UMEM Educational Pearls - Pediatrics

Pediatric Acute Respiratory Distress Syndrome: Consensus Recommendations from the Pediatric Acute Lung Injury Consensus Conference.  Pediatric Acute Lung Injury Consensus Conference Group. Pediatr Crit Care Med. 2015 Jun;16(5):428-39

Collaborators: Jouvet P, Thomas NJ, Wilson DF, Erickson S, Khemani R, Zimmerman J, Dahmer M, Flori H, Quasney M, Sapru A, Cheifetz IM, Rimensberger PC, Kneyber M, Tamburro RF, Curley MA, Nadkarni V, Valentine S, Emeriaud G, Newth C, Carroll CL, Essouri S, Dalton H, Macrae D, Lopez-Cruces Y, Quasney M, Santschi M, Watson RS, Bembea M.

Elective surgeries with general anesthesia are often cancelled when the child has an upper respiratory tract infection.  What are the adverse events when procedural sedation is used when the child has an upper respiratory tract infection?

Recent and current URIs were associated with an increased frequency of airway adverse events (AAE).  The frequency of AAEs increased from recent URIs, to current URIs with thin secretions to current URIs with thick secretions.   Adverse events not related to the airway were less likely to have a statistically significant difference between the URI and non-URI groups

AAEs for children with no URI was 6.3%.  Children with URI with thick/green secretions had AAEs in 22.2% of cases.  Children with URIs did NOT have a significant increase in the risk of apnea or need for emergent airway intervention.  The rates of AAEs, however, still remains low regardless of URI status.

Data was collected on over 83,000 patients retrospectively from a voluntary database, The Pediatric Sedation Research Consortium.  Children with URIs (no fever) who underwent procedural sedation for things such as imaging or hematology/oncology procedures were included.  Propofol, dexmedetomidine, ketamine and opiates were the most commonly used agents.

AAEs included wheezing, secretions requiring treatment, cough, stridor, desaturations, obstruction, snoring, laryngospasm, and apnea.

Mallory et al.  Upper Respiratory Infections and Airway Adverse Events in Pediatric Procedural Sedation.  Pediatrics. 2017; 140 (1): 1-10.

Van Ommen CH, Nowak-Gottl U. Inherited Thrombophilia in Pediatric Venous Thromboembolic Disease: Why and Who to Treat. Frontiers in Pediatrics. 2017: 5(20).

The Harriet Lane Handbook, 20th edition. Chapter 29: Drug Dosages. 2015

Anaphylaxis is a life threatening emergency with mortality of up to 2% [1]. Early recognition is imperative and administration of timely Epinephrine is the single most important intervention [2]. While providers may be hesitant to administer epinephrine in older patients due to fear of precipitating adverse cardiovascular events, they may also hesitate in younger patients due to fear of overdose. 

Iimmediate administration with any dose available is recommended because:

• the risks of untreated anaphylaxis are greater than the risk of over-treating with epinephrine.
• 20% of Anaphylaxis patients require a second dose of Epinephrine [3].
• The recommended IM dose of 0.01mg /kg was determined arbitrarily.
• The vast majority of epinephrine overdoses are via IV injection at doses 100 - 1000 fold the recommended  IV dose [4]

1-  Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol. 2001 Jan. 107(1):191-3. [Medline].

2-  Sheikh A, Shehata YA, Brown SG, Simons FE. Adrenaline for the treatment of anaphylaxis: cochrane systematic review. Allergy 2009; 64:204.

3-  Oren E, Banerji A, Clark S, Camargo CA Jr. Food-induced anaphylaxis and repeated epinephrine treatments. Ann Allergy Asthma Immunol 2007; 99:429.

4-  Wood JP, Traub SJ, Lipinski C. Safety of epinephrine for anaphylaxis in the emergency setting. World Journal of Emergency Medicine. 2013;4(4):245-251. doi:10.5847/wjem.j.issn.1920-8642.2013.04.001.

Guedji R et al.  Do All Children Who Present With a Complex Febrile Seizure Need a Lumbar Puncture?  Annals of Emergency Medicine. 2017; 70 (1):52-62.

Heinonen S, Silvennoinen H, Lehtinen  et al. Early oseltamivir treatment of influenza in children 1-3 years of age: A randomized controlled trial. Clin Infect Dis. 2010;51(8):87-94.

Marchese et al.  Reduced Radiation in children presenting to the ED with Suspected Ventricular Shunt Complication.  Pediatrics. 2017; 139 (5).

Methods involved reviewing regional Poison Control Center data from 1999 thruh 2013, during which 1431 calls regarding exposures of children less than or equal to age 19 or exposed to a veterinary medication. 

While the authors concluded that most exposures did not result in major adverse outcomes, 14.1% of exposures resulted in at least minor health effects.

A broader range of more highly toxic medications are increasingly being prescribed for animals, including anti-neoplastic drugs such as cyclophosphamide and chlorambucil.

Treatment of chronic health conditions and pets,  such as osteoarthritis, hypothyroidism, or anxiety is also increasingly common.

Tomasi S, Roberts KJ, Stull J, Spiller HA, McKenzie LB. Pediatric Exposures to Veterinary Pharmaceuticals. Pediatrics. 2017;139(3)

This was a retrospective review of children aged 0-17 with blunt trauma requiring trauma team activation who had a chest xray preformed.  483 eligible children were included, all of whom were admitted to the hospital.  108 children had their thoracic injury detected on chest xray, 110 on chest CT and 76 on abdominal CT.  Pneumothorax, pulmonary contusion and multiple rib fractures were the most commonly found thoracic injuries.  All children also had other injuries.

Weerdenburg et al.  Predicting Thoracic Injury in Children with Multi-trauma.  Pediatric Emergency Care.  Epub ahead of print.  2017.

This is the first study looking at ziprasidone in the pediatric emergency department population.  This was a retrospective observational study of children 5-18 years old who were treated with IM ziprasidone.  40 patients received IM ziprasidone in a tertiary care pediatric emergency department between 2007-2015.  2/3 of the patients had ADHD and 1/3 had autism spectrum disorder.  Other diagnosis included post-traumatic stress disorder, bipolar disorder and intellectual disabilities.

68% of patients responded to the initial dose.  The initial dose was 0.19 +/- 0.1 mg/kg in the responder group and 0.13 +/- 0.06 mg/kg in the non-responder group.  Single doses ranged from 2.5 mg to 20 mg total.

No patients had respiratory depression.  Two patients had potential extra-pyramidal symptoms, but one was prior to ziprasidone administration and the other patient had baseline facial twitching with no documentation if there was a change after ziprasidone administration.

Nguyen T, Stanton J and Foster R.  Intramuscular Ziprasidone Dosing for Acute Agitation in the Pediatric Emergency Department: An observational Study.  Journal of Pharmacy Practice 1-4.  2017.

A summary statement from the American Hospital Association (AHA) is posted below.

This was a retrospective study of 1991 children younger than 2 years that presented between 2000-2010 who were diagnosed with bronchiolitis.  Primary care records were reviewed 1 year after their visit to the ED to see if the patient had a primary care diagnosis of asthma. 

Of the initial study population, 817 patients had received a diagnosis of asthma at 1 year.

Since these patients were only followed up at 1 year, the amount of children who were later diagnosed with asthma may be underestimated.

Waseem et al.  Factors Predicting Asthma in children with Acute Bronchiolitis.  Pediatric Emergency Care.  March 2017.  Epub ahead of print.

This was a retrospective study of 2700 infants < 3 months old who were evaluated for urinary tract infections (UTI).  The UTI prevalence in this group was 7.8%.  A UTI was defined as at least 50,000 colony forming units/mL from a catheterized specimen.  Test characteristics looked at white blood cell and leukocyte esterase cut-offs, dichotomized into specific gravities: dilute (<1.015) and concentrated (>/=1.015).

For respiratory distress and hypoxia: Infants have a lower FRC and can desaturate very quickly!

Supplemental O₂ should be delivered via face mask or nasal cannula or other devices such as high flow nasal cannula or nasopharyngeal CPAP, even if O₂ saturation levels appear normal with peripheral monitoring devices

For improved circulation: utilize peripheral IO early

Peripheral IV or IO access can be used for fluid resuscitation, inotrope infusion, and antibiotic delivery when central access is not readily available or obtainable

Initial therapeutic resuscitative end points: hypotension and poor capillary refill may portend imminent cardiovascular collapse!

• Capillary refill of < or = 2s
• Normalization of heart rate for age
• Normalization of blood pressure for age
• Lack of difference between central and peripheral pulses
• Warm extremities
• Urine output >1mL/kg/hr
• Normal level of consciousness

Antibiotics and source control: Early and aggressive source control is key, just as in adults!

• In up to 75% of pediatric sepsis cases, the underlying pathogen(s) remain unknown,
• A child’s immune system is incompletely formed, and they are markedly more susceptible to viruses and encapsulated bacteria
• Empiric antibiotics should be administered within 1 hour
• Blood cultures prior to antibiotics is preferred, but should not delay starting antibiotics
• Tailor antimicrobials to epidemic and endemic ecologies and consider resistant organisms
• Clindamycin and anti-toxin therapies for toxic shock syndromes with refractory hypotension
• C. diff. colitis should be treated with enteral antibiotics if possible, with vancomycin preferred in severe cases

Fluid resuscitation: Support the pump, and fill, but don’t overload the tank!

• Bolus 20 mL/kg fluid (isotonic crystalloid) IV/IO over 5-20min or faster if needed
• Repeat 20 mL/kg bolus of fluid (up to 60 mL/kg) until clinical symptoms improve or patient develops respiratory distress/rales/ hepatomegaly
• Titrate to reversing hypotension, increasing urine output, and attaining normal capillary refill, peripheral pulses, and level of consciousness
• If hepatomegaly or rales are present, consider early inotropic support and carefully titrated fluids
• Use diuretics to reverse fluid overload when shock has resolved, and if unsuccessful then CVVH or intermittent dialysis to prevent >10% total body weight fluid overload
• In non-hypotensive children with severe hemolytic anemia (i.e. severe malaria or sickle cell crisis) blood transfusion is considered superior to crystalloids
• Consider adrenal insufficiency in refractory shock and give hydrocortisone accordingly

Inotropes and vasopressors: not just Levo for all!

• Normotensive shock (impaired perfusion but normal blood pressure): Dopamine 2-20 mcg/kg/min IV/IO, titrate to desired effect; if continued poor perfusion, consider dobutamine infusion 2-20 mcg/kg/min IV/IO, titrate to desired effect (may cause hypotension, tachycardia)
• Warm shock (warm extremities, flash capillary refill): Norepinephrine 0.1-2 mcg/kg/min IV/IO infusion, titrate to desired effect
• Cold shock (cool extremities, delayed capillary refill): Epinephrine 0.1-1 mcg/kg/min IV/IO infusion, titrate to desired effect

Extracorporeal Membrane Oxygenation (ECMO)

Consider ECMO for refractory pediatric septic shock with respiratory failure – in kids, survival is improved dramatically – consider it early!

Blood products

• In hemodynamically unstable children in shock on pressors, hgb levels of ≥10 g/dL are targeted
• In stable critically ill children, a lower hgb target of ≥7.0 g/dL is recommended
• Similar platelet transfusion targets in children as in adults
• Consider plasma therapies in children to correct sepsis-induced thrombotic disorders
• IV immunoglobulin may also be considered

Mechanical ventilation

• If mechanical ventilation is required, then cardiovascular instability during intubation may be less likely after appropriate cardiovascular resuscitation
• Use lung-protective strategies during mechanical ventilation
• Sedation/analgesia is recommended in critically ill mechanically ventilated kids with sepsis

Glycemic control

• Watch for hypoglycemia (neonates < 45 mg/dL, infants/children < 60 mg/dL)
• Control hyperglycemia using similar targets as in adults < or = 180 mg/dL

Randolph AG & McCulloh RJ. Pediatric sepsis: important considerations for diagnosing and managing severe infections in infants, children, and adolescents. Virulence. 2014: 1;5(1):179-89. doi: 10.4161/viru.27045.

Wheeler DS, Wong HR, Zingarelli B. Pediatric Sepsis - Part I: "Children are not small adults!" Open Inflamm J. 2011: 7;4:4-15. doi: 10.2174/1875041901104010004.

Diagnosis: Pathologic fracture with a unicameral bone cyst

Unicameral bone cysts are benign lesions that mainly affect children and adolescents.  On xray the cyst is noted to be a mildly expansile, lytic, thin walled lesion without periosteal reaction.  The most common sites are the proximal humerus and femur.  These lesions can resolve spontaneously, but there is a risk of pathologic fracture.  If fracture is detected, then the fracture site should be treated as any other fracture in the area.  These lesions can also be found incidentally in which case they should be referred to orthopedics for outpatient follow up.

Kadhim, M, Thacker M, Kadhim A and Holmes L.  Treatment of unicameral bone cyst: systemic review and meta analysis.  J Child Orthop.  2014 Mar; 8(2): 171-191.

Mascard E, Gomez-Brouchet A, Lambot K.  Bone cysts: Unicameral and aneurysmal bone cyst.  Orthop Traumatol Surg Res. 2015 Feb; 101.

Nail bed injuries occur in 15-24% of children with fingertip injuries.

In 1997, medical adhesive was first used to secure the avulsed nail plate back to the nail bed instead of suturing back into place.  By 2008, there were small studies looking at the utility of using medical adhesive to close the laceration of the nail bed.  The studies were small, but there was a tendency towards shorter repair times and no difference between pain, cosmetic outcome or function.

A total of 6 articles were included in this review – 2 using histoacryl and 4 using demabond.

Edwards, S, Parkinson L.  Is Fixing Pediatric Nail Bed Injuries with Medical Adhesives as Effective as Suturing?  A Review of the Literature.  Pediatric Emergency Care.  2016.