Faster discharge with lactated ringers than normal saline in first 72 h of acute pancreatitis: A multicenter randomized trial.

OBJECTIVES: Data driven strategies for acute pancreatitis (AP) in pediatrics are limited; adult data suggests lactated ringers (LR) compared to normal saline (NS) resulted in favorable outcomes, but has not been studied in pediatrics. Our objective was to evaluate the efficacy of LR during the first 48 h of an AP episode compared with NS. STUDY DESIGN: A multisite randomized controlled clinical trial, from 2015 to 2020 (Clinical Trials.gov NCT03242473). Patients were randomized to exclusively LR or NS for the first 48 h. Primary outcomes were serial C-reactive protein (CRP) values. Secondary outcomes included other lab values, time to feeds, length of stay (LOS), systemic inflammatory response syndrome (SIRS) development, and progression to severe AP (SAP). RESULTS: We studied 76 patients (38 LR, 38 NS). CRP at 24 and 48 h were not significantly different between LR or NS group. Additionally, there were no differences in trends of BUN, amylase, lipase, SIRS status, or SAP development between the LR and NS group at 24 and 48 h. A higher proportion of LR patients (32%, 12/38) were discharged before 48 h compared to NS (13%, 5/38). The LR group had a significantly higher rate of discharge within the first 72 h compared to the NS group (p = 0.02). CONCLUSION: The use of LR was associated with a faster rate of discharge during the intervention period and in the first 72 h, but no other differences compared to NS. This reduction in length of hospitalization has significant implications for patients and healthcare costs.

Adequacy of Emergency Department Documentation of Child Restraint Use After a Motor Vehicle Crash.

OBJECTIVES: There are limited data on how often providers collect and document adequate restraint information in children seen in the emergency department (ED) after motor vehicle crashes (MVCs). The objectives of this study are to determine (1) how often adequate child restraint information to determine age-appropriate use is documented after MVC; (2) the frequency of incorrect use of the child restraint when adequate details are documented; and (3) for those discharged from the ED with identified incorrect use, the frequency of provision of information on child passenger safety (CPS). METHODS: Retrospective chart review of visits of children younger than 13 years with an International Classification of Diseases, Tenth Revision code for MVC to an urban, academic, level 1 pediatric trauma center, from October 2015 to September 2018. Adequate documentation of child restraint use was defined as identification of location of the child in the car (front vs rear row), type of restraint used, and forward or rear facing for children 24 months or younger. RESULTS: A total of 165 visits qualified for inclusion. There was adequate documentation in 46% of visits. Of those, incorrect child restraint use was identified in 49%. Of discharged patients with incorrect use, 10% had documentation of provision of CPS information. CONCLUSIONS: Adequate details to determine proper age-appropriate restraint use are documented in only half of ED visits for MVC. Very few are given CPS instructions on discharge, even when incorrect use has been identified. Identification of incorrect restraint use in the ED is an opportunity for a teachable moment that is being underused.

Impact of CSF Meningitis and Encephalitis Panel on Resource Use for Febrile Well-Appearing Infants.

OBJECTIVES: To determine whether the BioFire FilmArray Meningitis/Encephalitis (ME) panel is associated with decreased resource use for febrile infants. The ME panel has a rapid turnaround time (1-2 hours) and may shorten length of stay (LOS) and antimicrobial use for febrile well-appearing infants. METHODS: Retrospective cohort study of febrile well-appearing infants ≤60 days with cerebrospinal fluid culture sent in the emergency department from July 2017 to April 2019. We examined the frequency of ME panel use and its relationship with hospital LOS and initiation and duration of antibiotics and acyclovir. We used nonparametric tests to compare median durations. RESULTS: The ME panel was performed for 85 (36%) of 237 infants. There was no difference in median hospital LOS for infants with versus without ME panel testing (42 hours, interquartile range [IQR] 36-52 vs 40 hours, IQR: 35-47, P = .09). More than 97% of infants with and without ME panel testing were initiated on antibiotics. Patients with ME panel were more likely to receive acyclovir (33% vs 18%; odds ratio: 2.2, 95%: confidence interval 1.2-4.0). There was no difference in median acyclovir duration with or without ME panel testing (1 hour, IQR: 1-7 vs 4.2 hours, IQR: 1-21, P = .10). When adjusting for potential covariates, these findings persisted. CONCLUSIONS: ME panel use was not associated with differences in hospital LOS, antibiotic initiation, or acyclovir duration in febrile well-appearing infants. ME panel testing was associated with acyclovir initiation.

Caregiver Perceptions Regarding Alternative Emergency Medical Services Dispositions for Children: A Cross-Sectional Survey Analysis.

INTRODUCTION: Emergency medical services (EMS) systems have developed alternative disposition processes for patients (including leaving the patient at the scene, using taxis, and transporting to clinics) vs taking patients directly to an emergency department (ED). Studies show that patients favorably support these alternative options but have not included the perspectives of caregivers of children. Our objective was to describe caregivers' views about these alternative disposition processes and analyze whether caregiver support is associated with sociodemographic factors. METHODS: We surveyed a convenience sample of caregivers in a pediatric ED. We asked caregivers 15 questions based on a previously validated survey. We then conducted logistic regressions to determine whether sociodemographic factors were associated with levels of support. RESULTS: We enrolled 241 caregivers. The median age of their children was five years. The majority of respondents were non-Hispanic Black (57%) and had public insurance (65%). We found that a majority of respondents supported all alternative EMS disposition options. The overall level of agreement for survey questions ranged from 51-93%. We grouped questions by theme: non-transport; alternative destinations; communication with EMS physician; communication with primary care physician and sharing records; restricted EMS role; and shared decision-making. Regression analyses for each theme found that race/ethnicity, public insurance, and patient age were not significantly associated with the level of support. CONCLUSION: Most caregivers were supportive of alternative EMS disposition options for children with low-acuity complaints. Support did not vary significantly by respondent race/ethnicity, public insurance status, or patient age.

Who's at Risk? A Prognostic Model for Severity Prediction in Pediatric Acute Pancreatitis.

OBJECTIVES: The aim of the study was to validate and optimize a severity prediction model for acute pancreatitis (AP) and to examine blood urea nitrogen (BUN) level changes from admission as a severity predictor. STUDY DESIGN: Patients from 2 hospitals were included for the validation model (Children's Hospital of the King's Daughters and Children's National Hospital). Children's Hospital of the King's Daughters and Cincinnati Children's Hospital Medical Center data were used for analysis of BUN at 24 to 48 hours. RESULTS: The validation cohort included 73 patients; 22 (30%) with either severe or moderately severe AP, combined into the all severe AP (SAP) group. Patients with SAP had higher BUN (P = 0.002) and lower albumin (P = 0.005). Admission BUN was confirmed as a significant predictor (P = 0.005) of SAP (area under the receiver operating characteristic [AUROC] 0.73, 95% confidence interval [CI] 0.60-0.86). Combining BUN (P = 0.005) and albumin (P = 0.004) resulted in better prediction for SAP (AUROC 0.83, 95% CI 0.72-0.94). A total of 176 AP patients were analyzed at 24-48 hours; 39 (22%) met criteria for SAP. Patients who developed SAP had a significantly higher BUN (P < 0.001) after 24 hours. Elevated BUN levels within 24 to 48 hours were independently predictive of developing SAP (AUROC: 0.76, 95% CI: 0.66-0.85). Patients who developed SAP had a significantly smaller percentage decrease in BUN from admission to 24 to 48 hours (P = 0.002). CONCLUSION: We externally validated the prior model with admission BUN levels and further optimized it by incorporating albumin. We also found that persistent elevation of BUN is associated with development of SAP. Our model can be used to risk stratify patients with AP on admission and again at 24 to 48 hours.