Thomas J. Abramo

Etiology and treatment of community-acquired pneumonia in ambulatory children.

OBJECTIVES To determine the etiology of community-acquired pneumonia in ambulatory children and to compare responses to treatment with azithromycin, amoxicillin-clavulanate or erythromycin estolate. METHODS Ambulatory patients with pneumonia were identified at the Childrens Medical Center of Dallas, TX. Children age 6 months to 16 years with radiographic and clinical evidence of pneumonia were enrolled and randomized to receive either azithromycin suspension for 5 days or a 10-day course of amoxicillin-clavulanate for those <5 years or erythromycin estolate suspension for those > or = 5 years. Blood culture was obtained in all patients and we obtained nasopharyngeal and pharyngeal swabs for culture and polymerase chain reaction (PCR) testing for Chlamydia pneumoniae and Mycoplasma pneumoniae and nasopharyngeal swabs for viral direct fluorescent antibody and culture. Acute and convalescent serum specimens were tested for antibodies to C. pneumoniae, M. pneumoniae and Streptococcus pneumoniae. Patients were evaluated 10 to 37 days later when repeat specimens for serology, PCR and culture were obtained. For comparative purposes healthy children attending the well-child clinic had nasopharyngeal and pharyngeal swabs obtained for PCR and culture for C. pneumoniae and M. pneumoniae. RESULTS Between February, 1996, and December, 1997, we enrolled 174 patients, 168 of whom fulfilled protocol criteria for evaluation. There were 55% males and 63% were <5 years of age. All blood cultures were sterile and there was no correlation between the white blood cell and differential counts and etiology of pneumonia. Etiologic agents were identified in 73 (43%) of 168 patients. Infection was attributed to M. pneumoniae in 7% (12 of 168), C. pneumoniae in 6% (10 of 168), S. pneumoniae in 27% (35 of 129) and viruses in 20% (31 of 157). None of the swab specimens from 75 healthy control children was positive for C. pneumoniae or M. pneumoniae. Clinical response to therapy was similar for the three antibiotic regimens evaluated, including those with infection attributed to bacterial agents. CONCLUSION Although a possible microbial etiology was identified in 43% of the evaluable patients, clinical findings and results of blood cultures, chest radiographs and white blood cell and differential counts did not distinguish patients with a defined etiology from those without a known cause for pneumonia. There were no differences in the clinical responses of patients to the antimicrobial regimens studied.

Otitis externa review.

LEARNING OBJECTIVES After completion of this article, the reader will be able to: 1. Define the pathogenesis and microbiology of otitis externa. 2. Describe the presenting sign and symptoms in children with infections of the external ear, as well as the complications. 3. Discuss the therapeutic options, including topical antibiotic drugs, anti-inflammatory agents, and the use of mechanical interventions (wick, ear plugs).

The state of pediatric interfacility transport: Consensus of the Second National Pediatric and Neonatal Interfacility Transport Medicine Leadership Conference

Interfacility transport of pediatric and neonatal patients for advanced or specialty medical care is an integral part of our medical delivery system. Assessment of current services and planning for the future are imperative. As part of this process, the American Academy of Pediatrics and the Section on Transport Medicine held the second National Pediatric and Neonatal Transport Leadership Conference in Chicago in June 2000. Ninety-nine total participants, representing 25 states and 5 international locations, debated and discussed issues relevant to the developing specialty of pediatric transport medicine. These topics included: 1) the role of the medical director, 2) benchmarking of neonatal and pediatric transport programs, 3) clinical research, 4) accreditation, 5) team configuration, 6) economics of transport medicine in health care delivery, 7) justification of transport teams in institutions, and 8) international transport/extracurricular transport opportunities. Insights and conclusions from this meeting of transport leaders are presented in the consensus statement.

Serious Group A β-Hemolytic Streptococcal Infections Complicating Varicella☆☆☆★

Abstract Study objective: To alert practicing emergency physicians to an important and possibly increasing relationship between life-threatening group A β-hemolytic streptococcal (GABHS) infections and children recovering from varicella. Design: A case series of six patients managed from January through March 1993. Setting: A university-affiliated pediatric specialty emergency department. Type of participants: Six previously healthy immunocompetent children between 1 and 5 years of age seen in our ED over a nine-week period. Results: Six children had onset of varicella two days to two weeks before developing a serious life-threatening GABHS infection. Children presented with clinical symptoms of invasive GABHS infection with bacteremia (one patient); streptococcal toxic shock syndrome with negative blood culture (two), pneumonia with pleural effusion and streptococcal toxic shock syndrome (one), pneumonia with pleural effusion (one), and pyomyositis of the thigh (one). Four of six patients required intensive care admissions and aggressive support of vital signs. All six survived. Conclusion: Emergency physicians should be aware of the association between varicella and serious GABHS infections and be prepared to recognize and aggressively manage serious complications should they occur. [Cowan MR, Primm PA, Scott SM, Abramo TJ, Wiebe RA: Serious group A s-hemolytic streptococcal infections complicating varicella. Ann Emerg Med April 1994;23:818-823.]

Capnometry for noninvasive continuous monitoring of metabolic status in pediatric diabetic ketoacidosis

ObjectiveTo determine the utility of continuous noninvasive capnometry for monitoring pediatric patients with diabetic ketoacidosis as assessed by the agreement between end-tidal carbon dioxide (Petco2) and Pco2. DesignClinical, prospective, observational study. SettingUniversity affiliated children’s hospital. InterventionsPatients with diabetic ketoacidosis were monitored with an oral/nasal carbon dioxide (CO2) sampling cannula while in the emergency department. Laboratory studies were ordered per protocol. Petco2values were correlated with respiratory rate, Pco2, and pH. Measurements and Main ResultsOne hundred twenty-one patients were monitored for 5.9 ± 0.32 hrs. The average (mean ± sd) initial values for pH were 7.08 ± 0.18; respiratory rate, 35.1 ± 9.1 breaths/min; Petco2, 18.6 ± 10.8 torr; and venous Pco2, 20.2 ± 10.6 torr. At the conclusion of the observation period, averages were pH, 7.29 ± 0.05; respiratory rate, 22.4 ± 3.7 breaths/min; Petco2, 35.3 ± 5.8 torr; and venous Pco2, 36.8 ± 5.3 torr. For all 592 observations, the correlations between Petco2 and venous Pco2 (r = .92, p = .0001), Petco2 and pH (r = .88, p = .0001), Petco2 and respiratory rate (r = −.79, p = .0001), and respiratory rate and pH (r = −.80, p = .0001) were statistically significant and the correlations with respiratory rate were inversely related to pH and Petco2. The difference scores were not related to the average scores for initial readings (r = −.073, p = .43), final readings (r = −.124, p = .18), and overall readings (r = .057, p = .17). Limits of agreement between the two methods were established with Petco2 lower than venous Pco2 with 95% limits of agreement 0.8 ± 8.3 (2 sd) torr. ConclusionsPetco2 monitoring of patients with diabetic ketoacidosis provides an accurate estimate of Pco2. Noninvasive Petco2 sampling may be useful in patients with diabetic ketoacidosis to allow for continuous monitoring of patients.

Noninvasive capnometry monitoring for respiratory status during pediatric seizures

OBJECTIVE To determine the reliability and clinical value of end-tidal CO2 by oral/nasal capnometry for monitoring pediatric patients presenting post ictal or with active seizures. DESIGN Clinical, prospective, observational study. SETTING University affiliated childrens hospital. INTERVENTIONS One hundred sixty-six patients (105 patients with active seizures, 61 post ictal patients) had end-tidal CO2 obtained by oral/nasal sidestream capnometry, and respiratory rates, oxygen saturation, and pulse rates recorded every 5 mins until 60 mins had elapsed. End-tidal CO2 values were compared with a capillary PCO2 and clinical observation. MEASUREMENTS AND MAIN RESULTS The mean end-tidal CO2 reading was 43.0 +/- 11.8 torr [5.7 +/- 1.6 kPa] and the mean capillary PCO2 reading was 43.4 +/- 11.7 torr [5.7 +/- 1.6 kPa]. The correlation between end-tidal CO2 and capillary PCO2 was significant (r2 = .97; p < .0001). A relative average bias of 0.33 torr (0.04 kPa) with end-tidal CO2 lower than capillary PCO2 was established with 95% limits of agreement +/-4.2 torr (+/-0.6 kPa). Variability of difference scores was not related to range of mean scores (r2 = .00003), age (r2 = .0004), or respiratory rates (r2 = .0009). End-tidal CO2 (r2 = .22; p < .001) correlated better with respiratory rate changes when compared with oxygen saturation (r2 = .02; p = .01). CONCLUSIONS Dependable end-tidal CO2 values can be obtained in pediatric seizure patients using an oral/nasal cannula capnometry circuit. Continuous end-tidal CO2 monitoring provides the clinician with a reliable assessment of pulmonary status that can assist with decisions to provide ventilatory support.

Comparison of Intravenous Terbutaline Versus Normal Saline in Pediatric Patients on Continuous High-dose Nebulized Albuterol for Status Asthmaticus

Objective: To determine if the addition of intravenous terbutaline provides any clinical benefit to children with acute severe asthma already on continuous high-dose nebulized albuterol. Methods: We conducted a prospective, randomized, double blind, placebo-controlled trial on pediatric patients with acute severe asthma presenting to a large inner city tertiary childrens emergency department. Consecutive patients between 2 and 17 years of age who failed acute asthma management and needed intensive care unit admission underwent informed consent and were enrolled into the study. Patients not requiring intubation were randomized to receive either intravenous terbutaline or intravenous normal saline while on continuous high-dose nebulized albuterol, ipratropium bromide, and systemic corticosteroids. Outcome measures included a clinical asthma severity score, hours on continuous nebulized albuterol, and duration of stay in the pediatric intensive care unit. In addition, electrocardiograms, electrolytes, lactic acid, and troponin I levels were obtained at routine intervals during the first 24 hours after admission. Patients who significantly worsened while enrolled in the study received intravenous aminophylline according to protocol. Results: Forty-nine patients were enrolled in the study. Patients on terbutaline had a mean improvement in the clinical asthma severity score over the first 24 hours of 6.5 points compared with 4.8 points in the placebo group (P = 0.073). Patients on terbutaline spent 38.19 hours on continuous nebulized albuterol compared with their placebo counterparts who spent 51.93 hours (P = 0.25). The length of stay in the PICU was on average 12.95 hours longer for those patients in the placebo group as compared with the terbutaline group (P = 0.345). One patient was removed from the study for a significant cardiac dysrhythmia. This patient was in the terbutaline group and recovered without complications. Troponin I values at 12 hours and 24 hours were elevated in 3 patients each, all within the terbutaline group. Conclusions: No outcome measures demonstrated statistical significance. Outcome measures revealed a trend toward improvement in the terbutaline group. Before recommending routine use of intravenous terbutaline for acute severe asthma, further study to determine safety and efficacy is necessary.

Noninvasive capnometry in a pediatric population with respiratory emergencies

Objective This study was designed to investigate the reliability, safety, and efficacy of measuring end tidal CO2 (ETCO2) in nonintubated pediatric patients presenting to an emergency department (ED) with respiratory emergencies. Design/Setting/Patients Eighty-five children were enrolled in a clinical, prospective, observational study at a university-affiliated childrens hospital. Children age four weeks to 15.3 years with upper and lower respiratory diseases were enrolled by convenience sampling over a five-month period. Interventions ETCO2 measurements were obtained on each patient by oral/nasal side-stream capnometry. When a consistent waveform was obtained, the value was compared with a capillary arterial partial pressure of CO2 (CapCO2), oxygen saturation (O2Sat), and clinical observations. Results Study patients had a mean ETCO2 reading of 33 mmHg with a standard deviation (SD) of 4.6 mmHg and CapCO2 reading of 36 mmHg with a SD of 4.5 mmHg. Pulmonary findings, final diagnosis, and age did not significantly alter the relationship between CapCO2 and ETCO2. The relationship between CapCO2 and ETCO2 was significant (t = 14.9, P < 0.0001, r = 0.87), with a 95% confidence interval for prediction of ±5 mmHg. Conclusion Dependable ETCO2 values can be obtained using an oral/nasal capnometry circuit, and they consistently correlate with CapCO2 in a pediatric population with upper and lower respiratory diseases. Noninvasive ETCO2 analysis is safe and reliable within the limitations of this study group. Further exploration is necessary to determine the value of this technology in assisting with clinical decisions in the patient with impending respiratory failure.

Near-infrared spectroscopy in the critical setting.

Near-infrared spectroscopy is a noninvasive means of determining real-time changes in regional oxygen saturation of cerebral and somatic tissues. Hypoxic neurologic injuries not only involve devastating effects on patients and their families but also increase health care costs to the society. At present, monitors of cerebral function such as electroencephalograms, transcranial Doppler, jugular bulb mixed venous oximetry, and brain tissue oxygenation monitoring involve an invasive procedure, are operator-dependent, and/or lack the sensitivity required to identify patients at risk for cerebral hypoxia. Although 20th century advances in the understanding and management of resuscitation of critically ill and injured children have focused on global parameters (ie, pulse oximetry, capnography, base deficit, lactate, etc), a growing body of evidence now points to regional disturbances in microcirculation that will lead us in a new direction of adjunctive tissue monitoring and response to resuscitation. In the coming years, near-infrared spectroscopy will be accepted as a way for clinicians to more quickly and noninvasively identify patients with altered levels of cerebral and/or somatic tissue oxygenation and, in conjunction with global physiologic parameters, guide efficient and effective resuscitation to improve outcomes for critically ill and injured pediatric patients.

Dexmedetomidine sedation: uses in pediatric procedural sedation outside the operating room.

As the field of pediatric procedural sedation continues to expand, so does the exploration of medications that have a role in such invasive and noninvasive procedures. One such medication that has emerged during the last decade is dexmedetomidine, a drug approved for use in the adult intensive care setting. Its role in pediatrics has varied in its use from sedation in ventilated children in the intensive care unit to treatment for emergence reactions from general anesthesia and in sedation needed for radiographic imaging studies, electroencephalography, and invasive procedures. This review article presents the pediatric studies that have been published thus far regarding dexmedetomidate in the nonventilated, spontaneously breathing patient and identifies those patients where the use of this agent may not be indicated.