Vincent J. Wang

Urine specific gravity and other urinary indices: Inaccurate tests for dehydration

Objective: Urine output, specific gravity, and ketones (urinary indices) are commonly used as an objective means to assess for dehydration and gastroenteritis severity; however, their utility has not been established. The study was designed to evaluate the accuracy of urinary indices as diagnostic tests to identify acute dehydration. Methods: We completed a prospective cohort study in the Emergency Department of an urban pediatric hospital. Seventy-nine subjects ages 3 months to 36 months with gastroenteritis, clinically suspected moderate dehydration, and the need for intravenous rehydration were enrolled in the trial. Urine specific gravity and urine ketone levels were determined with bedside calorimetric (dipstick) testing, and urine output during rehydration and observation was measured by commonly used techniques. An internally validated, weight-based criterion standard for the percent dehydration on enrollment was used to identify the cohort of dehydrated subjects. Correlation statistics were calculated for urine output, specific gravity, and ketones. In addition, multilevel tables were created to determine the sensitivity, specificity, and likelihood ratio at varying test cutoff values to detect 3% and 5% dehydration. Results: Urine specific gravity (r = −0.06, P = 0.64), urine ketones (r = 0.08, P = 0.52), and urine output during rehydration (r = 0.01, P = 0.96) did not correlate with the initial degree of dehydration present. Clinically useful cutoff values for urine specific gravity and ketones to increase or decrease the likelihood of dehydration at the time of enrollment could not be identified. Conclusions: Urinary indices are not useful diagnostic tests to identify the presence of dehydration during the initial assessment of children with gastroenteritis.

Diagnostic value of immature neutrophils (bands) in the cerebrospinal fluid of children with cerebrospinal fluid pleocytosis

OBJECTIVE. We evaluated the diagnostic utility of the presence and number of cerebrospinal fluid (CSF) bands in distinguishing bacterial from aseptic meningitis among children with CSF pleocytosis. METHODS. We identified retrospectively a cohort of children 29 days to 19 years of age with CSF pleocytosis (≥10 × 106 leukocytes per L) who were treated in the emergency departments of 8 pediatric centers between January 2001 and June 2004 and whose CSF was evaluated for the presence of bands. We performed bivariate and multivariate analyses to determine the ability of CSF bands to distinguish bacterial from aseptic meningitis. RESULTS. Among 1116 children whose CSF was evaluated for the presence of bands, 48 children (4% of study patients) had bacterial meningitis. Bacterial meningitis, compared with aseptic meningitis, was associated with a greater CSF band proportion (0.03 vs 0.01; difference: 0.02; 95% confidence interval: 0.00–0.04) and CSF absolute band count (392 × 106 cells per L vs 3 × 106 cells per L; difference: 389 × 106 cells per L; 95% confidence interval: −77 × 106 cells per L to 855 × 106 cells per L). In addition, 29% of patients with bacterial meningitis, compared with 18% of patients with aseptic meningitis, had any bands detected in the CSF. After adjustment for other factors associated with bacterial meningitis, however, CSF band presence, CSF absolute band count, and CSF band proportion were not independently associated with bacterial meningitis. CONCLUSION. In this multicenter study, neither the presence nor quantity of CSF bands independently predicted bacterial meningitis among children with CSF pleocytosis.

Clinical factors and incidence of acute chest syndrome or pneumonia among children with sickle cell disease presenting with a fever: a 17-year review.

Objectives The objectives of this study were to determine the incidence of acute chest syndrome (ACS) in children with sickle cell disease (SCD) presenting with fever before and after the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7) and to determine clinical factors associated with ACS for a febrile child with SCD. Methods A retrospective chart review was undertaken for children with SCD from 1993 to 2009 in a single, urban, tertiary-care pediatric center. Clinical and laboratory data for each febrile event for each child with SCD were recorded. We compared incidence of ACS for the 3 PCV7 eras: pre-PCV7, inter-PCV7, and post-PCV7. Univariate analysis and stepwise logistic regression were used to identify clinical factors most associated with ACS in the post-PCV7 era. Results Of 2504 febrile events in 466 children with SCD, we found 492 diagnoses of ACS. The incidence of ACS cumulatively decreased over time from 27.0% to 17.4% among febrile children with SCD (P < 0.001), although no change was seen in children younger than 2 years (P = 0.89). Independent predictors of ACS in the post-PCV7 era include history of previous ACS, upper respiratory tract infection symptoms, noncompliance to penicillin, male sex, hypoxemia, an absolute neutrophil count greater than 9 × 109/L, and hemoglobin less than 8.6 g/dL. Conclusions The incidence of ACS has decreased over time in febrile children with SCD. No effect was seen in those 2 years or younger. Children with SCD presenting with a fever had higher odds of developing ACS when accompanied by certain clinical, demographic, and laboratory features.

Cryotherapeutic Topical Analgesics for Pediatric Intravenous Catheter Placement: Ice versus Vapocoolant Spray

Objectives Intravenous catheter placement is one of the most common sources of pain for children in inpatient settings. We sought to compare the efficacy of 2 cryotherapeutic treatments for this procedure: vapocoolant spray versus topical ice pack. Methods We prospectively enrolled 95 patients, aged 9 to 18 years, in a pediatric emergency department who required intravenous (IV) catheters as part of their treatment. Subjects were randomly assigned to receive vapocoolant spray or topical ice pack for 3 minutes, before IV catheter placement. Subjects completed visual analog scale (VAS) scores for 3 time points: baseline, pretreatment with ice or spray, and IV insertion. The principal investigator and 2 physicians viewing video recordings of the procedure also completed VAS scores for observed pain levels. Visual analog scale scores were compared using the Wilcoxon rank sum test. Results Although median VAS scores were similar, the change in VAS from baseline was of greater magnitude in the Painease group, indicating that it may be more effective. More subjects in the Painease group (76%) felt their treatment worked well, compared with 49% in the ice group. Physician-assigned VAS scores were lower and less variable than those of subjects. Most IV insertions were successful (83%). Conclusions Vapocoolant spray may be more effective than ice as an analgesic for IV insertion. Subjects were more satisfied with vapocoolant spray. Neither agent caused a decrease in successful IV insertion rates.

Carbon dioxide monitoring in emergency medicine training programs

Objectives Although the measurement of carbon dioxide (CO2) in breath is the standard of care for verification of endotracheal tube placement in all anesthesia practice and in the prehospital setting, there is currently no uniform consensus on the status of CO2 monitoring in emergency medicine. We conducted this survey to delineate practice patterns of CO2 monitoring in academic emergency medicine training programs and to describe the preference for type of CO2 monitoring device. Methods We surveyed the availability, presence, and types of CO2 monitoring in all general emergency medicine (GEM) residency programs and all pediatric emergency medicine (PEM) fellowship programs. A two-question survey was used, and data were collected from March 1998 to June 1998. The clinicians surveyed were asked whether their emergency department (ED) used CO2 monitoring for detection of endotracheal tube placement and, if so, what type of CO2 monitoring devices was used. Types of CO2 monitoring devices were categorized as colorimetric, capnometric, capnographic, or combinations of these. Results Of the 168 programs surveyed, all GEM and PEM programs responded, and the survey results showed that 136 of 168 (81%) used some form of CO2 monitoring, and 32 of 168 (19%) did not use CO2 monitoring. The majority of programs (115/168, 68%) used a single device. Colorimetric devices were used most frequently (76/168, 45%), and capnometry was used the least (9/168, 5%). PEM programs had a significant preference for quantitative CO2 monitoring, whereas GEM programs had a significant preference for qualitative CO2 monitoring. Conclusions Although the majority of academic emergency medicine training programs used CO2 monitoring, 19% did not. Colorimetric devices were the most frequently used CO2 monitoring technology.

Improving education: just-in-time splinting video.

Just‐in‐time training (JITT) is an emerging concept in medical procedural education, but with few studies to support its routine use. Providing a brief educational intervention in the form of a digital video immediately prior to patient care may be an effective method to reteach knowledge for procedural techniques learned previously.

Intravenous Fluid Bolus Prior to Neonatal and Infant Lumbar Puncture: A Sonographic Assessment of the Subarachnoid Space After Intravenous Fluid Administration

IMPORTANCE Neonatal and infant lumbar puncture is a commonly performed procedure in emergency departments, yet traumatic and unsuccessful lumbar punctures occur 30% to 50% of the time. Dehydration may be a risk factor for unsuccessful lumbar punctures, but to our knowledge, no studies have investigated the use of intravenous (IV) fluid bolus prior to lumbar puncture. OBJECTIVE To investigate the association of IV fluid bolus administration with the sonographic measure of the neonatal and infant lumbar subarachnoid space. We hypothesized that IV fluids would increase subarachnoid space size. DESIGN, SETTING, AND PARTICIPANTS Prospective observational study conducted from August 2012 to April 2015.The study took place at the emergency department of the Childrens Hospital Los Angeles, an urban pediatric emergency department with an annual census of 76,000 visits.A convenience sample of patients aged 0 to 3 months were enrolled if they had a clinical presentation consistent with pyloric stenosis. This population was used as a proxy because they are similar in age to patients undergoing lumbar puncture for evaluation of neonatal fever and are routinely given IV fluids for dehydration. EXPOSURES Patients with a sonographic diagnosis of pyloric stenosis underwent additional ultrasonography evaluation to determine the size of the subarachnoid space before and after IV fluids. MAIN OUTCOMES AND MEASURES Primary outcomes included the difference in the size of the subarachnoid space in millimeters squared before and 1 hour after administration of an IV fluid bolus in the emergency department. Interobserver consistency for the subarachnoid space measurement between attending radiologists was measured using intraclass correlation coefficient. The Wilcoxon signed-rank test was used to examine changes in subarachnoid space measurements (millimeters squared). RESULTS The study sample consisted of 40 patients with a mean (SD) age of 37 (11.3) days (range, 15-71 days). The mean (SD) size of the subarachnoid space before and 1 hour after IV fluid bolus was 37.8 (11.1) mm(2) and 36.9 (11.2) mm(2) respectively (P = .42). The intraclass correlation coefficient ranged from 0.96 to 0.99 (95% CI, 0.90-0.99). CONCLUSIONS AND RELEVANCE Intravenous fluid boluses were not associated with a significant increase in the sonographic measure of the neonatal and infant subarachnoid space.

The Broselow and Handtevy Resuscitation Tapes: A Comparison of the Performance of Pediatric Weight Prediction.

OBJECTIVES To assess the performance of two pediatric length-based tapes (Broselow and Handtevy) in predicting actual weights of US children. METHODS In this descriptive study, weights and lengths of children (newborn through 13 years of age) were extracted from the 2009-2010 National Health and Nutrition Examination Survey (NHANES). Using the measured length ranges for each tape and the NHANES-extracted length data, every case from the study sample was coded into Broselow and Handtevy zones. Mean weights were calculated for each zone and compared to the predicted Broselow and Handtevy weights using measures of bias, precision, and accuracy. A sub-sample was examined that excluded cases with body mass index (BMI)≥95th percentile. Weights of children longer than each tape also were examined. RESULTS A total of 3,018 cases from the NHANES database met criteria. Although both tapes underestimated childrens weight, the Broselow tape outperformed the Handtevy tape across most length ranges in measures of bias, precision, and accuracy of predicted weights relative to actual weights. Accuracy was higher in the Broselow tape for shorter children and in the Handtevy tape for taller children. Among the sub-sample with cases of BMI≥95th percentile removed, performance of the Handtevy tape improved, yet the Broselow tape still performed better. When assessing the weights of children who were longer than either tape, the actual mean weights did not approximate adult weights; although, those exceeding the Handtevy tape were closer. CONCLUSIONS For pediatric weight estimation, the Broselow tape performed better overall than the Handtevy tape and more closely approximated actual weight. Lowe CG , Campwala RT , Ziv N , Wang VJ . The Broselow and Handtevy resuscitation tapes: a comparison of the performance of pediatric weight prediction. Prehosp Disaster Med. 2016;31(4):364-375.

Assessing the Utility of Urine Testing in Febrile Infants Aged 2 to 12 Months With Bronchiolitis.

Objectives The aims of the study were to investigate whether the prevalence of urinary tract infections (UTIs) in febrile infants aged 2 to 12 months with bronchiolitis is higher than the presumed prevalence of asymptomatic bacteriuria (1%) in similarly aged patients and thus to determine whether UTI testing is necessary for these patients. Methods This was a prospective cohort study in which we enrolled a convenience sample of febrile infants aged 2 to 12 months with a clinical diagnosis of bronchiolitis. All patients were seen in the emergency department at a large childrens hospital between November 1, 2011 and April 15, 2012, had reported or documented fever higher than 38°C, and had urine collected for determination of the presence of UTI. After the conclusion of enrollment, a chart review was conducted to assess missed cases. Results Positive urine cultures were found in 6/90 (6.7%) patients (confidence interval, 2.5%–13.9%). The positive urine cultures and urinalysis results were found in 4/90 (4.5%) patients (confidence interval, 1.2%–11%). Conclusions In our patient population, a significant proportion of infants aged 2 to 12 months who present with bronchiolitis and fever have a concurrent UTI. Obtaining a urine specimen for UTI testing should be considered in infants aged 2 to 12 months with bronchiolitis and fever. A larger multicenter study is needed to further assess the risk factors for UTIs in this patient population.

Predictors for bacteremia in febrile sickle cell disease children in the post-7-valent pneumococcal conjugate vaccine era.

Objectives: The objective of this study was to determine the incidence of bacteremia in febrile sickle cell disease (SCD) children before and after the 7-valent pneumococcal vaccine (PCV7), and to determine clinical factors associated with bacteremia following PCV7. Patients and Methods: We reviewed all febrile events in SCD children from 1993 to 2009 at a tertiary care pediatric center, comparing general bacteremia and pneumococcal bacteremia incidence for 3 time periods around the PCV7. Univariate analysis and stepwise logistic regression identified clinical factors most associated with bacteremia in this population. Results: Of 466 SCD children identified, there were 2504 febrile events. We found 84 cases of bacteremia; 8 were pneumococcal. The general bacteremia incidence decreased significantly from 5.60% to 2.44% (P<0.001) over time. Pneumococcal bacteremia incidence did not decrease (P=0.13). Following PCV7, we identified 4 significant independent risk factors associated with general bacteremia: the presence of a central venous line, higher absolute band count, toxic appearance, and older age. Conclusions: In febrile SCD children, the incidence of general bacteremia decreased over time. No decrease in pneumococcal bacteremia was found. The presence of a central venous line, absolute band count, clinical appearance, and age may help predict bacteremia in this population.