Bihemispheric Cerebral Oximetry Monitoring's Functionality in Suspected Cerebral Edema Diabetic Ketoacidosis With Therapeutic 3% Hyperosmolar Therapy in a Pediatric Emergency Department.

BACKGROUND: Suspected cerebral edema diabetic ketoacidosis (SCEDKA) is more common than perceived with symptoms including altered mentation, headache with vomiting, depressed Glasgow coma scale (GCS), abnormal motor or verbal responses, combativeness, and neurological depression. Suspected cerebral edema diabetic ketoacidosis has been associated with initial diabetic ketoacidosis (DKA) presentation and at start of DKA therapy.Cerebral oximetry (bihemispheric regional cerebral oxygen saturation [rcSO2] and cerebral blood volume index [CBVI]) can detect increased intracranial pressure (ICP)-induced altered bihemispheric cerebral physiology (rcSO2) (Crit Care Med 2006;34:2217-2223, J Pediatr 2013;163: 1111-1116, Curr Med Chem 2009;16:94-112, Diabetologia 1985;28:739-742, Pediatr Crit Care Med 2013;14:694-700). In pediatrics, rcSO2 of less than 60% or rcSO2 of greater than 85% reflects increased ICP and cerebral edema (Crit Care Med 2006;34:2217-2223, J Pediatr 2013;163: 1111-1116, Curr Med Chem 2009;16:94-112, Diabetologia 1985;28:739-742, Pediatr Crit Care Med 2013;14:694-700). Cerebral oximetry can detect increased ICP-induced altered bihemispheric cerebral physiology (rcSO2, CBVI) and cerebral physiological changes (rcSO2, CBVI changes) during therapeutic mechanical cerebral spinal fluid removal to decrease increased ICP (Crit Care Med 2006;34:2217-2223, J Pediatr 2013;163: 1111-1116, Curr Med Chem 2009;16:94-112, Diabetologia 1985;28:739-742, Pediatr Crit Care Med 2013;14:694-700).In the pediatric intensive care units, SCEDKA patients with nonbihemispheric cerebral oximetry showed an initial rcSO2 of greater than 90%. Bihemispheric rcSO2 with CBVI in SCEDKA patients has the potential to detect the abnormal cerebral physiology and disruptive autoregulation while detecting 3% hypertonic saline solution (HTS) effects on the SCEDKA altered cerebral physiology (rcSO2). PURPOSE: The purposes of this study were to analyze and compare 3% HTS effect on bihemispheric rcSO2 readings, neurological and biochemical parameters in SCEDKA with 3% HTS infusion to non-SCEDKA patients in pediatric emergency department (PED). METHODS: An observational retrospective comparative analysis study of bihemispheric rcSO2 readings, neurological and biochemical parameters in 2 groups of PED DKA patients were performed: PED DKA patients with SCEDKA +3% HTS infusions versus non-SCEDKA without 3% HTS infusions. RESULTS: From 2008 to 2013, of the 1899 PED DKA patients, 60 SCEDKA patients received 3% HTS (5 mL/kg via peripheral intravenous) infusion (median age of 5 years [range, 3.7-7 years]), with 42 new DKA insulin dependent diabetes mellitus onset. Suspected cerebral edema diabetic ketoacidosis patients had GCS of 11 (range, 11-12), with consistent SCEDKA signs and symptoms (severe headaches with vomiting, confusion, blurred vision, altered speech, lethargy, and combativeness). Suspected cerebral edema diabetic ketoacidosis patients' initial (0-5 minutes) left rcSO2 readings were 91.4% (range, 88.4%-94.1%) and right was 90.3% (range, 88.6%-94.1%) compared with non-SCEDKA patients' left rcSO2 readings of 73.2% (range, 69.7%-77.8%) and right of 73.2% (range, 67.6%-77%) (P < 0.0001). The rcSO2 monitoring time before 3% HTS infusion was 54.9 minutes (range, 48.3-66.8 minutes) with 3% HTS time effect change: pre-3% HTS (54.9 minutes [range, 48.3-66.8 minutes]). Before 3% HTS infusion, the left rcSO2 readings were 90.0% (range, 89%-95%) and right was 91% (range, 86%-95%). The 30 to 45 minutes post-3% HTS showed that left was 64% (range, 62%-69%) and right was 65.4% (range, 63%-70%) (P < 0.0001). rcSO2 Δ change for post-3% HTS (0-20 minutes) to pre-3% HTS was as follows: left, -26.58 (-29.5 to -23.7) (P < 0.0001); right, -25.2 (-27.7 to -22.6) (P < 0.0001). Post-3% HTS GCS (14,15) and biochemistry compared with pre-3% HTS infusions all improved (P < 0.001). CONCLUSIONS: In PED SCEDKA patients, the pre-3% HTS bihemispheric rcSO2 readings were greater than 90% and had lower GCS than non-SCEDKA patients. The post-3% HTS infusion rcSO2 readings showed within minutes a substantial reduction compared with non-SCEDKA patients, with no complications. Changes in rcSO2 readings after 3% HTS correlated with improved SCEDKA indicators (improved mental status, headache, and GCS) without any complications. We showed that cerebral oximetry in PED SCEDKA patients has shown an initial bihemispheric of greater than 90% readings signifying abnormal bihemispheric cerebral physiology. We also showed the cerebral oximetry's functionality in detecting 3% HTS therapeutic effects on SCEDKA's abnormal cerebral physiology and the beneficial therapeutic effects of 3% HTS infusion in SCEDKA patients. Using cerebral oximetry in pediatric DKA patients' initial cerebral assessment could have a significant impact in detecting SCEDKA patients. Further SCEDKA research using cerebral oximetry should be considered.

Medium-term monitoring reveals effects of El Niño Southern Oscillation climate variability on local salinity and faunal dynamics on a restored oyster reef.

Human activities and regional-scale climate variability drive changes in the ecology of coastal and marine ecosystems. Ecological restoration has emerged as a best-management practice to combat habitat degradation and restore lost ecological functions. However, relatively short project monitoring timeframes have limited our understanding of the effects of interannual climate cycles on water quality and restoration dynamics. We collected measurements on a 23-ha oyster reef constructed in the Gulf of Mexico to determine the relationship between El Niño Southern Oscillation (ENSO)-driven climate variability and local salinity patterns, and to evaluate the effects of this climate variability and salinity on oyster population dynamics and faunal community composition over a medium-term (five-year) timeframe. The role of ENSO-driven climate variability on local salinity patterns (primarily from changes in precipitation and evaporation) and faunal dynamics was investigated using the Oceanic Niño Index (ONI). Salinity was negatively correlated with ONI with an approximately 4-month lag. Higher ONI values (El Niño periods) were followed by reductions in salinity, increases in oyster recruitment and density, and reductions in resident motile fauna density and species richness. Lower ONI values (La Niña periods) had higher and less variable salinities, and higher areal coverage of restoration substrates by large oysters. ENSO-driven salinity reductions in the second year after reef construction coincided with a shift in resident motile faunal community composition that was maintained despite a second strong salinity reduction in year 5. Our results indicate that it is important to expand the typical monitoring timeframes to at least five years so that resource managers and restoration practitioners can better understand how both short-term environmental variability and longer-term climate cycles can affect the outcomes of restoration actions.

Improving Bronchiolitis Care in Outpatient Settings Across a Health Care System.

OBJECTIVE: This study aimed (1) to reduce use of ineffective testing and therapies in children with bronchiolitis across outpatient settings in a large pediatric health care system and (2) to assess the cost impact and sustainability of these initiatives. METHODS: We designed a system-wide quality improvement project for patients with bronchiolitis seen in 3 emergency departments (EDs) and 5 urgent care (UC) centers. Interventions included development of a best-practice guideline and education of all clinicians (physicians, nurses, and respiratory therapists), ongoing performance feedback for physicians, and a small physician financial incentive. Measures evaluated included use of chest x-ray (CXR), albuterol, viral testing, and direct (variable) costs. Data were tracked using statistical process control charts. RESULTS: For 3 bronchiolitis seasons, albuterol use decreased from 54% to 16% in UC and from 45% to 16% in ED. Chest x-ray usage decreased from 29% to 9% in UC and from 21% to 12% in the ED. Viral testing in UC decreased from 18% to 2%. Cost of care was reduced by $283,384 within our system in the first 2 seasons following guideline implementation. Improvements beginning in the first bronchiolitis season were sustained and strengthened in the second and third seasons. Admissions from the ED and admissions after return to the ED within 48 hours of initial discharge did not change. CONCLUSION: A system-wide quality improvement project involving multiple outpatient care settings reduced the use of ineffective therapies and interventions in patients with bronchiolitis and resulted in significant cost savings. Improvements in care were sustained for 3 bronchiolitis seasons.

Paediatric ED BiPAP continuous quality improvement programme with patient analysis: 2005-2013.

OBJECTIVE: In paediatric moderate-to-severe asthmatics, there is significant bronchospasm, airway obstruction, air trapping causing severe hyperinflation with more positive intraplural pressure preventing passive air movement. These effects cause an increased respiratory rate (RR), less airflow and shortened inspiratory breath time. In certain asthmatics, aerosols are ineffective due to their inadequate ventilation. Bilevel positive airway pressure (BiPAP) in acute paediatric asthmatics can be an effective treatment. BiPAP works by unloading fatigued inspiratory muscles, a direct bronchodilation effect, offsetting intrinsic PEEP and recruiting collapsed alveoli that reduces the patient's work of breathing and achieves their total lung capacity quicker. Unfortunately, paediatric emergency department (PED) BiPAP is underused and quality analysis is non-existent. A PED BiPAP Continuous Quality Improvement Program (CQIP) from 2005 to 2013 was evaluated using descriptive analytics for the primary outcomes of usage, safety, BiPAP settings, therapeutics and patient disposition. INTERVENTIONS: PED BiPAP CQIP descriptive analytics. SETTING: Academic PED. PARTICIPANTS: 1157 patients. INTERVENTIONS: A PED BiPAP CQIP from 2005 to 2013 for the usage, safety, BiPAP settings, therapeutic response parameters and patient disposition was evaluated using descriptive analytics. PRIMARY AND SECONDARY OUTCOMES: Safety, usage, compliance, therapeutic response parameters, BiPAP settings and patient disposition. RESULTS: 1157 patients had excellent compliance without complications. Only 6 (0.5%) BiPAP patients were intubated. BiPAP median settings: IPAP 18 (16,20) cm H2O range 12-28; EPAP 8 cmH2O (8,8) range 6-10; inspiratory-to-expiratory time (I:E) ratio 1.75 (1.5,1.75). Pediatric Asthma Severity score and RR decreased (p<0.001) while tidal volume increased (p<0.001). Patient disposition: 325 paediatric intensive care units (PICU), 832 wards, with 52 of these PED ward patients were discharged home with only 2 hours of PED BiPAP with no returning to the PED within 72 hours. CONCLUSIONS: BiPAP is a safe and effective therapeutic option for paediatric patients with asthma presenting to a PED or emergency department. This BiPAP CQIP showed significant patient compliance, no complications, improved therapeutics times, very low intubations and decreased PICU admissions. CQIP analysis demonstrated that using a higher IPAP, low EPAP with longer I:E optimises the patient's BiPAP settings and showed a significant improvement in PAS, RR and tidal volume. BiPAP should be considered as an early treatment in the PED severe or non-responsive moderate asthmatics.

Initiation of exemestane in two warfarin-treated patients leading to elevation and variability of INR.

Aromatase inhibitors are sometimes chosen for adjuvant therapy in post-menopausal breast cancer patients with a history of venous thromboembolism over an antiestrogen due to the lower risk of venous thromboembolism associated with aromatase inhibitors compared to antiestrogens. We report two cases where patients on warfarin therapy had an increase in their international normalized ratio with the initiation of exemestane therapy. Initially, the patients also showed international normalized ratio variability possibly due to variable absorption of exemestane. We suggest patients being treated with warfarin and exemestane concomitantly need close monitoring and education in order to decrease the risk of adverse events that could be associated with this possible interaction. To our knowledge, there are no similar reported cases in the literature.

Cerebral oximetry with cerebral blood volume index in detecting pediatric stroke in a pediatric ED.

BACKGROUND: Despite pediatric stroke awareness and pediatric stroke activation systems, recognition and imaging delays along with activation inconsistency still occur. Reliable objective pediatric stroke detection tools are needed to improve detection and activations. Regional cerebral oxygen saturation (rcso2) with cerebral blood volume index (CBVI) can detect abnormal cerebral physiology. OBJECTIVE: To determine cerebral oximetry in detecting strokes in stroke alert and overall stroke patients. METHOD: Left rcso2, right rcso2, and rcso2 side differences for stroke, location, and types were analyzed. RESULTS: Compared with stroke alert (n = 25) and overall strokes (n = 52), rcso2 and CBVI were less than those in nonstrokes (n = 133; P < .0001). Rcso2 side differences in stroke alert and overall strokes were greater than in nonstrokes (P < .0001). Lower rcso2 and CBVI correlated with both groups' stroke location, left (P < .0001) and right rcso2 (P = .004). Rcso2 differences greater than 10 had a 100% positive predictive value for stroke. Both groups' rcso2 and CBVI side differences were consistent for stroke location and type (P < .0001). For both groups, left rcso2 and CBVI were greater than those of the right (P < .0001). Hemorrhagic strokes had lower bilateral rcso2 and CBVI than did ischemic strokes (P < .001). CONCLUSIONS: Cerebral oximetry and CBVI detected abnormal cerebral physiology, stroke location, and type (hemorrhagic or ischemic). Rcso2 side differences greater than 10 or rcso2 readings less than 50% had a 100% positive predictive value for stroke. Cerebral oximetry has shown potential as a detection tool for stroke location and type in a pediatric stroke alert and nonalert stroke patients. Using cerebral oximetry by the nonneurologist, we found that the patient's rcso2 side difference greater than 10 or one or both sides having less than 50% rcso2 readings suggests abnormal hemispheric pathology and expedites the patient's diagnosis, neuroresuscitation, and radiologic imaging.

Innovative Application of Cerebral rSO2 Monitoring During Shunt Tap in Pediatric Ventricular Malfunctioning Shunts.

OBJECTIVE: This study aimed to determine the reliability and potential application of cerebral regional tissue oxygenation (rSO2) monitoring in malfunctioning ventricular shunts during tap. METHODS: This is a prospective case series using convenience sample in subjects with confirmed malfunctioning shunt who had left and right cerebral rSO2 monitoring every 5 seconds before, during, and 1 hour after shunt tap. RESULTS: Ninety-four subjects had cerebral rSO2 monitoring. Sixty-three subjects had proximal malfunctions, and 31 subjects had distal shunt malfunctions. The intrasubject's cerebral rSO2 trend and variability at pretap, during, and posttap times were highly correlated. Overall, the average rSO2 is lower in pretap as compared with posttap. Left cerebral rSO2 had lower means and larger SD as compared with right cerebral rSO2. Left pretap and posttap cerebral rSO2 variability was significantly associated with the location of shunt malfunction regardless of pretap, during, or posttap periods (P < 0.001), whereas right rSO2 variability was not predictive for malfunction location. Left cerebral rSO2 variability showed utility for identifying the location of malfunction with area under the receiver operating characteristic curve equal to 0.8. CONCLUSIONS: Reliable cerebral rSO2 readings before, during, and after shunt tap were demonstrated. Left cerebral rSO2 changes from before to after shunt tap were more predictive for shunt malfunction location than right cerebral rSO2 changes. Observing cerebral rSO2 changes in relationship to shunt tap represents a potential surrogate in measuring cerebral pressures and blood flow changes after cerebral spinal fluid drainage. Significantly greater cerebral rSO2 changes occur for distal malfunction versus proximal malfunction after shunt tap, indicating its potential as an adjunct tool for detecting shunt malfunction type.

Cerebral oxygen saturation monitoring in pediatric altered mental status patients.

OBJECTIVES: A pilot study assessing the potential utility of cerebral oximetry (local cerebral oxygen saturation [rcSO2]) in children presenting to the emergency department (ED) with altered mental status (AMS) and no history of trauma. METHODS: Patients who presented to a tertiary pediatric ED with AMS were monitored with left and right cerebral near-infrared spectroscopy probes and the first 30 minutes of rcSO2 data was analyzed. Patients with a history of trauma were excluded. Patients with an abnormal head computed tomography (CT) (n = 146) were compared with those with a negative head CT (n = 45). RESULTS: Mean rcSO2 values were consistent during each time period studied (5, 10, 20, and 30 minutes). In this study population, rcSO2 less than 50% or greater than 80% and increased absolute difference between the left and right rcSO2 measurements were associated with an abnormal CT scan. A difference of 12.2% between the left and right rcSO2 values had a 100% positive predictive value for an abnormal head CT among our patients. Cumulative graphical plots of rcSO2 trends showed that values <50% were associated with subdural hematomas (SDH) and values >80% were associated with epidural hematomas (EDH). CONCLUSIONS: This study demonstrated that cerebral oximetry can noninvasively detect altered cerebral physiology among a selected patient population. The difference between the left and right rcSO2 readings most reliably identified those subjects with altered cerebral physiology. In the future, rcSO2 monitoring has the potential to be used as a screening tool to identify, localize, and characterize intracranial injuries among children with AMS without a history of trauma.

Safety and clinical findings of BiPAP utilization in children 20 kg or less for asthma exacerbations.

PURPOSE: To investigate safety and clinical findings of bilevel positive airway pressure (BiPAP) utilization in children 20 kg or less for asthma exacerbations. METHODS: Retrospective and prospective descriptive analysis of 165 enrolled subjects with moderate and severe asthma exacerbations who weighed 20 kg or less and who received BiPAP treatment at a large, urban children's hospital pediatric emergency department (PED). RESULTS: Age was 0.6-8.27 years (mean 3.7 years, SD 1.6 years). None exhibited worsening hypoxia, pneumothorax, or death. Four progressed to intubation after significant period on BiPAP. Overall, BiPAP subjects showed improvement in pediatric asthma score (PAS). BiPAP initiation PAS range was 8-15 (mean 12.1, SD 1.6); BiPAP termination or 4 h PAS mean was 6.3 (SD 2.2); delta PAS showed improvement mean 5.8 (SD 2.4). Seventy-one had trial off BiPAP in PED for clinical improvement; seven were restarted. PED BiPAP duration range was 30-720 min (mean 210 min, SD 158 min); total hospitalization BiPAP duration was 1-90 h. Ninety-nine (60%) subjects were admitted to the PICU and continued BiPAP for 0-47 h (mean 6.6 h, SD 8.6 h). Fifty-seven (35%) required ward admission; none were transferred to PICU. Nine (5%) were discharged home from the PED; none returned within 72 h. CONCLUSIONS: BiPAP utilization in acute pediatric asthma exacerbations for patients 20 kg or less is safe and may improve clinical outcomes. These findings warrant future prospective investigation of BiPAP efficacy in pediatric asthma patients.