Integrating network pharmacology and in silico analysis deciphers Withaferin-A's anti-breast cancer potential via hedgehog pathway and target network interplay.

This study examines the remarkable effectiveness of Withaferin-A (WA), a withanolide obtained from Withania somnifera (Ashwagandha), in encountering the mortiferous breast malignancy, a global peril. The predominant objective is to investigate WA's intrinsic target proteins and hedgehog (Hh) pathway proteins in breast cancer targeting through the application of in silico computational techniques and network pharmacology predictions. The databases and webtools like Swiss target prediction, GeneCards, DisGeNet and Online Mendelian Inheritance in Man were exploited to identify the common target proteins. The culmination of the WA network and protein-protein interaction network were devised using Stitch and String web tools, through which the drug-target network of 30 common proteins was constructed employing Cytoscape-version 3.9. Enrichment analysis was performed by incorporating Gprofiler, Metascape and Cytoscape plugins. David compounded the Gene Ontology and Kyoto Encyclopedia of Genes and Genomes, and enrichment was computed through bioinformatics tools. The 20 pivotal proteins were docked harnessing Glide, Schrodinger Suite 2023-2. The investigation was governed by docking scores and affinity. The shared target proteins underscored the precise Hh and WA network roles with the affirmation enrichment P-value of <0.025. The implications for hedgehog and cancer pathways were profound with enrichment (P < 0.01). Further, the ADMET and drug-likeness assessments assisted the claim. Robust interactions were noticed with docking studies, authenticated through molecular dynamics, molecular mechanics generalized born surface area scores and bonds. The computational investigation emphasized WA's credible anti-breast activity, specifically with Hh proteins, implying stem-cell-level checkpoint restraints. Rigorous testament is imperative through in vitro and in vivo studies.

Azithromycin therapy in infants hospitalized for respiratory syncytial virus bronchiolitis: Airway matrix metalloproteinase-9 levels and subsequent recurrent wheeze.

BACKGROUND: Early life respiratory syncytial virus (RSV) bronchiolitis is a significant risk factor for childhood asthma. In vitro and in vivo studies suggested that decreasing levels of airway matrix metalloproteinase (MMP)-9 during RSV bronchiolitis may be associated with clinical benefits. OBJECTIVE: To investigate whether azithromycin therapy during severe RSV bronchiolitis reduces upper airway MMP-9 levels, whether upper airway MMP-9 levels correlate with upper airway interleukin IL-8 levels, and whether MMP-9 level reduction is associated with reduced post-RSV recurrent wheeze (RW). METHODS: A total of 200 otherwise healthy 1- to 18-month-old infants hospitalized with RSV bronchiolitis were randomized into a double-blind, placebo-controlled trial of oral azithromycin (10 mg/kg daily for 7 days followed by 5 mg/kg daily for 7 days) or placebo. Infants were followed for 2 to 4 years for the outcome of RW (3 or more wheezing episodes). Nasal lavage samples for MMP-9 levels were obtained at baseline, day 14 (end of the study treatment), and after 6 months. RESULTS: Upper airway MMP-9 levels were highly correlated with IL-8 levels at all 3 time points: randomization, day 14, and 6 months (r = 0.80; P < .0001 for all time points). MMP-9 levels were similar between treatment groups at randomization, were lower on day 14 among children treated with azithromycin (P = .0085), but no longer different after 6 months. MMP-9 levels at baseline and change from baseline to day 14 were not associated with the development of RW (P = .49, .39, respectively). CONCLUSION: Azithromycin therapy in children hospitalized with RSV bronchiolitis had a short-term anti-inflammatory effect in reducing upper airway MMP-9 levels. However, the reduction in MMP-9 levels did not relate to subsequent RW post-RSV. TRIAL REGISTRATION: This study is a secondary analysis of the Azithromycin to Prevent Wheezing following severe RSV bronchiolitis-II clinical trial registered at Clinicaltrials.gov (NCT02911935).

Evaluating the Proportion of Low-Value Blood Cultures Obtained in a Pediatric Emergency Department.

BACKGROUND: Existing literature suggests that for some pediatric conditions, blood cultures may be of low value in specific clinical circumstances. The goals of our study were to: 1) identify common pediatric illnesses and define criteria for low-value blood cultures in children aged from 91 days to 19 years, 2) apply these criteria retrospectively to identify the patients in our emergency department (ED) who had low-value blood cultures obtained, and 3) describe this cohort and assess the proportion of true bacteremia in low-value blood cultures. METHOD: The study team reviewed the literature and developed consensus criteria to identify conditions in which blood cultures were of low value for our study population. The criteria were applied retrospectively to well-appearing patients aged from 91 days to 19 years, without a central venous catheter, and evaluated in our ED with a peripheral blood culture from June 2018 to April 2020. Children admitted to the intensive care/hematology-oncology/cardiology/pulmonary units, those transferred from our ED to an outside facility, who transferred to our ED due to a positive blood culture from an outside facility, and repeat visits of a patient within 30 days from a previous visit were excluded from the study. After chart review, children with fever for 7 days or more, who were unvaccinated, immunosuppressed, had implanted devices, had a complex medical history, or had provider concerns for bacteremia/sepsis were excluded. RESULTS: The study population consisted of 1436 children. Children at risk for bacteremia (n = 718) were excluded. Four hundred twenty-four children had discharge diagnoses not included in our study. There were 294 (20.5%) patients who had low-value cultures per our study criteria. Nine children (9/294, 3.1%) had false-positive blood cultures, and three (3/294, 1.0%) had true-positive blood cultures. CONCLUSIONS: We identified a cohort of patients in our ED with blood cultures obtained when available literature indicates they were of low value.

Enterovirus D68 Surveillance, St. Louis, Missouri, USA, 2016.

A fall 2016 outbreak of enterovirus D68 infection in St. Louis, Missouri, USA, had less effect than a fall 2014 outbreak on hospital census, intensive care unit census, and hospitalization for a diagnosis of respiratory illness. Without ongoing surveillance and specific testing, these cases might have been missed.

Intravenous Versus Oral Antibiotics for the Prevention of Treatment Failure in Children With Complicated Appendicitis: Has the Abandonment of Peripherally Inserted Catheters Been Justified?

OBJECTIVE: To compare treatment failure leading to hospital readmission in children with complicated appendicitis who received oral versus intravenous antibiotics after discharge. BACKGROUND: Antibiotics are often employed after discharge to prevent treatment failure in children with complicated appendicitis, although existing studies comparing intravenous and oral antibiotics for this purpose are limited. METHODS: We identified all patients aged 3 to 18 years undergoing appendectomy for complicated appendicitis, who received postdischarge antibiotics at 35 childrens hospitals from 2009 to 2012. Discharge codes were used to identify study subjects from the Pediatric Health Information System database, and chart review confirmed eligibility, treatment assignment, and outcomes. Exposure status was based on outpatient antibiotic therapy, and analysis used optimal and full matching methods to adjust for demographic and clinical characteristics. Treatment failure (defined as an organ-space infection) requiring inpatient readmission was the primary outcome. Secondary outcomes included revisits from any cause to either the inpatient or emergency department setting. RESULTS: In all, 4579 patients were included (median: 99/hospital), and utilization of intravenous antibiotics after discharge ranged from 0% to 91.7% across hospitals. In the matched analysis, the rate of treatment failure was significantly higher for the intravenous group than the oral group [odds ratio (OR) 1.74, 95% confidence interval (CI) 1.05-2.88; risk difference: 4.0%, 95% CI 0.4-7.6%], as was the rate of all-cause revisits (OR 2.11, 95% CI 1.44-3.11; risk difference: 9.4%, 95% CI 4.7-14.2%). The rate of peripherally inserted central catheter line complications was 3.2% in the intravenous group, and drug reactions were rare in both groups (intravenous: 0.7%, oral: 0.5%). CONCLUSIONS: Compared with oral antibiotics, use of intravenous antibiotics after discharge in children with complicated appendicitis was associated with higher rates of both treatment failure and all-cause hospital revisits.

Procedural sedation for diagnostic imaging in children by pediatric hospitalists using propofol: analysis of the nature, frequency, and predictors of adverse events and interventions.

OBJECTIVE: To evaluate the nature, frequency, and predictors of adverse events during the use of propofol by pediatric hospitalists. STUDY DESIGN: We reviewed 1649 charts of patients sedated with propofol by pediatric hospitalists at St Louis Children's Hospital between January 2005 and September 2009. RESULTS: Hospitalists were able to complete 1633 of the 1649 sedations reviewed (99%). Major complications included 2 patients with aspiration and 1 patient intubated to complete the study. We observed a 74% reduction in the number of patients with respiratory events and airway interventions from 2005 to 2009. Predictors of respiratory events were history of snoring (OR, 2.40; 95% CI, 1.52-3.80), American Society of Anesthesiologists (ASA) physical status classification of ASA 3 (OR, 2.30; 95% CI, 1.22-4.33), age >12 years (OR, 4.01; 95% CI, 2.02-7.98), premedication with midazolam (OR, 1.85; 95% CI, 1.15-2.98), and use of adjuvant glycopyrrolate (OR, 4.70; 95% CI, 2.35-9.40). All except ASA 3 status were also predictors for airway intervention. There was a decline in the prevalence of all of these predictors over the study years (P < .05) except for use of glycopyrrolate. CONCLUSION: Our pediatric hospitalists implemented a successful propofol sedation program that realized a 74% reduction in respiratory events and airway interventions between 2005 and 2009. Decreased prevalence of the predictors of adverse events that we identified likely contributed to this reduction.

Azithromycin to Prevent Recurrent Wheeze Following Severe Respiratory Syncytial Virus Bronchiolitis.

BACKGROUND: Early-life severe respiratory syncytial virus (RSV) bronchiolitis is a risk factor for childhood asthma. Because azithromycin may attenuate airway inflammation during RSV bronchiolitis, we evaluated whether it would reduce the occurrence of post-RSV recurrent wheeze. METHODS: We prospectively enrolled 200 otherwise healthy 1- to 18-month-old children hospitalized with RSV bronchiolitis in this single-center, double-blind, placebo-controlled study and randomly assigned them to receive oral azithromycin (10 mg/kg daily for 7 days, followed by 5 mg/kg daily for 7 days) or placebo. Randomization was stratified by recent open-label antibiotic use. The primary outcome was the occurrence of recurrent wheeze, defined as a third episode of post-RSV wheeze over the following 2 to 4 years. RESULTS: As an indication of the biologic activity of azithromycin, nasal wash interleukin-8 levels, at day 14 after randomization, were lower among azithromycin-treated participants (P<0.01). Despite evidence of biologic activity, azithromycin did not reduce the risk of post-RSV recurrent wheeze (47% in the azithromycin group vs. 36% in the placebo group; adjusted hazard ratio, 1.45; 95% confidence interval [CI], 0.92 to 2.29; P=0.11). Azithromycin also did not modify the risk of recurrent wheeze among participants already receiving other antibiotic treatment at the time of enrollment (hazard ratio, 0.94; 95% CI, 0.43 to 2.07). There was a potential signal among antibiotic-naïve participants who received azithromycin to have an increased risk of recurrent wheeze (hazard ratio, 1.79; 95% CI, 1.03 to 3.1). CONCLUSIONS: Azithromycin therapy for 14 days during acute severe RSV bronchiolitis did not reduce recurrent wheeze occurrence over the following 2 to 4 years. Our data suggest no benefit of azithromycin administration with the goal of preventing recurrent wheeze in later life. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT02911935.).

Use of a Sterile Collection Process to Reduce Contaminated Peripheral Blood Cultures.

BACKGROUND: Contaminated blood cultures pose a significant burden by subjecting children to unnecessary testing, procedures, and antibiotics and increasing health care costs. The aim of our quality improvement (QI) initiative was to decrease the percentage of contaminated peripheral blood cultures in our pediatric emergency department (ED) from an average of 6.7% to <3% over a 16-month period. METHODS: The QI initiative was implemented in the pediatric ED of a tertiary care children's hospital. Interventions included change of the peripheral blood culture collection from a clean to a sterile process, nursing education, and individualized feedback. The primary outcome measure was the percentage of contaminated peripheral blood cultures. The process measure was the percentage of nurses who completed 75% to 100% of the steps of the sterile collection process, as measured by self-reporting in audit cards. The balancing measures were time from antibiotic ordering to time of administration and ED length of stay. RESULTS: We decreased the percentage of contaminated peripheral blood cultures threefold from a baseline (June 2, 2018, to December 31, 2018) of 6.7% to 2.1% during the intervention period (January 1, 2019, to April 30, 2020). Ninety-eight percent of nurses who completed audit cards reported performing 75% to 100% of the steps of the new sterile process. There was no significant difference in the average time from antibiotic ordering to antibiotic administration or ED length of stay between the baseline and intervention periods. CONCLUSIONS: Use of a sterile blood culture collection process, in addition to nursing education and individualized feedback, is an effective method to decrease peripheral blood culture contamination rates in a pediatric ED.

The azithromycin to prevent wheezing following severe RSV bronchiolitis-II clinical trial: Rationale, study design, methods, and characteristics of study population.

Severe respiratory syncytial virus (RSV) bronchiolitis in early life is a significant risk factor for future recurrent wheeze (RW) and asthma. The goal of the Azithromycin to Prevent Wheezing following severe RSV bronchiolitis II (APW-RSV II) clinical trial is to evaluate if azithromycin treatment in infants hospitalized with RSV bronchiolitis reduces the occurrence of RW during the preschool years. The APW-RSV II clinical trial is a double-blind, placebo-controlled, parallel-group, randomized trial, including otherwise healthy participants, ages 30 days-18 months, who are hospitalized due to RSV bronchiolitis. The study includes an active randomized treatment phase with azithromycin or placebo for 2 weeks, and an observational phase of 18-48 months. Two hundred participants were enrolled during three consecutive RSV seasons beginning in the fall of 2016 and were randomized to receive oral azithromycin 10 mg/kg/day for 7 days followed by 5 mg/kg/day for an additional 7 days, or matched placebo. The study hypothesis is that in infants hospitalized with RSV bronchiolitis, the addition of azithromycin therapy to routine bronchiolitis care would reduce the likelihood of developing post-RSV recurrent wheeze (≥3 episodes). The primary clinical outcome is the occurrence of a third episode of wheezing, which is evaluated every other month by phone questionnaires and during yearly in-person visits. A secondary objective of the APW-RSV II clinical trial is to examine how azithromycin therapy changes the upper airway microbiome composition, and to determine if these changes are related to the occurrence of post-RSV RW. Microbiome composition is characterized in nasal wash samples obtained before and after the study treatments. This clinical trial may identify the first effective intervention applied during severe RSV bronchiolitis to reduce the risk of post-RSV RW and ultimately asthma.

Use of Peer Comparison, Provider Education, and Electronic Medical Record Triggers to Increase Influenza Vaccination Rates in Hospitalized Children.

BACKGROUND: The American Academy of Pediatrics recommends annual influenza vaccination for all children 6 months and older, yet only 59% of children nationally received the vaccine during the 2014-2016 influenza seasons. Of these, only 4% received the vaccine in a hospital setting. The goal of this quality improvement (QI) initiative was to increase influenza vaccination status at discharge at least twofold in children admitted to our hospital during the 2017-2018 influenza season compared with the 2016-2017 season. METHODS: The QI initiative was conducted in the inpatient units at a tertiary care children's hospital. Interventions included electronic medical record triggers, provider education, and peer comparison. The primary outcome measure was the percentage of children discharged from the hospital with at least 1 dose of the influenza vaccine received either at the hospital or before admission. Queries about the influenza vaccination status of children were used as a process measure. Length of stay was used as a balancing measure. RESULTS: The percentage of hospitalized children discharged with at least 1 dose of the vaccine increased 4.7-fold during the QI initiative (46%) compared with baseline (10%). There was a fourfold increase in parental query about the influenza vaccination status of their children (68%) during the QI initiative compared with the baseline period (16%). No significant difference occurred in the median length of stay among patients admitted during the QI initiative versus the baseline period. CONCLUSIONS: We increased influenza vaccination status among children admitted to our hospital using electronic medical record triggers, provider education, and peer comparison.

Impact of Contaminated Blood Cultures on Children, Families, and the Health Care System.

BACKGROUND: Contaminated blood cultures pose a significant burden. We sought to determine the impact of contaminated peripheral blood cultures on patients, families, and the health care system. METHODS: In this retrospective case-control study from January 1, 2014, to December 31, 2017, we compared the hospital course, return visits and/or admissions, charges, and length of stay of patients with contaminated peripheral blood cultures (case patients) with those of patients with negative cultures (controls). Patients were categorized into those evaluated and discharged from the emergency department (ED) (ED patients) and those who were hospitalized (inpatients). RESULTS: A total of 104 ED case patients were matched with 208 ED control patients. A total of 343 case inpatients were matched with 686 inpatient controls. There was no significant difference between case and control patient demographics, ED, or hospital course at presentation. Fifty-five percent of discharged ED patients returned to the hospital for evaluation and/or admission versus 4% of controls. There was a significant (P < .0001) increase in repeat blood cultures (43% vs 1%), consultations obtained (21% vs 2%), cerebrospinal fluid studies (10% vs 0%), and antibiotic administration (27% vs 1%) in ED patients compared with controls. Each ED patient requiring revisit to the hospital incurred, on average, $4660 in additional charges. There was a significant (P < .04) increase in repeat blood cultures (57% vs 7%), consultations obtained (35% vs 28%), broadening of antibiotic coverage (18% vs 11%), median length of stay (75 vs 64 hours), and median laboratory charges ($3723 vs $3296) in case inpatients compared with controls. CONCLUSIONS: Contaminated blood cultures result in increased readmissions, testing and/or procedures, length of stay, and hospital charges in children.

Quality Improvement Initiative to Increase the Use of Nasogastric Hydration in Infants With Bronchiolitis.

BACKGROUND AND OBJECTIVES: Intravenous (IV) hydration is used primarily in children with bronchiolitis at our institution. Because nasogastric (NG) hydration can provide better nutrition, the goal of our quality improvement (QI) initiative was to increase the rate of NG hydration in eligible children 1 to 23 months old with bronchiolitis by 20% over 6 months. METHODS: We used Plan-Do-Study-Act cycles to increase the use of NG hydration in eligible children. Interventions included educational and system-based changes and sharing parental feedback with providers. Chart reviews were performed to identify the rates of NG hydration, which were plotted over time in a statistical process control p chart. The balancing measure was the rate of complications in children with NG versus IV hydration. RESULTS: Two hundred and ninety-three children who were hospitalized with bronchiolitis needed supplemental hydration during the QI initiative (January 2016-April 2016). Ninety-one children were candidates for NG hydration, and 53 (58%) received NG hydration. The rates of NG hydration increased from a baseline of 0% pre-QI bronchiolitis season (January 2015-April 2015) to 58% during the initiative. There was no aspiration and no accidental placement of the NG tube into a child's airway. Nine patients (17%) in the NG group had a progression of disease requiring nil per os status, and 6 of these were transferred to the PICU whereas none of those in the IV group were transferred to the PICU. Post-QI initiative, the majority of nurses (63%) and physicians (95%) stated that they are more likely to consider NG hydration in children with bronchiolitis. CONCLUSIONS: We successfully increased the rates of NG hydration in eligible children with bronchiolitis by using educational and system-based interventions.

Clinical Characterization of Children Presenting to the Hospital with Enterovirus D68 Infection During the 2014 Outbreak in St. Louis.

BACKGROUND: The largest known outbreak of enterovirus D68 (EV-D68) infections occurred during 2014. The goal of our study is to characterize the illness severity and clinical presentation of children infected with EV-D68 in comparison to non-EV-D68-human rhinoviruses/enteroviruses (HRV/EV). METHOD: Our study is a retrospective analysis of severity level, charges and length of stay of children who presented to St. Louis Children's Hospital from August 8, 2014 to October 31, 2014 and tested positive for EV-D68 in comparison to non-EV-D68-HRV/EV-infected patients. Chart review was performed for all EV-D68-infected patients and age and severity matched non-EV-D68-HRV/EV-infected patients. RESULT: There was a striking increase in hospital census in August of 2014 in our hospital with simultaneous increase in the number of patients with EV-D68 infection. There was no significant difference in severity of illness, length of stay or total charges between EV-D68-infected and non-EV-D68-HRV/EV-infected children. EV-D68 infection was characterized by presenting complaints of difficulty breathing (80%) and wheezing (67%) and by findings of tachypnea (65%), wheezing (71%) and retractions (65%) on examination. The most common interventions were albuterol (79%) and corticosteroid (68%) treatments, and the most common discharge diagnosis was asthma exacerbation (55%). CONCLUSION: EV-D68 caused a significant outbreak in 2014 with increased hospital admissions and associated increased charges. There was no significant difference in severity of illness caused by EV-D68 compared with non-EV-D68-HRV/EV infections suggesting that the impact from EV-D68 was because of increased number of infected children presenting to the hospital and not necessarily due to increased severity of illness.

Rates of Complications After Newborn Circumcision in a Well-Baby Nursery, Special Care Nursery, and Neonatal Intensive Care Unit.

OBJECTIVE/METHOD: To determine rates of complications after newborn circumcision by performing a retrospective chart review of patients circumcised at a well-baby nursery, neonatal intensive care units (NICU), and special care nursery (SCN) from 2007 to 2012. RESULT: A total of 5129 babies (73%) were circumcised at the well-baby nursery and 1909 babies (27%) at the NICU and SCN. Forty-seven patients (0.67%, 95% CI 0.49% to 0.89%) had circumcision-related complications: 5 (0.07%) patients with acute and 42 (0.6%) with late complications. Babies in the NICU/SCN had increased odds of complication (OR 4.00, 95% CI 2.23 to 7.19) compared with those in well-baby nursery. There were increased odds of complications in babies with Caucasian ethnicity (OR 2.60, 95% CI 1.48 to 4.89) compared with African American babies and in babies with private insurance (OR 4.0, 95% CI 2.1 to 7.5) compared with nonprivate insurance. CONCLUSIONS: The rates of complications after newborn circumcisions were low. Babies in the NICU/SCN had increased odds of complication.

Variation in Procedural Sedation Practices Among Children's Hospitals.

BACKGROUND AND OBJECTIVE: Children often need procedural sedation for painful procedures. There are few data on type of provider, site of sedation, and agents used for procedural sedation in hospitals across the nation. The objective was to determine procedural sedation practices for hospitalized children outside the PICU and emergency department. METHODS: Surveys were sent to 89 pediatric hospitalist (PH) leaders in hospitals belonging to the Child Health Corporation of America or the National Association of Children's Hospitals and Related Institutions. RESULTS: We received responses from 56 PHs (63%), of whom 49 (55%) completed the survey. PHs provided sedation in 18 hospitals. Provider, setting, and agents used for procedural sedation varied. The primary providers of procedural sedation for abscess incision and drainage, renal biopsy, joint aspiration, computed tomography, and MRI were anesthesiologists. A significantly greater percentage of hospitals where PHs did not provide procedural sedation used the operating room for abscess incision and drainage compared with hospitals where PHs provided procedural sedation (63% vs 28%, respectively). Postoperative/abscess dressing change, vesicocystourethrogram, and ≥1 painful procedure were performed without sedation in significantly greater percentage of hospitals where PHs did not provide procedural sedation compared with hospitals where PHs provided procedural sedation. CONCLUSIONS: There is variability in sedation practices in hospitals across the nation, which affects patient care and use of resources such as the operating room. In hospitals where PHs provide procedural sedation, there is less operating room use and fewer painful procedures for which no sedation is provided.

Procedural sedation by pediatric hospitalists: analysis of the nature and incidence of complications during ketamine and nitrous oxide sedation.

OBJECTIVE: The goal of this study was to determine the nature and rate of complications during procedural sedation by pediatric hospitalists (PH) using ketamine and nitrous oxide (N2O). METHODS: This study was a retrospective review and analysis of a quality improvement database for sedations performed by PH at St Louis Children's Hospital from February 2007 to February 2013. Information was obtained on sedations performed and reported in the quality improvement database by PH over this time period using ketamine and N2O. RESULTS: PH performed 8870 sedations from 2007 to 2013, 60.2% using ketamine and 39.8% using N2O. Procedural completion rates were >99%; 0.12% of sedations were not completed due to inadequate sedation, and sedation level was not achieved in 1.71% of sedations. There were no occurrences of death, need for cardiopulmonary resuscitation, unplanned intubation, or emergency anesthesia consultation. The only major complications were 4 unplanned admissions, 2 each with ketamine and N2O. With ketamine, the 2 highest rates of complications were airway repositioning (3.99%) and nausea and/or vomiting (2.98%). With N2O, the 2 highest complication rates were nausea and/or vomiting (8.50%) and airway repositioning (1.10%). Respiratory and cardiovascular events were more frequently encountered with ketamine, whereas nausea/vomiting, sedation level not achieved, and inadequate sedation resulting in procedure not completed occurred more frequently with N2O. CONCLUSIONS: PH at St Louis Children's Hospital successfully provided sedation by using ketamine and N2O with low rates of complications for a variety of procedures.

A proposed mechanism to assess knowledge of pediatric hospitalists to identify and manage rare events during procedural sedation.

OBJECTIVE: The goal of this study was to assess the knowledge of pediatric hospitalists (PHs) in identifying and managing rare events during procedural sedation (PS) with ketamine and nitrous oxide (N2O). METHODS: A Web-based survey with multiple choice questions and case scenarios was used to determine the knowledge of PHs in identifying infrequent contraindications and managing laryngospasm, a rare life-threatening complication during PS. The survey was sent to all PHs at St Louis Children's Hospital. RESULTS: Forty percent of experienced PHs (>50 sedation procedures performed) and 5% of inexperienced PHs (<50 sedation procedures performed) identified all 4 ketamine contraindications. Twenty-one percent of experienced PHs and 4% of inexperienced PHs identified all 6 N2O contraindications. Ninety-five percent of PHs identified presence of laryngospasm in a case scenario. As the patient in the case scenario progressed from partial to complete laryngospasm, 84% and 82% of PHs chose either the preferred or acceptable strategy to manage the patient. With further deterioration in the patient's status in the scenario, 66% and 71% of PHs chose either the preferred or acceptable strategy to manage the patient. The preferred strategy at each step is one that attempted the least invasive maneuver to manage the patient. There was no significant difference between experienced and inexperienced PHs in the management of laryngospasm. CONCLUSIONS: Knowledge gaps exist among PHs regarding contraindications for ketamine and N2O that are infrequently encountered in patients and for the management of laryngospasm, a rare adverse event with ketamine. Ongoing teaching tools are necessary to assess and maintain the knowledge of sedation providers regarding rare events during PS that can improve their proficiency.