Pilot Trial of the Performance of Electrocardiogram in the Evaluation of Childhood Syncope in the Emergency Department.

INTRODUCTION: The electrocardiogram (ECG) is widely considered a standard part of the syncope workup, and it is recommended to be obtained in all children with syncope. Nevertheless, a newly recognized cardiac cause is rare and largely incidental findings are commonly seen, leading to unneeded worry, additional testing, and added health care costs. OBJECTIVE: The aim of this study was to analyze the performance of ECG in the evaluation of childhood syncope in the emergency department (ED). METHODS: This was a descriptive, retrospective, multicenter pilot study of patients younger than 14 years diagnosed with syncope in which an ECG was obtained in the ED in 2015 and 2016. RESULTS: During the study period, 440 patients were diagnosed with syncope, of which an ECG was performed in 197 (44.7%). Of these, 64 (32.5%) were related to any concerning features associated with the event, including 33 occurring during or after physical exertion. No major alteration of the ECG was noted, and the ECG revealed multiple minor findings in 38 (19.2%; 95% confidence interval, 14.4-25.4). Twenty-five (12.7%) children were referred to a pediatric cardiologist. No patient was noted to have a previously undiagnosed cardiac cause of syncope. CONCLUSIONS: A newly recognized cardiac cause is extremely rare among children evaluated for syncope in the ED, and ECG is not systematically obtained in this population. Larger studies are needed to clarify if it is possible to identify a group of children that can be safely managed without a systematic ECG. Best practices need to be better implemented for an adequate management of pediatric syncope in the ED.

Pilot Clinical Trial of High-Flow Oxygen Therapy in Children with Asthma in the Emergency Service.

OBJECTIVES: To assess the efficacy of high-flow nasal cannula (HFNC) oxygen therapy and safety in children with asthma and moderate respiratory failure in the emergency department (ED). STUDY DESIGN: This was a prospective randomized pilot trial of children (aged 1-14 years) presenting to a tertiary academic pediatric ED with moderate-to-severe asthma exacerbations between September 2012 and December 2015. Patients with a pulmonary score (PS) ≥6 or oxygen saturation <94% with a face mask despite initial treatment (salbutamol/ipratropium bromide and corticosteroids) were randomized to HFNC or to conventional oxygen therapy. Pharmacologic treatment was at the discretion of attending physicians. The primary outcome was a decrease in PS ≥2 in the first 2 hours. Secondary outcomes included disposition, length of stay, and need for additional therapies. RESULTS: We randomly allocated 62 children to receive either HFNC (n = 30) or standard oxygen therapy (n = 32). Baseline patient characteristics were similar in the 2 groups. At 2 hours after the start of therapy, PS had decreased by ≥2 points in 16 patients in the HFNC group (53%) compared with 9 controls (28%) (P = .01). Between-group differences in disposition, length of stay, and need for additional therapies were not significant. No side effects were reported. CONCLUSION: HFNC appears to be superior to conventional oxygen therapy for reducing respiratory distress within the first 2 hours of treatment in children with moderate-to-severe asthma exacerbation refractory to first-line treatment. Further studies are needed to demonstrate its overall efficacy in the management of asthma and respiratory failure in the ED. TRIAL REGISTRATION: EudraCT: 2012-001771-36.

Relationship between hyperglycemia, hormone disturbances, and clinical evolution in severely hyperglycemic post surgery critically ill children: an observational study.

BACKGROUND: To study hormonal changes associated with severe hyperglycemia in critically ill children and the relationship with prognosis and length of stay in intensive care. METHODS: Observational study in twenty-nine critically ill children with severe hyperglycemia defined as 2 blood glucose measurements greater than 180 mg/dL. Severity of illness was assessed using pediatric index of mortality (PIM2), pediatric risk of mortality (PRISM) score, and pediatric logistic organ dysfunction (PELOD) scales. Blood glucose, glycosuria, insulin, C-peptide, cortisol, corticotropin, insulinlike growth factor-1, growth hormone, thyrotropin, thyroxine, and treatment with insulin were recorded. ß-cell function and insulin sensitivity and resistance were determined on the basis of the homeostatic model assessment (HOMA), using blood glucose and C-peptide levels. RESULTS: The initial blood glucose level was 249 mg/dL and fell gradually to 125 mg/dL at 72 hours. Initial ß-cell function (49.2%) and insulin sensitivity (13.2%) were low. At the time of diagnosis of hyperglycemia, 50% of the patients presented insulin resistance and ß-cell dysfunction, 46% presented isolated insulin resistance, and 4% isolated ß-cell dysfunction. ß-cell function improved rapidly but insulin resistance persisted. Initial glycemia did not correlate with any other factor, and there was no relationship between glycemia and mortality. Patients who died had higher cortisol and growth hormone levels at diagnosis. Length of stay was correlated by univariate analysis, but not by multivariate analysis, with C-peptide and glycemic control at 24 hours, insulin resistance, and severity of illness scores. CONCLUSIONS: Critically ill children with severe hyperglycemia initially present decreased ß-cell function and insulin sensitivity. Nonsurvivors had higher cortisol and growth hormone levels and developed hyperglycemia later than survivors.

Measurement of cardiac output in children by bioreactance.

The objective of this study was to evaluate a new bioreactance method for noninvasive cardiac output (CO) measurement (NICOM) in children. Ten patients between 1 and 144 months of age and with no hemodynamic disturbances were studied. Using bioreactance, heart rate (HR), mean arterial pressure (MAP), and cardiac index (CI) measurements were made every 6-8 h. CI was 2.4 ± 1.03 l/min/1.73 m(2) (range 1-4.9 l/min/1.73 m(2)); There were significant correlations between CI and age (r = 0.50, P = 0.003), weight (r = 0.66, P < 0.001), and MAP (r = 0.369, P = 0.037). Significant differences in CI (P < 0.001) were detected between children weighing <10 kg (1.9 ± 0.73 l/min/1.73 m(2); range 1-3.2), 10-20 kg (2.07 ± 0.7 l/min/1.73 m(2); range 1-3.6), and >20 kg (3.7 ± 0.8 l/min/1.73 m(2); range 2.4-4.9). We conclude that the CI measured by bioreactance in children varies with the age and weight of the patients and is lower than the normal range in a large percentage of measurements. These data suggest that this method is not useful for evaluating CI in small children.

Complications of continuous renal replacement therapy in critically ill children: a prospective observational evaluation study.

INTRODUCTION: Continuous renal replacement therapy (CRRT) frequently gives rise to complications in critically ill children. However, no studies have analyzed these complications prospectively. The purpose of this study was to analyze the complications of CRRT in children and to study the associated risk factors. METHODS: A prospective, single-centre, observational study was performed in all critically ill children treated using CRRT in order to determine the incidence of complications related to the technique (problems of catheterization, hypotension at the time of connection to the CRRT, hemorrhage, electrolyte disturbances) and their relationship with patient characteristics, clinical severity, need for vasoactive drugs and mechanical ventilation, and the characteristics of the filtration techniques. RESULTS: Of 174 children treated with CRRT, 13 (7.4%) presented problems of venous catheterization; this complication was significantly more common in children under 12 months of age and in those weighing less than 10 kg. Hypotension on connection to CRRT was detected in 53 patients (30.4%). Hypotension was not associated with any patient or CRRT characteristics. Clinically significant hemorrhage occurred in 18 patients (10.3%); this complication was not related to any of the variables studied. The sodium, chloride, and phosphate levels fell during the first 72 hours of CRRT; the changes in electrolyte levels during the course of treatment were not found to be related to any of the variables analyzed, nor were they associated with mortality. CONCLUSIONS: CRRT-related complications are common in children and some are potentially serious. The most common are hypotension at the time of connection and electrolyte disturbances. Strict control and continuous monitoring of the technique are therefore necessary in children on CRRT.

Hyponatremic dehydration as a presentation of cystic fibrosis.

BACKGROUND: The purpose of this study is to present a case report of a child with hyponatremic dehydration diagnosed after CF and to review the cases of 13 patients with CF who had the same initial presentation in our hospital. METHODS: This report reviewed the clinical records of children diagnosed with CF to ascertain the prevalence of metabolic alkalosis with electrolyte depletion as the presentation of CF. It also used sweat tests to diagnose a child with CF. RESULTS: The laboratory tests of a 12-month-old girl presented 3 times to the ;pediatric emergency department with vomiting and weight loss showed hyponatremia, hypochloremia, and metabolic alkalosis. The patient was subsequently diagnosed with CF by means of 2 positive sweat tests. Meanwhile, the review of the clinical records of all children diagnosed with CF from 1985 to 2004 (N = 77) showed that the prevalence of metabolic alkalosis with electrolyte depletion as the presentation of CF was 16.8%. The age of the infants ranged from 3 to 14 months. All episodes took place during summer. CONCLUSIONS: There are not many causes of metabolic alkalosis with hyponatremic dehydration, and one of them is CF. This report emphasizes sodium depletion as a common sign of CF presentation. This is most important in countries where the neonatal screening test for CF is not available because the disease may be asymptomatic or oligosymptomatic for several months or even years. Cystic fibrosis should be considered in differential diagnosis of any child presenting with unexplained hyponatremic dehydration.

[Impact of a quality of care improvement team on the use of sedatives during wound repair in young children]. / Impacto de las acciones emprendidas por un equipo de mejora sobre la utilización de sedación farmacológica en la reparación de heridas en niños.

OBJECTIVES: To analyze the impact of actions organized by a quality of care improvement team on the use of sedatives when treating wounds in children under the age of 5 years. MATERIAL AND METHODS: Quasiexperimental pre/post study enrolling children under the age of 5 years brought to a pediatric emergency department with wounds requiring surgical repair with suturing. A team to promote the use of sedation in such minor procedures in these children was established. The team organized the following interventions: training workshops, development and circulation of a sedation protocol, and establishment of a computerized alert. The first analysis of results was done at 2 months and the second at 9 months. The quality of care indicators, the use of sedatives while wounds were treated in children, was analized in 2 age groups: (under the age of 2 years and between 2 and 5 years) and results were compared with the preintervention phase. RESULTS: A total of 22 958 emergencies were registered in children under 5 years old; 548 (2.4%) involved uncomplicated wounds. Of the 548 patients, 350 (63.8%) required surgical repair, 75 of them (21.4%) in children under the age of 2 years. Ten percent of these children had received a sedative in the period before the team's intervention; 22% had been sedated at the 2-month analysis and 31.4% at 9 months (P<.01). For children between 2 and 5 years old, the percentages were 4.4% (pre-intervention), 10% (2 months), and 25% (9 months) (P<.01). Eighty-two percent of the families and 69% of the physicians thought that anxiety was adequately controlled. CONCLUSION: Actions designed by a multidisciplinary quality of care team are effective for increasing the use of sedatives while wounds are treated in children under the age of 5 years.

OBJETIVO: Analizar el impacto de las acciones promovidas por un equipo de mejora (EM) sobre utilización de sedación farmacológica (SDF) en menores de 5 años en los que se repara quirúrgicamente una herida. METODO: Estudio quasiexperimental realizado con la inclusión de los niños menores de 5 años que consultaron en un servicio de urgencias pediátricas (SUP) por una herida por la que precisaron reparación quirúrgica con sutura. Un EM creado en urgencias para promover SDF en procedimientos menores programó las siguientes acciones: talleres de formación, elaboración y difusión de un protocolo sobre SDF e inclusión de una alarma informática. Se realizó un primer análisis a los dos meses y un segundo a los 9 meses, utilizando dos indicadores, porcentaje de pacientes menores 2 años y porcentaje de pacientes de 2 a 5 años, a los que se administró SDF durante la reparación de una herida, que se compararon con la fase preintervención. RESULTADOS: Durante el periodo de estudio, se registraron 22.958 episodios en menores de 5 años, 548 (2,4%) con heridas no complicadas. De ellos 350 (63,8%) pacientes precisaron reparación quirúrgica, 75 (21,4%) eran menores de 2 años. Previo a la intervención, un 10% de los menores de 2 años recibieron SDF, 22% a los 2 meses y 31,4% a los 9 meses (p < 0,01). Entre 2 y 5 años, los porcentajes fueron 4,4%, 10% y 25% respectivamente (p < 0,01). El 82% de familias y 69% de médicos presentes consideraron que el control de la ansiedad había sido adecuado. CONCLUSIONES: Las acciones diseñadas por un EM multidisciplinar son eficaces para incrementar la SDF durante la reparación quirúrgica de heridas en menores de 5 años.

Recovery position significantly associated with a reduced admission rate of children with loss of consciousness.

BACKGROUND: Loss of consciousness (LOC) is often seen in children. The response of caregivers to a child with LOC has been poorly investigated. Potential caregivers (parents, teachers) seem to have a poor knowledge of the recovery position (RP)-that is, the position into which an unconscious child should be placed in order to protect the airway. OBJECTIVES: To report the management and diagnoses of LOC in childhood, and to evaluate variables associated with an increased hospital admission rate. METHODS: We conducted a prospective cohort study of consecutive children aged between 0 and 18 years diagnosed with LOC at 11 paediatric emergency departments (PEDs) of 6 European countries. The enrolment period was 3 months. Data were obtained from parental interviews, PED reports and clinical examination. RESULTS: 553 children were enrolled. The most frequent final diagnoses causing LOC were seizures (n=278, 50.3%), and vasovagal syncope (n=124, 22.4%). Caregivers put the child in the RP in 145 cases (26.2%). The RP was independently associated with a significant decrease in the admission rate (aOR=0.28; 95% CI 0.17 to 0.48; p<0.0001). CONCLUSIONS: Our study demonstrates for the first time that the RP may reduce the admission rate of infants with LOC. Caregivers often perform inadequate manoeuvres when a child becomes unconscious. Campaigns aiming at increasing knowledge of the RP should be promoted.

Pulmonary arterial thermodilution, femoral arterial thermodilution and bioreactance cardiac output monitoring in a pediatric hemorrhagic hypovolemic shock model.

AIM: Bioreactance is a new non-invasive method for cardiac output measurement (NICOM). There are no studies that have analysed the utility of this technique in a pediatric animal model of hemorrhagic shock. METHODS: A prospective study was performed using 9 immature Maryland pigs weighing 9 to 12 kg was performed. A Swan-Ganz catheter, a PiCCO catheter and 4 dual surface electrodes were placed at the four corners of the anterior thoracic body surface. Shock was induced by withdrawing a blood volume of 30 mL/kg, and then after, 30 mL/kg of Normal saline was administered. Seven simultaneous measurements of cardiac index (CI) were made by pulmonary artery thermodilution (PATD), Femoral artery thermodilution (FATD), and NICOM before, during, and after hypovolaemia and during and after volume expansion. RESULTS: The mean difference (bias) of differences (limits of agreement) between PATD and FATD was 0.84 (-1.87-3.51)L/min/1.77 m(2), between PATD and NICOM was 1.95 (-1.79-5.69)L/min/1.77 m(2), and between FATD and NICOM was 1.06 (-1.40-3.52)L/min/1.77 m(2). A moderate correlation was found between PATD and FATD (r=0.43; P=0.01), but no correlation was found between bioreactance and either PATD or FATD. Hypovolemia and volume expansion produced important significant differences in CI as measured by PATD and FATD, while the changes with bioreactance were small and non significant. CONCLUSIONS: PATD and FATD measurements showed similar responses to hypovolemic shock and volume expansion. Bioreactance persistently underestimates the CI and is not significantly altered by either inducing hemorrhagic shock, or later, through volume expansion. Bioreactance is not a suitable method for monitoring the CI in pediatric hemorrhagic shock.

Impacto de las acciones emprendidas por un equipo de mejora sobre la utilización de sedación farmacológica en la reparación de heridas en niños / Impact of a quality of care improvement team on the use of sedatives during wound repair in young children

Objetivo: Analizar el impacto de las acciones promovidas por un equipo de mejora (EM) sobre utilización de sedación farmacológica (SDF) en menores de 5 años en los que se repara quirúrgicamente una herida. Método: Estudio quasiexperimental realizado con la inclusión de los niños menores de 5 años que consultaron en un servicio de urgencias pediátricas (SUP) por una herida por la que precisaron reparación quirúrgica con sutura. Un EM creado en urgencias para promover SDF en procedimientos menores programó las siguientes acciones: talleres de formación, elaboración y difusión de un protocolo sobre SDF e inclusión de una alarma informática. Se realizó un primer análisis a los dos meses y un segundo a los 9 meses, utilizando dos indicadores, porcentaje de pacientes menores 2 años y porcentaje de pacientes de 2 a 5 años, a los que se administró SDF durante la reparación de una herida, que se compararon con la fase preintervención. Resultados: Durante el periodo de estudio, se registraron 22.958 episodios en menores de 5 años, 548 (2,4%) con heridas no complicadas. De ellos 350 (63,8%) pacientes precisaron reparación quirúrgica, 75 (21,4%) eran menores de 2 años. Previo a la intervención, un 10% de los menores de 2 años recibieron SDF, 22% a los 2 meses y 31,4% a los 9 meses (p < 0,01). Entre 2 y 5 años, los porcentajes fueron 4,4%, 10% y 25% respectivamente (p < 0,01). El 82% de familias y 69% de médicos presentes consideraron que el control de la ansiedad había sido adecuado. Conclusiones: Las acciones diseñadas por un EM multidisciplinar son eficaces para incrementar la SDF durante la reparación quirúrgica de heridas en menores de 5 años (AU)

Objective: To analyze the impact of actions organized by a quality of care improvement team on the use of sedatives when treating wounds in children under the age of 5 years. Methods: Quasiexperimental pre/post study enrolling children under the age of 5 years brought to a pediatric emergency department with wounds requiring surgical repair with suturing. A team to promote the use of sedation in such minor procedures in these children was established. The team organized the following interventions: training workshops, development and circulation of a sedation protocol, and establishment of a computerized alert. The first analysis of results was done at 2 months and the second at 9 months. The quality of care indicators, the use of sedatives while wounds were treated in children, was analized in 2 age groups: (under the age of 2 years and between 2 and 5 years) and results were compared with the preintervention phase. Results: A total of 22 958 emergencies were registered in children under 5 years old; 548 (2.4%) involved uncomplicated wounds. Of the 548 patients, 350 (63.8%) required surgical repair, 75 of them (21.4%) in children under the age of 2 years. Ten percent of these children had received a sedative in the period before the team’s intervention; 22% had been sedated at the 2-month analysis and 31.4% at 9 months (P<.01). For children between 2 and 5 years old, the percentages were 4.4% (pre-intervention), 10% (2 months), and 25% (9 months) (P<.01). Eighty-two percent of the families and 69% of the physicians thought that anxiety was adequately controlled. Conclusion: Actions designed by a multidisciplinary quality of care team are effective for increasing the use of sedatives while wounds are treated in children under the age of 5 years (AU)

Clinical course and mortality risk factors in critically ill children requiring continuous renal replacement therapy.

OBJECTIVE: To study the clinical course in children requiring continuous renal replacement therapy (CRRT) and to analyse factors associated with mortality. DESIGN: Prospective observational study. SETTING: Paediatric intensive care department of a tertiary university hospital. PATIENTS: Critically ill children with CRRT were included in the study. INTERVENTION: Continuous renal replacement therapy. MEASUREMENTS AND RESULTS: Univariate and multivariate analyses were performed to analyse the influence of each factor on mortality. The ability of the PRISM, PIM II and PELOD severity of illness scores to predict mortality was tested using receiver-operating characteristic curve statistics. A total of 174 children aged between 1 month and 22 years were treated with CRRT. Mortality was 35.6%, and multiorgan failure and haemodynamic disturbances were the principal causes of death. Mortality was higher in children less than 12 months of age (44.7%; P = 0.037) and in patients with a diagnosis of sepsis (44.1%; P = 0.001). Haemodynamic disturbances at the time of starting CRRT (hypotension or need for adrenaline >0.6 microg/kg/min) and the presence of multiorgan failure were the factors associated with an increased risk of mortality. The PRISM scale was the severity score with the best predictive capacity, although all three scales underestimated the actual mortality. CONCLUSIONS: Mortality in children who require CRRT is high. Haemodynamic disturbances and the presence of multiorgan failure at the time of starting the technique are the factors associated with a higher mortality. The clinical severity scores underestimate mortality in children requiring CRRT.