ADC/DFTB Journal Club #3 – January – POCUS vs Pneumonia?

Cite this article as:
Henry Goldstein. ADC/DFTB Journal Club #3 – January – POCUS vs Pneumonia?, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17878

Diagnosing pneumonia can be tricky. Each year, 1.2 million children under five years of age die from pneumonia. In developed countries, the incidence is 0.05 per person-year. Pneumonia can imply both bacterial or viral, and there is a distinct challenge in differentiating between these given similar clinical and investigative pictures, or even the presence of pneumonia at all.

What about some POCUS? Can we utilise this investigative modality to spot a child with pneumonia?  The paper from Archives of Disease of Childhood featured in our third #DFTB_JC sought to answer this question.

What’s it about?

 

The general sentiment from the Twitter discussion was that making a diagnosis of pneumonia is challenging. More specifically, there’s no reliable way of differentiating between viral and bacterial pneumonia, nor any particularly strong evidence for whom should or should not receive antibiotic therapy.

Most of those actively contributing (including Sarah McNab, Edd B, Damian Roland & Ding online identified the use of clinical skills; with an emphasis on history (of fever, cough) and examination features (pallor, focal chest findings), with the use of chest radiograph (or roentgenogram if you’re feeling formal), to augment or refute this diagnosis.

Blake (@cobra6blake) suggested a 2017 JAMA review article by Shah et al. as a good summary.

 

The authors methodology made sense with respect to answering the stated question regarding the diagnostic accuracy of LUS vs CXR for diagnosing pneumonia, using this approach:

Although there are well established pros and cons for each modality there was a distinct lack of congruity about which modality was the more accurate, including the rates of agreement between both operators. Jessica Wong (@jessicawswong) also identified Dominguez et al.’s related 2018 article in the Journal of Paediatrics and Child Health.

 

Sonia Twigg and Damian Roland identified the intricacies of anatomic pathology, citing the difference between the clinical entity of pneumonia and the pathologic entity of hepatisation (grey vs red); I recommend Robbins’ pathology for a refresher.

 

Both Sonia & Edd B have identified the key challenge with the paper (and frankly acknowledged the next step, nicely summarised by Lassi et al in this Cochrane Review (emphasis mine).

“Pneumonia is an infection of the lungs. In children it is one of the leading causes of childhood deaths across the globe. Pneumonia can be classified based on the World Health Organization (WHO) guidelines. This classification involves assessment of certain clinical signs and symptoms and the severity of disease. The treatment is then tailored according to the classification. For non-severe pneumonia, the WHO recommends the use of oral antibiotics for treatment. However, pneumonia is caused more commonly by viruses that do not require antibiotic management but rather supportive care. On the other hand, pneumonia caused by bacteria needs management with antibiotics to avoid complications. Since there is no clear way to distinguish quickly which organism actually caused pneumonia, it is considered safe to give antibiotics. However, it may lead to the development of antibiotic resistance and thus limit their use in future infections. Thus the question arises as to whether the use of antibiotics is justified in non-severe pneumonia.” – Lassi et al.

 

For me personally, this paper has sought to highlight an emerging utilisation of POCUS; whilst it contributes to – rather than definitively answering – the evidence and understanding around both paediatric pneumonia and the availability and utility of USS & CXR.

So, a short summary of what we’ve discussed;

– CXR is the “Gold standard” Ix, but the clinical diagnosis of pneumonia remains the most accepted, with occasional augmentation via CXR

– LUS vs CXR are roughly comparable, both with flaws regarding isolated accuracy & predictability

– This study hasn’t been designed to inform whom should receive treatment, but it’s what we’d all like to know

– POCUS is an emerging skill set for emergency +/- paediatric providers to consider

Thanks again to everyone who participated in our #DFTB_JC and we hope you will join us again later this month for our next paper, thanks to #ADC_BMJ.

“Drug preparation and administration errors during simulated paediatric resuscitations”

Things will be kicking off on Twitter at UTC 2000hrs, 21/02/2019. with this paper…

Murugan S, Parris P, Wells M. Drug preparation and administration errors during simulated paediatric resuscitations. Archives of disease in childhood. 2018 Nov 9:archdischild-2018.

 

 

If you want to level up your POCUS skills then why not sign up to one of our point of care ultrasound workshops. They are going to take place on the Sunday before DFTB19. Check out the website for more details.

ADC/DFTB Journal Club #2 – December – How well do we manage suspected meningitis in ED?

Cite this article as:
Grace Leo. ADC/DFTB Journal Club #2 – December – How well do we manage suspected meningitis in ED?, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17786

Vaccines have been instrumental in reducing rates of bacterial meningitis. However bacterial meningitis still represents 4-19% (1) of cases of meningitis and has been estimated to be cause 2% of all child deaths (2). Timely administration of antibiotics helps save lives with adult research suggesting that every hour of delayed treatment increases the risk of death or permanent disability by 10-30% (3). So how swiftly do we investigate and treat children with suspected meningitis? The paper from Archives of Disease of Childhood featured in our second #DFTB_JC sought to answer this question:

 

What’s it about?

This was a prospective cohort study of 388 children who attended three UK paediatric tertiary centres between 2011-2. They had been either hospitalised with suspected meningitis or underwent lumbar puncture (LP) during sepsis evaluation.

Of the 388 children, 18% (70) were given a diagnosis of meningitis but only 13 were documented as bacterial and 26 as viral with and 31 patients having no known or identified cause. Just over half the children (57%) had seen a doctor in the same illness prior to ED presentation.

The median time from initial hospital assessment to antibiotic administration was 3.1 hours.  The time to LP was even longer at 4.8 hours, but once discounting intentional postponement for reasons including convulsions, concern regarding raised intracranial pressure, coagulopathy or shock, this time reduced to 3 hours. Over half of the children (62%) had their LP following antibiotics.

In further discussion with the corresponding author @manishs_  the mean was chosen due to skewing of the data and the time from initial hospital assessment was equivalent to arrival in ED. The time between initial assessment and LP ranged from 0-183 hours whilst the time between initial assessment and antibiotics ranged from 0 to 136 hours. For the 221 patients who they had data in hours available; only 31 received antibiotics in the first hour. However 131 of the 221 patients did receive antibiotics in the first 4 hours.

 

 

The general sentiment from the twitter discussion was  that the median time of 3.1hours to antibiotic administration was longer than expected, and suboptimal. Whilst the actual time point may have been somewhat surprising; many could identify common reasons for antibiotic delay and in particular, discussion about the difficulties that lumbar puncture can pose in different age groups and its contribution towards delay of antibiotics.

“It surprised me. Think we generally give abx before LP in children and LP before abx in babies… probably because of less anxiety around the procedure in babies. But no excuse for 3 hour delay in any age group really.” – @DrRoseM

 

 

 

We then delved deeper into the importance of LP before or after antibiotics and factors affecting unintentional LP delay. Paediatrician from Ontario, Tom Lacroix shared concern that with improved vaccines, he has seen skill attrition.

“…I wonder how much of delay is bc we have become unaccustomed to doing LPs. I have seen a fall in LPs 90%+ since intro of pneumococcal conjugate vaccine” – @drtom_lacroix

Across in the UK, the perceived anxiety surrounding performing an LP in older children was raised including staffing challenges, concerns about pain and procedural sedation.

“In neonates we rush to get the LP done within an hour, but in older children it always seems to take a lot longer. Do we have misplaced anxiety in this age group?” – @TessaRDavis

“…It takes one NICU nurse to flex a 6 day old up for an LP, but a play specialist, at least two nurses and one parent to get an older child in position for an LP” – @edd_broad

Differences in practice in terms of performing a FBC and Coags screen prior to LP were also highlighted.

“Not sure about mandatory, but I’ve been taught (and continue to practice) confirming PLT > 50×10^9/L prior to LP. ” – @henrygoldstein

“…Unless evidence of coagulopathy ie purpura. Do LP and then give abx” – @DocAnthonyT

 

 

 

In the supplementary tables from the paper, of all children in the study, just under a quarter (24.7%) had bacterial and/or viral CSF PCR performed. Of the 70 children who had meningitis, CSF PCR was performed on only 9 (13%). The rate was slightly higher for meningitis of cause unknown (6 of 29 patients, 21%). The authors commented that this represents a significant underutilisation, particularly as CSF PCR is recommended in the current UK guidelines. The suspected cause of this was a long turnaround time to PCR.

However the benefits of positive viral CSF PCR results would include reducing length of treatment and inpatient stay as well as building a more accurate understanding of true disease rates.

The results of this paper contrast with experiences of our journal club participants where CSF PCR appeared to be a more common order, particularly in the neonatal setting:

“Might depend on the CSF WCC for the bacterial PCR? If zero, I wouldn’t necessarily send bacterial PCR (but will still frequently send viral PCR)…Parechovirus PCR is automatically sent for our neonates. #DFTB_JC ” – @DrSarahMcNab

“NICU where I work send viral PCRs as standard with turnaround in 24 hours. Think you still need to request in paeds. ” – @DavidKing83

 

Paediatric Registrar Rose provided a good summary of what she learned from the article and the #DFTB_JC chat:

take home- give the abx as soon as possible and definitely within 1 hour. If unable to do LP pre abx due to delays etc then do LP ASAP after abx. Consider PCR as a valuable tool to aid decision re duration of treatment” – @DrRoseM

From the DFTB team, the discussion has made us rethink how each step in assessment and management of suspected meningitis may delay optimal care. In particular we’ll be thinking about how strong the evidence is behind ‘the golden hour’ of antibiotic administration, the anxiety surrounding LPs in older children and evidence behind performing coagulation studies prior to LP…now that sounds like a potential post for the future.

Thanks again to everyone who participated in our #DFTB_JC and we hope you will join us again later this month for our next paper.

 

Please join us for our next ADC/DFTB Journal Club on twitter at Tue 22/1/19 at UTC2000hrs (That’s Wednesday 0700 23/1 AEST) January’s featured FREE access article from @ADC_BMJ featuring a FREE access article from the latest issues of Archives of Disease of Childhood. January’s pick  is ‘ Can we use POCUS to Diagnose Pneumonia?’ Read the article here: bit.ly/2TMDf2M The chat will happen on twitter, hosted by @DFTB_Bubbles. Remember to use the hashtag #DFTB_JC for all related posts.

ADC/DFTB Journal Club #1 – November – when is a child not septic?

Cite this article as:
Tessa Davis. ADC/DFTB Journal Club #1 – November – when is a child not septic?, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17297

Sepsis is a word we hear many many times a day. As clinicians treating children, it is one of our main concerns. Amongst all the unwell children we see, how do we work out who is septic and who is not?

This month, for our inaugural #DFTB_JC, we discussed this paper by Snelson and Ramlakhan and we were lucky enough to be joined by the authors themselves.

Snelson E, Ramlakhan S. Which observed behaviours may reassure physicians that a child is not septic? An international Delphi study, Archives of Disease in Childhood, 2018, 103:864-967.

We all have experience of using a sepsis guideline or a sepsis decision aid:


There were a few examples of individual centres and their sepsis tool:


However, most people mainly use a combination of clinical judgement, physiological observation, and gestalt – essentially a combination of factors that nobody could quite put their finger on.

 

The evidence shows that none of these guides are very sensitive or specific. This means that we tend to over-treat for fear (not unreasonably) of missing sepsis. The authors highlight that all these guidelines rely on quantifiable measures (pyrexia, tachycardia, tachypnoea) or subjective negative features (withdrawn, flat). In real life, we frequently use features of wellness to reassure us that a child does not have sepsis. In this study, the authors tried to identify reassuring features of wellness, that help clinicians decide to exclude sepsis.

 

Who was included in the study?

The inclusion criteria were ‘clinicians who routinely assessed undifferentiated children in their practice and had done so from the majority of their career”.

The authors approached professional societies of paediatricians, emergency physicians, and general practitioners with an interest in paediatrics. They also asked these respondents to recommend other respondents.

This was a two round questionnaire. They had 195 respondents in the first round, and 104 in the second round (the same group was asked each time).

The group consisted of 188 physicians, two nurse practitioners, two paramedics, and one physician associate.

50% were from North America, 36.6% from the UK, and the others were from a range of other countries.

The group felt that this was a reasonable way to recruit participants but discussed reasons for there being many more US respondents than UK ones.


What was studied?

The author used a modified Delphi technique.

The Delphi method is a structured communication technique which uses a panel of experts being asked questions in one or more round. After each round, the experts receive a summary of the results from the previous round, along with reasoning. The idea is for them to consider revising their view in light of the previous answers from the expert panel. The Delphi method is usually carried out face-to-face, but a modified Delphi can be carried out via email or online communication.

In the first round, participants were asked ‘What activities or behaviours do you feel are reassuring and significantly reduce the likelihood that a febrile child has possible sepsis?”

There were 856 responses – duplicates and illogical responses were removed, and similar responses were grouped together in themes. The authors were able to narrow the results down to 14 statements describing observed behaviour.

These 14 statements were circulated to participants for round two. They were asked to grade the degree of reassurance each statement offered on a 4-point Likert scale.

A Likert scale is where respondents mark their agreement/disagreement with a statement on a scale. The scale is usually symmetrical and balanced.

 

What were the results?

The most reassuring behaviour was ‘actively energetic’ – 99% of respondents found this very or moderately reassuring. The least reassuring behaviour was ‘showing fear of the examining clinician’ – 45% of respondents felt this was not at all reassuring.

Using an electronic device and being consolable were both only seen as slightly reassuring. All the others were moderately reassuring, with being energetic, smiling or laughing, and chatting/babbling/being talkative were seen as very reassuring.

There was no mention of the famous ‘positive Quaver test’*

We had lots of discussion on twitter about whether or not a child playing on an iPhone in the waiting room was a reassuring sign.


And then we had a stark reminder from a parent of how easy it can be to miss sepsis:

 

What were the authors’ conclusions?

We have worked very hard over the last few years in paediatrics to use and develop tools to help us rule in sepsis. But in spite of the vast bodies of work, we have failed to standardise sepsis tools and really only have guidelines with poor sensitivity and specificity. Consequently we over-diagnose and over-treat this group of patients.

Much of our daily practice encompasses looking for reassuring signs in these patients, and utilising those signs to rule out sepsis. This is the first paper to identify a consensus on which features reduce the probability of sepsis. The next step is to validate the negative predictive value of each of these behaviours.

 

 

*other brands of crisps do exist

DFTB/ADC Journal Club – The Rules

Cite this article as:
Andrew Tagg. DFTB/ADC Journal Club – The Rules, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16905

We all know that it can take up to 17 years for knowledge to go from benchside to bedside. One of the things we pride ourselves on at DFTB is our ability to cut down this knowledge translation window. We do this in the form of our monthly Bubble Wrap, critical appraisals of key literature and engagement with key thought leaders via Twitter.

Now we are going to try something new – a monthly twitter journal club as a collaboration with Archives of Disease in Childhood.