Severe iron deficiency anemia in the paediatric emergency department: A retrospective study.

Background: Transfusion is discouraged in hemodynamically stable children with severe iron deficiency anemia (IDA). Intravenous (IV) iron sucrose (IS) could be an alternative for some patients; however, there is a paucity of data on its use in the paediatric emergency department (ED). Methods: We analyzed patients presenting with severe IDA at the Children's Hospital of Eastern Ontario (CHEO) ED between September 1, 2017, and June 1, 2021. We defined severe IDA as microcytic anemia <70 g/L and either a ferritin <12 ng/mL or a documented clinical diagnosis. Results: Of 57 patients, 34 (59%) presented with nutritional IDA and 16 (28%) presented with IDA secondary to menstrual bleeding. Fifty-five (95%) patients received oral iron. Thirteen (23%) patients additionally received IS and after 2 weeks, the average Hgb was similar to transfused patients. The median time for patients receiving IS without PRBC transfusion to increase their Hgb by at least 20 g/L was 7 days (95%CI 0.7 to 10.5 days). Of 16 (28%) children who were transfused with PRBC, there were three mild reactions, and one patient who developed transfusion associated circulatory overload (TACO). There were two mild and no severe reactions to IV iron. There were no return visits to the ED due to anemia in the following 30 days. Conclusions: Management of severe IDA with IS was associated with a rapid rise in Hgb without severe reactions or returns to ED. This study highlights a strategy for management of severe IDA in hemodynamically stable children that spares them the risks associated with PRBC transfusion. Paediatric specific guidelines and prospective studies are needed to guide the use of IV iron in this population.

Evaluation of the Quality of ED Management for Patients with COPD.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is associated with exacerbations and high risk of serious outcomes. Our goal was to determine the appropriateness of the ED management of COPD exacerbations. METHODS: This observational cohort study incorporated a health records review and included COPD exacerbation cases seen at two large academic EDs. We included all patients with the primary diagnosis of COPD exacerbation. From the electronic medical record, demographic and clinical data were abstracted, and the Ottawa COPD Risk Score (OCRS) was calculated for each. Short-term serious outcomes (SSO) included ICU admission, intubation, myocardial infarction, non-invasive positive pressure ventilation (NIV), and death at 30 days. Cases were judged for appropriateness of treatment according to explicit indications and standards developed a priori. RESULTS: We enrolled 500 cases with mean age 71.9, female 51.2%, admitted 50.2%, and death 4.4%. The calculated OCRS score was >2 for 70.8% of patients. The treatments provided were inhaled beta-agonists (82.6%), inhaled anticholinergics (76.6%), corticosteroids (75.2%), antibiotics (71.0%), oxygen (63.8%), NIV (8.8%) and intubation (0.6%). Overall, 50.0% of cases were judged to have had inadequate management due to missing treatments. Specifically, the proportion of missing treatments were inhaled beta agonist (17.0%), inhaled anticholinergic (22.6%), corticosteroids (24.4%), antibiotics (12.8%), and NIV (2.0%). CONCLUSIONS: Adequate treatment of COPD exacerbation was lacking in 50.0% of patients in these two large academic EDs. Concerning were the number of patients not receiving corticosteroids or antibiotics. Implementation of explicit treatment standards should lead to improved patient care of this common and serious condition.

Successful Transjugular Portosystemic Shunt Treatment of Pediatric Sinusoidal Obstruction: Case Report and Review of Literature.

Background: In adults with medically refractory sinusoidal obstruction syndrome (SOS), a transjugular intrahepatic portosystemic shunt (TIPS) has been used successfully to improve portal hypertension and symptoms such as ascites. There is limited data on the use of TIPS for SOS in pediatric patients. Methods: The index case was reviewed retrospectively. PubMed and Medline databases were searched to identify other cases. Results: A 4-year-old male with high-risk neuroblastoma, developed SOS after tandem autologous stem cell transplant. He was medically managed with defibrotide, diuretics, and peritoneal drainage, but, due to refractoriness, he underwent TIPS day +54 following bone marrow transplant. Hepatic venous pressure gradient improved from 17 to 8 mm Hg following TIPS placement with significant improvement in the patient's clinical status and ascites. However, 15 months later, his shunt remained patent, and he remains clinically well with stable liver enzymes. A literature review identified 13 pediatric cases of TIPS for SOS due to varied causes. TIPS caused a median hepatic venous pressure gradient of 9 mmHg (range, 2-38 mm Hg). The mortality following the procedure was 15%, with 2 cases who died at 2- and 11-days post-TIPS. At the time of the last follow-up (range 8-25 months), 5 patients were alive, and 8 were lost to follow-up. Conclusion: We present here a pediatric case of SOS due to stem cell transplant treated successfully with TIPS with a review of the literature. A timely, individualized application of TIPS can be effective in treating children with medication-refractory SOS.