Physician Self-Reported Practice Patterns: Midazolam for Minor Procedures in Pediatric Patients.

Midazolam is frequently used as a single agent to provide minimal sedation (also called anxiolysis) when performing procedures in minor children. Published guidelines on the optimal use of intranasal (INM) and oral midazolam (POM) are lacking. The purpose of this study is to explore the self-reported physician practice related to midazolam use in facilitating minor procedures in children. We developed a survey that was approved by the Academy of Pediatrics Section on Emergency Medicine (APP-SOEM) and was then electronically distributed via its listserve. Questions were posed about the therapeutic and maximum dosing of INM and POM, consideration of Nothing-By-Mouth (NPO) status, use of cardiopulmonary monitors, as well as discharge criteria. There was a 47% (218/465) response rate. For therapeutic INM doses, 65% of responders used a dose range of 0.3 to 0.6 mg/kg, and 75% selected a maximum dose of 10 mg irrespective of the child's weight. About 20% of the responders selected a dosage range of 0.7 to 1 mg/kg for therapeutic POM dose, with 43% opting for a maximum dose of 20 mg irrespective of the child's weight. We observed a dichotomous variation in reported physician use of cardiopulmonary monitors; 42% never employ monitors, and the remainder used monitors some of the time. There was consensus on the NPO status and discharge criteria; 80% of physicians did not consider NPO status prior to midazolam use. The level of alertness was the most commonly selected discharge criterion. This nationwide survey of physicians indicates practice variation with midazolam dosing and cardiopulmonary monitor usage when performing minor procedures in children. Implementing practice guidelines, specifically for minimal sedation with mainstay agents such as midazolam, may standardize physician practice and improve overall patient care.

Increase in the Number of Pediatric New-Onset Diabetes and Diabetic Ketoacidosis Cases During the COVID-19 Pandemic.

OBJECTIVE: Infection with SARS-CoV-2 induces a proinflammatory state that causes hyperglycemia and may precipitate diabetic ketoacidosis (DKA) in patients with known or new-onset diabetes. We examined the trends in new-onset diabetes and DKA prior to and following the onset of the COVID-19 pandemic. METHODS: This single-center retrospective observational study included pediatric patients (aged 0 to <18 years) hospitalized with new-onset type 1 diabetes or type 2 diabetes (T2D) before (March 1, 2018, to February 29, 2020) and after (March 1, 2020 to December 31, 2020) the pandemic onset. Demographic, anthropometrics, laboratory and clinical data, and outcomes were obtained. RESULTS: Among 615 children admitted with new-onset diabetes during the entire study period, 401 were admitted before the pandemic onset, and 214 were admitted after the pandemic onset. Children admitted with new-onset diabetes in the postpandemic period were significantly more likely to present with DKA (odds ratio, 1.76; 95% confidence interval, 1.24-2.52) than in the prepandemic phase. Children with DKA after the pandemic onset had higher lengths of hospitalization and were significantly more likely to experience severe DKA (odds ratio, 2.17; 95% confidence interval, 1.34-3.52). A higher proportion of children with DKA admitted to the pediatric intensive care unit required oxygen support after the pandemic onset than before the pandemic onset (8.85% vs 1.92%). Most cases of T2D with DKA occurred following the onset of the pandemic (62.5%). CONCLUSION: A significant increase in T2D cases occurred following the onset of the COVID-19 pandemic with a greater risk of DKA and severe ketoacidosis. Racial disparity was evident with a higher proportion of Black and American Indian children presenting with ketoacidosis following the pandemic onset.

Inhaled corticosteroid prescriptions in the ED for recurrent asthma using IT clinical decision support: revisit after cessation of an incentive program.

INTRODUCTION: The objective of this study was to assess whether inhaled corticosteroid (ICS) prescription rates for patients with poorly controlled asthma presenting to the emergency department (ED) remained high with a clinical support system in place, after a financial incentive program ended. This study is the second phase of a previous study done at our institution. The first phase demonstrated that the introduction of an electronic alert system advising providers to prescribe ICS to patients with poorly controlled asthma, along with a financial incentive, increased ICS prescription rates from 2% to 77%. Clinical support systems are necessary to improve control for patients with asthma, as prescribing ICS in the ED has not previously been standard of care. METHODS: This retrospective study identified 96 eligible patients during the study period of January 1, 2019 to December 31, 2019. Subjects included patients aged 4-18 with at least two ED visits for asthma within 365 days and no recent ICS prescription. For subjects meeting these criteria, an electronic alert activated, advising the provider to prescribe ICS. RESULTS: ICS prescription rate without the incentive remained high at 0.74 (0.59, 0.86) and was not significantly different than the rate with the incentive of 0.77 (0.65, 0.87), with p value 0.82. No significant differences were detected in baseline characteristics between patients discharged with and without an ICS prescription. CONCLUSIONS: This study confirmed that an electronic alert advising ICS prescription in the ED for patients with recurrent asthma visits is effective, even without a financial incentive.

Trends in adult patients presenting to pediatric emergency departments.

OBJECTIVE: Adults presenting to pediatric emergency departments (PEDs) include those with complex chronic conditions (CCCs) often still followed by pediatric providers, and those without CCCs (non-CCCs). This paper describes recent trends in adults seen within PEDs, both by age subgroups and CCC status. METHODS: Data were retrospectively reviewed from the Pediatric Health Information System for PED visits between Jan 1, 2013 and Dec 31, 2017. Yearly visit rates were trended for all adult visits, age subgroups (18-21, 22-25, 26-40, and 41-95 years), and by CCC status. The most frequent diagnoses were reviewed for each adult age group and CCC category. RESULTS: Rates of adult PED visits significantly increased from 3.7% in 2013 to 4.2% in 2017 (P < 0.0001). While the overall majority (88% overall and >70% for each age group) of adult PED patients were non-CCC, the rate of CCC patients increased overall (P < 0.0001), especially among older patients (41-95 years) from 8.7% in 2013 to 29% in 2017 (P < 0.0001). The most frequent CCC diagnoses were sickle cell disease (18-21 and 22-25 years), cardiac pathology (26-40 years), and hyperlipidemia (41-95 years). The most frequent non-CCC diagnoses were abdominal pain (18-21 years), pregnancy-related (22-25 and 26-40 years), and chest pain (41-95 years). CONCLUSION: Visits to PEDs by adult patients have increased over time, with the majority of the population being represented by non-CCC adults. The results of this study can be used to guide specifics in adult medicine training during Pediatric Emergency Medicine fellowship and assist in continuing education efforts.