. Paediatric acute illness and injury are amenable to short stay medicine. Before January 2004, when Maroondah Hospital recommenced inpatient care for children, 700 children were transferred annually to other hospitals. We describe the implementation and performance of the first paediatric short stay unit (SSU) in Victoria, which was designed to remedy this situation.

Cellulitis: Home Or Inpatient in Children from the Emergency Department (CHOICE): protocol for a randomised controlled trial.

Introduction Children needing intravenous antibiotics for cellulitis are usually admitted to hospital, whereas adults commonly receive intravenous treatment at home. This is a randomised controlled trial (RCT) of intravenous antibiotic treatment of cellulitis in children comparing administration of ceftriaxone at home with standard care of flucloxacillin in hospital. The study aims to compare (1) the rate of treatment failure at home versus hospital (2) the safety of treatment at home versus hospital; and (3) the effect of exposure to short course ceftriaxone versus flucloxacillin on nasal and gut micro-organism resistance patterns and the clinical implications. Methods and analysis Inclusion criteria: children aged 6 months to <18 years with uncomplicated moderate/severe cellulitis, requiring intravenous antibiotics. Exclusions: complicated cellulitis (eg, orbital, foreign body) and immunosuppressed or toxic patients. The study is a single-centre, open-label, non-inferiority RCT. It is set in the emergency department (ED) at the Royal Childrens Hospital (RCH) in Melbourne, Australia and the Hospital-in-the-Home (HITH) programme; a home-care programme, which provides outreach from RCH. Recruitment will occur in ED from January 2015 to December 2016. Participants will be randomised to either treatment in hospital, or transfer home under the HITH programme. The calculated sample size is 188 patients (94 per group) and data will be analysed by intention-to-treat. Primary outcome: treatment failure defined as a change in treatment due to lack of clinical improvement according to the treating physician or adverse events, within 48 h Secondary outcomes: readmission to hospital, representation, adverse events, length of stay, microbiological results, development of resistance, cost-effectiveness, patient/parent satisfaction. This study has started recruitment. Ethics and dissemination This study has been approved by the Human Research Ethics Committee of the RCH Melbourne (34254C) and registered with the ClinicalTrials.gov registry (NCT02334124). We aim to disseminate the findings through international peer-reviewed journals and conferences. Clinical trial Pre-results.