Pediatric Emergency Medicine Didactics and Simulation (PEMDAS): Pediatric Sedation Complications.

Introduction: Ketamine and propofol are commonly used agents for sedation in the pediatric emergency department (PED). While these medications routinely provide safe sedations, there are side effects providers should be able to recognize and manage. Currently, no pediatric sedation simulations exist in the literature. Methods: We created two sedation simulation cases for learners, including pediatric emergency medicine (PEM) fellows, working in the PED: case 1, a 12-year-old male with a shoulder dislocation requiring reduction under propofol sedation, and case 2, a forearm fracture requiring reduction under ketamine sedation. Learner actions included setting up equipment for sedations, dosing medications correctly, and managing complications. Additionally, in case 2, learners assigned an American Society of Anesthesiologists classification and selected the appropriate candidate for PED sedation from amongst three patients. A debrief followed the cases. Next, a didactic presentation reinforced concepts discussed in the debrief. Participants then completed an evaluation of the simulation. Results: Fifty-eight emergency medicine residents and PEM fellows across four sites at three institutions participated. Participants scored the simulations and the debriefing session on a 5-point Likert scale. Learners rated the scenario as clinically relevant (M = 4.37) and effective at improving their comfort level in caring for critically ill patients (M = 4.36). Learners felt the debrief provided valuable learning (M = 4.40) and was a safe learning environment (M = 4.50). Discussion: These cases can be utilized as resources for learners in any emergency department and can be tailored to any training background of learner providing sedation.

Behavioral Management of Children With Autism in the Emergency Department.

ABSTRACT: Autism spectrum disorder (ASD) is characterized by impaired social communication in conjunction with patterned behaviors. Often associated with emotional dysregulation, irritability, aggression, depression, and suicidality, ASD youth frequently present to the emergency department for behavioral and mental health evaluation. Psychiatric comorbidities, agitation, and depression are commonly encountered. During these visits, practitioners must thoughtfully consider organic etiologies for presenting symptoms, formulate plans to address risk of agitation, and understand how to effectively formulate disposition options in this patient population.

Reducing Admission for Anaphylaxis in a Pediatric Emergency Department Using a Clinical Decision Support Tool.

Introduction: Anaphylaxis is a life-threatening condition necessitating emergent management. However, the benefits of prolonged observation and indications for hospitalization are not well established. Through the implementation of a disposition-focused clinical decision support tool (CDST), this quality improvement initiative aimed to reduce hospitalization for low-risk patients presenting to the pediatric emergency department (PED) with anaphylaxis from 49% to ≤12% within 12 months of implementation. Methods: The intervention included patients 18 years and younger of age presenting with anaphylaxis to the PED. A multidisciplinary team identified a 2006 evidence-based guideline as a significant contributor to hospitalization. The updated guideline incorporated a disposition-focused CDST that stratified patients as low-risk or high-risk and recommended discharge of low-risk patients after a 4-hour observation period. The primary outcome measure was the percentage of low-risk patients hospitalized. Balancing measures included low-risk patient 72-hour return rate and PED length of stay for all comers. Secondary outcomes included a focused cost analysis. Results: Fifty-three children preintervention and 43 children postintervention presenting with anaphylaxis met low-risk criteria. Postimplementation, hospitalization of low-risk patients decreased from 49% to 7% (P < 0.0001). No low-risk patients returned in 72 hours for an anaphylaxis-related concern (P = 0.83). The median PED length of stay increased from 189 to 193 minutes (P < 0.0001). The median cost per low-risk encounter decreased by $377 (P = 0.013). Conclusions: After implementing an evidence-based disposition-focused CDST, hospitalization of low-risk patients presenting to the PED with anaphylaxis significantly decreased without an increase in 72-hour returns. In addition, patient encounters demonstrated cost savings.

The Presentation of a Fussy Infant With Bruising: Late-Onset Vitamin K Deficiency Bleeding.

Vitamin K plays an integral role in the clotting cascade. Deficiency, specifically in vulnerable neonates with insufficient stores, can lead to spontaneous bleeding and devastating effects. In this case, we report a young infant with late-onset vitamin K deficiency bleeding who did not receive vitamin K prophylaxis after birth. Initially presenting with bruising and fussiness, the patient was later found to have intracerebral hemorrhage with midline shift and uncal herniation. The infant was not a surgical candidate and died shortly thereafter. Laboratory studies confirmed the diagnosis of late-onset vitamin K deficiency bleeding as the cause of hemorrhage and death.

Hemoglobin Level at Stage 1 Discharge has No Impact on Inter-stage Growth and Stability in Single Ventricle Infants.

Hemoglobin levels (Hgb) of infants with a single ventricle (SV) are traditionally maintained high to maximize oxygen-carrying capacity during stage 1 palliation (S1P), stage 2 palliation (S2P), and between stages (IS). A single-center observational cohort study was performed to determine if red blood cell transfusion during the convalescent phase of the S1P (late S1P transfusion) to achieve higher Hgb is associated with benefits during the IS including improved growth and decreased acute medical events. 137 infants <1 year with SV with SIP undergoing care from January 2008 to June 2015 were retrospectively evaluated. 78 (57%) infants received a late S1P transfusion. Median Hgb at S1P discharge was 15.9 g/dL (IQR 14.7-17.1) and median Hgb S2P at admission was 15.3 g/dL (IQR 14-16.3). Median daily weight gain was 22 g/day during IS (IQR 17-26) and median daily length gain was 0.09 cm (IQR 0.06-0.11). Hgb at SIP discharge was not associated with IS growth or fewer IS acute events. However, late S1P transfusions were associated with illness severity at S1P and more complicated S1P care. Our data suggest that SV infants after S1P, who are steadily recovering, do not benefit from late transfusion to raise their hemoglobin level at discharge.

Reducing Blood Testing in Pediatric Patients after Heart Surgery: Proving Sustainability.

INTRODUCTION: Frequent blood testing increases risk of iatrogenic anemia, infection, and blood transfusion. This study describes 3 years of sustained blood testing reduction from a quality improvement (QI) initiative which began in 2011. METHODS: The cohort consisted of postop children whose surgery had a Risk Adjustment for Congenital Heart Surgery (RACHS) classification consecutively admitted to a tertiary Cardiac Intensive Care Unit. Data were collected for a 2010 preintervention, 2011 intervention, and 2012-13 postintervention periods, tabulating common laboratory studies per patient (labs/pt) and adjusted for length of stay (labs/pt/d). The QI initiative eliminated standing laboratory orders and changed to testing based on individualized patient condition. Adverse outcomes data were collected including reintubation, central line-associated bloodstream infections and hospital mortality. Safety was measured by the number of abnormal laboratory studies, electrolyte replacements, code blue events, and arrhythmias. RESULTS: A total of 1169 patients were enrolled (303 preintervention, 315 intervention, and 551 postintervention periods). The number of labs/pt after the QI intervention was sustained (38 vs. 23 vs. 23) and labs/pt/d (15 vs. 11 vs. 10). The postintervention group had greater surgical complexity (P = 0.002), were significantly younger (P = 0.002) and smaller (P = 0.008). Children with RACHS 3-4 classification in the postintervention phase had significant increased risk of reintubation and arrhythmias. CONCLUSIONS: After the implementation of a QI initiative, blood testing was reduced and sustained in young, complex children after heart surgery. This may or may not have contributed to greater reintubation and arrhythmias among patients with RACHS 3-4 category procedures.

Hematocrit Levels, Blood Testing, and Blood Transfusion in Infants After Heart Surgery.

OBJECTIVE: To determine whether judicious blood testing impacts timing or amount of packed RBC transfusions in infants after heart surgery. DESIGN: A retrospective study comparing before and after initiation of a quality improvement process. SETTING: A university-affiliated cardiac ICU at a tertiary care children's hospital. PATIENTS: Infants less than 1 year old with Risk Adjustment for Congenital Heart Surgery category 4, 5, 6, or d-transposition of great arteries (Risk Adjustment for Congenital Heart Surgery 3) consecutively treated during 2010 through 2013. INTERVENTION: A quality improvement process implemented in 2011 to decrease routine laboratory testing after surgery. MEASUREMENTS AND MAIN RESULTS: Fifty-two infants preintervention and 214 postintervention had similar age, weight, proportion of cyanotic lesions, and surgical complexity. Infants with single versus biventricular physiology were compared separately. The number of laboratory tests per patient adjusted for cardiac ICU length of stay (laboratory tests/patient/day) was significantly lower in postintervention populations for single and biventricular groups (9 vs 15 and 10 vs 15, respectively; p < 0.001). The proportion of single ventricle patients transfused post- and preintervention was not statistically different (72% vs 90%; p = 0.130). Transfusion in the biventricular groups was the same over time (65% vs 65%). Time to first transfusion was significantly longer in the postintervention single ventricle group (4 vs 1 d; p < 0.001), and was not statistically different in the biventricular patients (4 vs 7 d; p = 0.058). The median hematocrit level at first transfusion was significantly lower (37% vs 40%; p = 0.004) postintervention in the cyanotic population, but did not differ in the biventricular group (31% vs 31%; p = 0.840). CONCLUSION: In infants after heart surgery, blood testing targeted to individual needs significantly decreased the number of blood tests, but did not significantly decrease postoperative blood transfusion.