Hyperkalemia in a Hemolyzed Sample in Pediatric Patients: Repeat or Do Not Repeat?

OBJECTIVE: The aim of the study is to analyze whether repeat testing is necessary in healthy children presenting to a pediatric emergency department (ED) who are found to have hyperkalemia on a hemolyzed specimen. METHODS: A 5-year retrospective analysis of pediatric ED patients found to have elevated potassium values on laboratory testing of a sample reported to be hemolyzed. All patients aged 0 to 17 years who had an elevated potassium level after an intravenous draw resulted from a serum sample that was reported as hemolyzed during an ED visit were included in the study. RESULTS: One hundred eighty-seven patients with some degree of both hemolysis and hyperkalemia were included in the final analysis. The median age was 1.9 years of age. The most common race among all patients was White, followed by African American, and Asian. One hundred forty-five children had repeat sampling for hemolyzed hyperkalemia, 142 children, 97.9% (95% confidence interval, 95.6%-100%) had a normal potassium on repeat and 3 children, 2.1% (95% confidence interval, 0.0%-4.4%) had true hyperkalemia. The frequency of true hyperkalemia in our study population was 2% (3/145). All 3 of these patients had underlying conditions that would appropriately have raised clinician suspicion for hyperkalemia. CONCLUSIONS: It may be unnecessary to obtain repeat samples to confirm normal potassium in a hemolyzed sample with normal blood urea nitrogen and creatinine.

Accuracy and Interrater Reliability of Point-of-Care Ultrasonography Image Interpretation for Intussusception.

OBJECTIVES: The aim of this study was to determine the accuracy and interrater reliability of (1) point-of-care ultrasound (POCUS) image interpretation for identification of intussusception and (2) reliability of secondary signs associated with intussusception among experts compared with novice POCUS reviewers. METHODS: We conducted a planned secondary analysis of a prospective, convenience sample of children aged 3 months to 6 years who were evaluated with POCUS for intussusception across 17 international pediatric emergency departments between October 2018 and December 2020. A random sample of 100 POCUS examinations was reviewed by novice and expert POCUS reviewers. The primary outcome was identification of the presence or absence of intussusception. Secondary outcomes included intussusception size and the presence of trapped free fluid or echogenic foci. Accuracy was summarized using sensitivity and specificity, which were estimated via generalized mixed effects logistic regression. Interrater reliability was summarized via Light's κ statistics with bootstrapped standard errors (SEs). Accuracy and reliability of expert and novice POCUS reviewers were compared. RESULTS: Eighteen expert and 16 novice POCUS reviewers completed the reviews. The average expert sensitivity was 94.5% (95% confidence interval [CI], 88.6-97.5), and the specificity was 94.3% (95% CI, 90.3-96.7), significantly higher than the average novice sensitivity of 84.7% (95% CI, 74.3-91.4) and specificity of 80.4% (95% CI, 72.4, 86.7). κ was significantly greater for expert (0.679, SE 0.039) compared with novice POCUS reviewers (0.424, SE 0.044; difference 0.256, SE 0.033). For our secondary outcome measure of intussusception size, κ was significantly greater for experts (0.661, SE 0.038) compared with novices (0.397, SE 0.041; difference 0.264, SE 0.029). Interrater reliability was weak for expert and minimal for novice reviewers regarding the detection of trapped free fluid and echogenic foci. CONCLUSIONS: Expert POCUS reviewers demonstrate high accuracy and moderate interrater reliability when identifying intussusception via image interpretation and perform better than novice reviewers.

Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests.

STUDY OBJECTIVE: To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction. METHODS: We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings. RESULTS: The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI -0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23). CONCLUSION: Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.

Otherwise Healthy 15-Month-Old With Rapid-Onset Soft Tissue Swelling.

Necrotizing soft tissue infections are a serious medical emergency that involve necrosis within the soft tissue space including the dermis, subcutaneous tissue, superficial fascia, deep fascia, and muscle. Inciting factors include recent varicella infection, omphalitis, trauma, intramuscular injections, perianal trauma, and surgery. Unlike adult cases, children presenting with necrotizing soft tissue infections are more likely to be immunocompetent and without underlying chronic illnesses. Although rare in children, familiarity with the clinical manifestations of necrotizing soft tissue infections is essential for early diagnosis and surgical debridement, as significant mortality is associated with advanced disease.

Cat Inflicted Eye Injury in a Child.

Ocular injuries, especially corneal abrasions are a common phenomenon noted in the pediatric emergency department. Most of these are minor injuries and are well described in literature. However, there is very limited data on corneal cat scratch injuries and their management. We present the case of a 10-year-old female with cat scratch inflicted superficial corneal laceration. In addition to immediate identification of the injury, it is essential to investigate and evaluate the depth of the ocular injury for prompt management, including route of antibiotics, need for an immediate surgical intervention and future follow-up.