Transfusion Strategies for Acute Upper Gastrointestinal Bleeding

Summarized by Trevor Pour MD

Transfusion Strategies for Acute Upper Gastrointestinal Bleeding, N Engl J Med. 2013 Jan 3;368(1):11-21

Background
Upper GI bleed is a common emergency condition with wide ranging severity. There is some controversy regarding hemoglobin transfusion thresholds in acute upper GI bleed, with previous studies (which excluded GI bleeds) showing that a restrictive transfusion strategy were at least as effective as more liberal transfusion strategies in treating critically ill patients. This study was conducted to determine whether a restrictive transfusion strategy was associated with improved patient survival.

Methods
Randomized controlled trial
Single center, enrolled from 2003-2009
921 patients underwent randomization
No commercial support
Analyzed with intention to treat

Inclusion criteria

  • 18 years or older
  • Hematemesis, melena, or both


Exclusion criteria

  • Patient declined blood transfusion
  • Massive exsanguinating bleeding
  • Acute coronary syndrome
  • Symptomatic peripheral vasculopathy
  • Stroke/TIA
  • Transfusion within the previous 90 days
  • Recent history of trauma or surgery
  • Lower gastrointestinal bleeding
  • Previous decision on the part of the attending physician that the patient should avoid specific medical therapy
  • Clinical Rockall score of 0 with a hemoglobin level higher than 12 g per deciliter

 

Intervention
Restrictive arm received transfusion of PRBC for Hgb <7 g/dL
Liberal arm received transfusion of PRBC for Hgb <9 g/dL
Both groups received one unit PRBCs at a time followed by a post-transfusion Hgb level

Primary Endpoint
Rate of death by any cause within 45 days

Secondary Endpoint
Rate of further bleeding
Rate of in-hospital complications

Results

  • Mortality at 45 days was significantly lower in restrictive-strategy group (5% compared to 9%, Hazard Ratio 0.55 [0.33-0.92], P=0.02)
  • Further bleeding was significantly lower in restrictive-strategy group (10% vs 16%, Hazard Ratio 0.62 [0.43-0.91], P=0.01)
  • Restrictive-strategy patients spent fewer days in-hospital (9.6+/-8.7 vs. 11.5+/-12.8)
  • Adverse events were less common in restrictive-strategy group (40% vs 48%, Hazard Ratio 0.73 [0.56-0.95] P=0.02)
    • Adverse events included transfusion reactions, cardiac/pulmonary complications, AKI, stroke/TIA, or bacterial infections.
Posted in 1Intermediate, GI, NEJM, pediatrics | Leave a comment

Ultrasound Podcast with Mike and Matt on Small Bowel Obstruction

By Elizabeth Dei Rossi, MD

Please refer to The Ultrasound Podcast

Different modalities can be used for diagnosing SBO

  • CT scan is considered gold standard
    • sensitivity of 92% and a specificity of 93%
    • Mallo RD et al. CT diagnosis of ischemic and complete obstruction in SBO: a sys review. J Gastrointest Surg 2005
    • Abd xray is often used a rapid test in the ER but has very poor sensitivity/specificity
      • Looks for air fluid levels
      • sensitivity of 66-77% and specificity of 50-57%
      • Shrake PK, Rex DK, Lappas JC, et al. (1991) Radiographic evaluation of suspected small bowel obstruction.  Am J Gastroenterology 86:175-178
      • Ultrasound can be used for diagnosis of SBO
        • Sensitivity of 88% and specificity of 96%
        • Ogata M et al Prospective Evaluation of Abdominal Sonography for the diagnosis of bowel obstruction. Annals of surgery in 1996
        • can see SBO without air

 

Ultrasound findings in patients with SBO

  • Fluid filled bowel
  • Dilated bowel with back and forth peristalsis

 

Bedside ultrasonography of the detection of small bowel obstruction in the emergency department by Timothy B Jang, Danielle Schindler, and Amy H Kaji

  • Methods
    • Residents were given 10 min of training with 5 scans performed then patient’s with suspected small bowel obstruction had an US and XRAY, CT scan was used as the gold standard
    • Using a phased array probe bilateral colic gutters, epigastric and suprapubic areas were assessed for dilated loops of bowel with peristalsis (big loops of bowel with movement back and forth of bowel)
    • Results
      • Dilated bowel on US had a sensitivity of 91% and a specificity of 84%
      • Xray had a sensitivity of 46% and specificity of 67%
      • Some tips from Dr. Timothy Jang
        • Decreased peristalsis is a late finding and therefore not something for which to look
        • If you see dilated bowel also consider non-SBO etiologies like ileus
        • Study didn’t assess for transition point
        • Look for gallstones if you see dilated bowel (gallstone ileus)
        • In SBO bowel wall thickening is a prognostic sign and may suggest diagnosis like IBD and colitis

In summary US is potentially a quicker study without side effects of radiation that has a better sensitivity and specificity than XRAY.  Develop your own practice with this information: maybe use to rule out low risk patients.

Post Test Here

 

 

 

 

 

 

 

 

 

Posted in 1Advanced, GI, Ultrasound | Leave a comment

Bleeding Patients on Dabigatran aka Pradaxa

By Dr. Ling Zang, MD

Please refer to

Indication: stroke prevention in atrial fibrillation

Mechanism of action: reversible, competitive, direct thrombin inhibitor (downstream from other anticoagulants)

Pharmacokinetics:

  • Half time: 13 hours in patients with normal renal function (Cr clearance > 80%), up to 28 hours in those with renal function impairment (Cr clearance < 30%)
  • Peak effect: 2-3 hours
  • Excretion: renal

 

Why it is preferred over Coumadin:

  • more predictable pharmacokinetics
  • no CYP450 interaction
  • one dose for all patients
  • no monitoring
  • Similar to – if not better than – Coumadin in stroke prevention as an outcome

 

How to measure the anticoagulation effect of Dabigatran?

  • Thrombin time – very sensitive, but not standardized
  • aPTT – sensitive, but underestimates level of anticoagulation at high doses
  • INR – not useful as it only cause mild elevation even at high doses

 

Which agents could be used to reverse Dabigatran?

  • Vit K – allows synthesis of clotting factors, upstream from Dabigatran, won’t work.
  • FFP – contains all clotting factors, including thrombin.  Consider using.
  • PCC – contains some factors and some thrombin. Consider using.
  • Factor VIIa – can directly activate thrombin.  Considering using.

Or…Dialysis:

At 2 hours, about 62% of Dabigatran will be removed.

 

Approach to a bleeding patient on Dabigatran

  1. Assess the severity of bleeding
  2. Determine timing of last dose of Dabigatran to see if patient is being anticoagulated by it
  3. Hemorrhage control
  4. Draw aPTT and TT.  If normal, it is unlikely that the patient has significant anticoagulation
  5. Consider FFP, Factor VIIa, and dialysis.  If last dose is within 2 hours, give activated charcoal.
Posted in 1Intermediate, hematology | Leave a comment

Critical Care Palliation with Ashley Shreves

By Gene Schiappa, MD

Please refer to EMCrit

As terminal disease course progresses:

Disease driven care: decrease

Palliative care : increase

 

Overall care required may increase.

Patients and family require additional assistance and services.

 

3 areas of improvement

1. Communication

Never say:

-Do you want us to do everything?

-Do you want us to Resuscitate him/her?

-There is nothing more we can do.

 

2. Environment

-Private room

-Turn off monitors

 

3. Symptom Management

Dyspnea

-Opiods

-Opiods

-Opiods

Post-Test Here

Posted in 1Intermediate, EMCRIT | Leave a comment

Severe Accidental Hypothermia

By Taylor Moran-Gates, MD

Please refer to EMCrit

1. >32c:
-Treatment is simple: Passive rewarming, warm blankets.
-Evaluate other causes: hypoglycemia, etoh, myxedema, Addison’s, sepsis.
-Labs: cbc, chemistry, tfts, cortisol, cultures.
-Bradycardia: sinus bradycardia is expected, and does not require treatment.

2. <32c: Unstable.
-Temperature probe: Thermometers will not give reliable temperatures. You need to place a temperature probe, esophageal is preferred.
- Active rewarming:
-IVF: Warm iv fluids maintain temperature but do not raise temperature. However if the patient needs fluid, only heated fluid is appropriate.
-Warm humidified air: If your ventilator is capable, will raise temp 1.5C per hour.
-Warming blankets: Minimal efficacy.
-Catheter warming devices: e.g. Alsius, probably effective if you have them.
-Peritoneal lavage: Ok rewarming rates, but there are significant risks to entering peritoneum.
-Thoracic lavage: 3-6C per hour. Place two chest tubes, 32F, 4th-5th intercostal space, one just anterior and the other just posterior to the mid axillary line. Ideally one anterior tip up, one posterior tip down. To connect with IV tubing, use Salem sump adaptor or equivalent.  To anterior chest tube attach level 1.  To posterior chest tube attach pleurovac.
-Bypass: Effective if you have this available.
-Dialysis: Effective warming of the patient, but not your first move given delays to get equipment involved.

3. Cardiac arrest.
- When do you stop?  No clear evidence in the literature, probably 30 to 32C.
-Vfib, one shock, then rewarm with CPR.  Try defibrillation again when the patients temperature is >30C
-Meds: One dose epinephrine.  Begin regular ACLS med algorithm when >30C.

 

Post-Test Here

Posted in 1Advanced, EMCRIT, Environmental, Hypothermia, Resuscitation | Leave a comment

Validation of San Francisco Syncope Rule

Summarized By Raviraj Patel, MD

Source: Quinn J, McDermott D, Stiell I “Prospective Validation of the San Francisco Syncope rule to Predict Patients With Serious Outcomes.” Annals of Emergency Medicine, Vol 47, No. 5: May 2006

Intro

Syncope accounts for 1-2% of all ED visits and hospital admissions and admissions may cost as high as $2 billion annually.

25% of the population will experience syncope in their lifetime

Purpose of the study was to validate San Francisco Syncope Rule using a prospective cohort.

San Francisco Syncope Rule

Positive if patient has :

  1. History of CHF
  2. Hematocrit < 30%
  3. Abnormal EKG (new changes or non-sinus rhythm)
  4. Complaint of SOB
  5. SBP < 90 mmHg at triage

The original study showed 98% sensitivity and 56% specificity in predicting adverse outcome.

Materials and Methods

Prospective cohort study at large university (UCSF) teaching hospital using EHR to track patients presenting with syncope and near syncope defined as “transient loss of consciousness with return to baseline neurologic function.”

Physicians completed Web-based data for to enroll patient with SFS Rule and asked whether rule predicted high or low risk, whether serious outcome had been identified already.

Outcome Measures

30 day follow up to determine short term outcomes requiring admission. Outcomes included death, MI, Arrhythmia, PE, CVA, SAH, significant hemorrhage or anemia requiring transfusion, hospitalization or procedural intervention treating related cause or condition to syncope.

  1. Death – confirmed in medical record, death certificate or social security death index
  2. MI – elevated trop or ekg changes w/ diagnosis of MI on discharge
  3. Arrhythmia – non-sinus rhythm (known or new) thought to be related to syncope as per treating MD
  4. PE – confirmed by V/Q scan or CT or Angiography and on discharge diagnosis, pt had to receive treatment or seen on autopsy
  5. CVA/SAH – confirmed by discharge diagnosis and chart review

Revisits for syncope or related symptoms who were admitted were considered serious outcomes

Acute intervention defined as dialysis, PPM placement, heart valve surgery, balloon-pump insertion, vasopressions, AAA surgery, surgery for splenic rupture/ectopic pregnancy, EGD for varices.

Blinded trained research RN and study investigators determined criteria for serious outcomes

Follow up completed via review of medical records, discussion with physician, patient or patients’ family, review of Social Security Death Index and a canvass of local hospitals to determine if admitted elsewhere.

Sensitivity Analysis

Required 50 outcomes for 95% Confidence Intervals width less than 10%

Results

Table 2. Characteristics of patients presenting with syncope

(N_791).

Characteristic No. (%)

Age, mean (SD), y 61 (22)

Range, y 6–99

Female 427 (54%)

Admitted 469 (59%)

Patients with serious outcomes after ED visit 54 (6.8%)

Death 3

Arrhythmia 23

Myocardial infarction 11

Valvular heart disease 1

Significant hemorrhage 7

TIA/stroke 3

Sepsis 3

Admission after ED discharge 3

760 patients had 791 visits with completed forms for 767 visits.

39 patients unable to follow up but no deaths as per SSDI or local hospital canvass.

108 patients had serious outcomes within 30 days.

  1. 54 outcomes were present or diagnosed at ED visit
  2. 54 occurred within 30 days after ED visit
    1. 51/54 were admitted at ED visit
    2. 53 had data forms completed

Rule 98% Sensitive and 56% specific for serious outcomes.

1 patient the rule failed was 54 yo DM male with negative ACS w/u however found to have carotid and vertebral artery disease and subsequent stenting as thought syncope was 2/2 TIA

Limitations

Single hospital where used composite serious outcome as determined by consensus of experts.

Rule should be used as risk stratifier in conjunction with thorough evaluation. Does not account for social factors, further necessary testing as outpatient.

Requires implementation study to determine true benefits.

Discussion

Implementation to risk stratify could save millions of dollars as approximately 50% of syncope patients admitted undergo further specific testing leaving many syncope patients with unclear etiology.

Admitted patients length of stay normally limited to 1-2 days with only 16% receiving testing beyond simple monitoring.

Found 1 year outcomes difficult to justify need for emergency hospitalization as used in prior studies. In addition,  chose not to use Age as hard guideline as has been shown to be poor predictor of 30-day serious outcomes in ED patients with unknown syncope.

CHESS mnemonic makes easy to remember

Authors believe that absolute admission rates can decrease by 10% in low risk group with implementation of the rule.

Post-Test Here

 

Posted in 1Intermediate, Annals, Cardiology | Leave a comment

Erasing Death

By Sabrina Schmitz, MD

“Erasing Death” Explores the Science of Resuscitation (NPR—Feb 20, 2013)

SUMMARY:

 

  • This is an NPR interview of Dr. Sam Parnia, Director of Resuscitation Medicine at Stony Brook, in which he discusses ideas presented in his book, “Erasing Death.”
  • Dr. Parnia fields many lay questions about resuscitation and critical care medicine (which should be helpful by giving us a better idea of the public’s level of understanding of resuscitation), but also presents some questions/ideas that are potentially new and interesting to even physicians intimately involved in resuscitation medicine:
    • How do we define death in the light of significant advances in resuscitation medicine?
    • How do we explain the similarity of “after-death experiences” (a term he is attempting to distinguish from “near-death experiences”)?  They are very similar around the world, and across religions, genders, age groups, etc.
    • How can we objectively study these experiences?  Some of his research efforts are briefly discussed.
    • How can we explain why 80-90% of successfully resuscitated people do NOT have recollections of such experiences?  Here, Dr. Parnia questions whether this could be a function of the quality of resuscitation the patient received.  How can we explain why some people have these recollections shortly after resuscitation, but forget them later?
    • Death as a process (rather than a moment) is discussed from perspectives such as the length of time it takes different types of cells (e.g., neurons) to die after cardiac arrest.  This is incorporated into ideas of “after-death experiences.”
    • Dr. Parnia briefly touches on the popular “Dying Brain Hypothesis,” which postulates that these experiences are similar to hallucinations and dreams.  He also discusses current physician opinions on where the “seat of consciousness” lies (of course a philosophical question which has been debated for centuries).
    • Finally, Dr. Parnia reveals what drives him to pursue this research.  He states that many philosophical questions have fallen into the realm of becoming questions behind scientific research, and since cardiac arrest is a universal experience, the question of “what happens after we die” is worthy of investigation.  He also discusses the importance of efforts to create better standards in post cardiac arrest care.
Posted in 1Advanced, 1Beginner, 1Intermediate, Critical Care, Resuscitation | Leave a comment

TCA Overdose

By Christie Lech, MD

Please refer to EMRAP

  • Classically, you see a wide QRS complex and a tall R wave in aVr (elevation in the terminal 40 msec of aVr)
  • Treatment of your sick, dying TCA overdose patient – lots of sodium bicarbonate – IV push
  • What should you do if you have given multiple amps of bicarb and the QRS complex is still widening out?
    • Increase the patient’s ventilatory rate, to cause respiratory alkalosis
    • Add on LIDOCAINE
    • Activated charcoal (if patient’s continue to get sick, it suggests increasing absorption in the gut).
    • Consider intralipid.
  • In a TCA overdose, sodium bicarbonate works in two ways:
    • TCAs are sodium channel blockers – (you can also give hypertonic saline drips)
    • Alkalinization, increase volume of distribution and plasma protein binding – and the drug becomes no longer active
  • Even after multiple amps of sodium bicarbonate, patients do not become hypernatremia or fluid overloaded
  • Intubate these patients early!
  • Give them a benzo early to prevent seizures
  • Give charcoal after the intubation – not when patient is awake, given risk of seizures/decompensation
  • The tachycardia seen in these patients is related to the anticholinergic effects of the TCA, you should be more concerned if you see a normal heart rate or relative bradycardia
  • Do not give beta-blockers or other interventions to slow the patient’s heart rate.
  • TCAs also have alpha-blockade effects, causing hypotension.  In terms of vasopressors, you should use phenylephrine (pure alpha effects) or norepinephrine. Avoid dopamine.
  • You can give a lidocaine IV bolus in patients that have received multiple doses of sodium bicarbonate and have not had narrowing of their QRS complex. If no effect, consider lidocaine drip.
  • Lidocaine is a 1B agent, it is fast on and fast off.  It displaces the TCA from the cardiac cell.
  • Vent settings for the TCA overdose:
    • You can aggressively bag patients after intubation, and keep the pH on the higher side.
    • You should have the RR at 16-18 – up to 24 (as was used in the case mentioned).
  • Labs to send: VBG***,  APAP, ASA levels; relatively no utility to TCA levels.
  • Admit to ICU.
Posted in 1Intermediate, Cardiology, EMRAP, Toxicology | Leave a comment

Pseudoseizures AKA PNES

By Christie Lech, MD

Please refer to EMRAP

  • PNES – psychogenic nonepileptic seizures
  • Pseudoseizure – non-epileptic seizure
  • PNES is characterized by neurological disturbances i.e. motor, sensory, autonomic, cognitive, emotional that may mimic epilepsy, but there is no CNS dysfunction
  • Incidence is 1 to 3 per 100,000, prevalence 2-33 per 100,000 – both are probably underestimates
  • There is also a subset of patients with PNES and epilepsy – prevalence is 5-56%
  • No race, marital status, or education correlation associated with this diagnosis
  • Often with an epileptic episode there will be some focality to it, and there will be some type of rhythm or cadence to the movement.
  • In a non-epileptic episode there is more of a waxing and waning of movement and there is no focality
  • The incidence of tongue biting, unresponsiveness, self-injury, and incontinence is more common with epilepsy, but both can happen in pseudoseizures as well
  • If the episode is long in duration the chances are that it is a pseudoseizure
  • Pelvic thrusting does not usually happen during an epileptic episode
  • Side to side movements of head and body usually happen in a pseudoseizure
  • Eye closing, especially forced eye closing almost always is a pseudoseizure
  • Ictal crying is usually a pseudoseizure
  • Most of the time there is no or very brief post-ictal period with pseudoseizure
  • Put these patients on ETCO2 – in a true epileptic episode, the O2 saturation will go down and the CO2 will go up
  • Video EEG monitoring is the gold standard for diagnosing pseudoseizures, but it does not have good accuracy in the diagnosis of PNES
  • Seizure movement is more variable in PNES than in epilepsy
  • Opisthotonus is more common in PNES
Posted in 1Beginner, EMRAP, neuro, psych | Leave a comment

Pediatric Fever

By Jeremy Faust, MD

ERcast with Dr. Rob Orman and guest PEM specialist Dr. Andrew Sloas
Pediatric Fever Part 2. Link:

Question: Does height of fever increase risk that you’re dealing with Serious Bacterial Infection?
Answer: Old studies (poorly controlled, according to Dr. Sloas) mostly were done looking at Strep
Pneumococcus showed some possible correlation. Since Prevnar, the studies show no significant correlation.  Overall, the answer today seems to be that the older literature is not valid because the data were flawed and the pathogen that was being studied is largely not a concern in the United States..
More useful is to ask: Is the kid well-appearing?

Question: Does height of fever have a correlation to bacteremia?
Answer: seems not to. In modern era with the vaccines we currently have, there does not seem to be any data supporting this idea.

Question: Should we control all pediatric fevers?
Answer: Pros and Cons. In favor of controlling fever: child feels better and more likely to hydrate which is one of the main goals of supportive care. Against treating (or aggressive treatment) is the concept that fever is an immune defense helpful in killing infectious agents.

Question: How high of a fever is too high?
Answer: 106.7 F (41.5 C) fever is the level at which there is genuine risk of denaturing of brain protein (from adult data). In this situation, goal is to lower fever 1-2 degrees per hour

Question: When sending a child home from the ED, what threshold should you give parents for bringing child back to ED?
Answer:
Child <6 weeks old, child should return to ED with temp of 100.4
Child >8 weeks old, less aggressive threshold of 102.2 can be used as a cutoff.
Any child with a fever approaching 106.7 F (or 41.5 C) as per above.

Question: In terms of risk stratification, when is the correct time to assess a child, before or after anti-pyrexis?
Answer: There is no good data since Philadelphia, Rochester, and Boston studies on bacteremia. So, Dr. Sloas states that assessing the child prior to anti-pyrexis would be the more conservative approach.

Question:  What is the approach to a high fever with no immediate obvious source?
Answer: LUCAS! In a classic moment in #FOAMed (Free Open Access Meducation), during this podcast Rob Orman coined this mnemonic for pediatric fever sources based on Dr. Sloas’ answer to this question. LUCAS stands for: L=Lung, U=Urine, C=CNS, A=Abdomen, S=Skin. Of course there are other sources like blood (and you do not want to miss endocarditis), sinus infections, and if the patient has any lines or medical equipment, that is always a concern as a possible source.

Question: How likely is a serious bacterial infection at 1 and 3 months?
Answer: At 1 month of age, likelihood of SBI is 1/100. At 3 months of age, likelihood is 1/1000, assuming vaccines.

Question: What are “acceptable” sources for pediatric fever?
Answer: Brionchiolitis, RSV, Croup, aphthous stomatitis, Herpes Zoster, HSV, Hand/Foot/Mouth Coxsackie virus, enterococcus, viral exanthems, otitis media (if >2 months of age). Side note on otitis: Philadelphia, Rochester and Boston studies excluded soft tissue infections including otitis.

Question: Do you need to change your practice towards Fever of Unknown/Unclear Origin in well-appearing child <6 months old who is not vaccinated?
Answer: Look hard for a source as you would prior to Prevnar era. In this case, data from Rochester and Philly (pre-Prevnar) is still applicable: Dr. Sload advises that you can do everything (including LP) because you just have to be thorough. A “middle of road approach” would be: CBC and urine (modified Rochester would give you 92% sensitivity for occult bacteremia). Least invasive strategy: only check urine. Dr. Sloas also states that it is at times like this when it might be good to talk to parents about vaccines and address concerns. Also, in cases of unvaccinated children, If you don’t have Pediatric Emergency Medicine specialists in your shop but there is one nearby, it’s ok to transfer to them if you are concerned your hospital does not have a lot of experience with cases such as these.

Question: What are the doses for suspected pediatric bacteremia?
Answer: Ceftriaxone dose: 50 mg/kg for non-meningitis and 100 mg/kg if you suspect meningitis.
Many use cefotaxime for neonates <1 month of age (related to bilirubin interaction with ceftriaxone)

Question: Does antibiotic dose matter? In the early 1980s a study looked at blood concentration over
time for various Rocephin doses. That’s how the doses above were derived.

Question: Should very young patients get steroids if there is confirmed meningitis?
Answer: The very young mostly should not receive steroids. Anyone under 2 years with confirmed meningitis would probably not get steroids unless concern for adrenal insufficiency. Controversial between age 2-5. Certainly a five year old with confirmed meningitis would be indicated for steroids (plus antibiotics of course!)

Question: When giving steroids for meningitis (generally hydrocortisone), what is the doing scheme?
Answer: Stress doses hydrocortisone as follows:
Newborn: 25 mg/kg/meter-squared (Body Surface Area)
Up to a year old : 50 mg/kg/meter-squared
Over a year old: 100 mg/kg/meter-squared

Question: For a child receiving Decadron as the choice of steroids for meningitis, what would be the dose?
Answer: 0.6 mg/kg with a maximum of 10 mg although some places are using lower doses.

Question: When doing a lumbar puncture, should I have the parents hold the child?
Answer: No. The best person to hold the child is in fact not the parent but rather the most experienced person in Emergency Department. Often this will be a nurse or a technician.

Question: What is the best positioning for a pediatric lumbar puncture?
Answer: one hand on upper back / lower neck, other on buttocks/hamstring. Your goal is to get hips perpendicular to table with no movement except inspiration. (Dr Sloas adds: No mercy! Crunch them and watch for hypoxia. Be careful not to flex the kid too much because literature shows this is when
pediatric patients are more likely to get hypoxic. To alleviate this, give breaks between preparation, numbing, and actual puncture. EMLA is an acceptable adjunct to local anesthesia but should not be used in place of subcutaneous lidocaine because once the LP needle is in, you need the subcutaneous lidocaine to keep the child pain free below the surface and minimize the child from withdrawing to pain.

Question: What is the role for sedation for pediatric lumbar punctures?
Answer: Once the child is 6 months old, they can really move! So that is a cutoff many use.

Question: What medications are good for sedation for a lumbar puncture?
Answer: Ketamine and Propofol. A combination of these medications can provide excellent procedural sedation for a minute or two and if you have experience with these medications, you can well control the length of sedation. Fentanyl and Versed in small amounts can be a good combination as well but Dr. Sloas advises to use very small amounts of Ketamine.

Question: What is the role of CRP or pro-calcitonin in pediatric fever/sepsis work-up?
Answer: According to Dr. Sloas, not too helpful at this time. The problem is that the sensitivity in different studies has varied from 60-90% which is too wide to know the real sensitivity.

Question: What is the utility of blood cultures in kids?
Answer: As a practical matter, most commonly, one set of cultures is drawn, especially younger babies.
The issue is that positive cultures are so frequently false positives, can also get a sense of which positive cultures might be false just as in adults especially after a few days. No evidence here though. However, an Academic Emergency Medicine paper from 2009 showed false positive: true positive ratio in
children <60 days old was 6:1 (caveat: the study included at-risk babies with underlying lines which might have increased that ratio more than would have been seen in a healthier baseline population. The study also did not factor in immune status which might have been lower in the study population).

Question: In premature infants, how do old do you consider a patient? Are they aged in terms of membranes being open? Post-conceptual age? Post-partum age?
Answer: In the ED, Chronological Age (time since delivery, i.e. “time in the atmosphere!”) is the only thing you care about because this is what matters from an immunological status. In non-ED settings though the Corrected Age (Time since delivery – # of weeks premature) can be used for monitoring of developmental milestones (And yes, some babies will have a negative Corrected Age!). But when assessing immune status, Dr. Sloas recommends using chronological age, especially if baby is up-to-date on all vaccines.

Question: At what gestational age does a pre-mature infant start acting like a normal neonate?
Answer:  32-34 weeks gestation is magic time when fetus starts acting like baby. Suck reflex comes down and respiratory drive goes up.

 

Post Test Here

 

Posted in 1Beginner, ERCAST, pediatrics | Leave a comment