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The 57th Bubble Wrap

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With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

Article 1: Infrared thermometers and infants: The device is hot,  the baby maybe not

Tham D, Davis C, Hopper SM. Infrared thermometers and infants: The device is hot, the baby maybe not. J Paediatr Child Health. 2021. doi: 10.1111/jpc.15787

What’s it about? 

This paper explores the use of infrared thermometers in infants (less than 60 days old) as a marker for more serious illness and confirmed fever in the ED setting. The authors investigated the outcomes of frequency of infrared thermometer use, progress to documented fever in ED, and rate of serious illness (meningitis, UTI, bacteraemia) in febrile infants through a single-centre retrospective chart review between 2016-2017.

Of 159 infants, two-thirds (66%) had temperatures measured using an infrared device at home. Of these, less than one in four (22%) had a fever documented in ED, compared to 52% of infants who had a fever measured by a direct device. Interestingly, the type of device used at home was not significantly associated with the likelihood of serious illness (direct 25.9% vs infrared 18.1%). Rather, fever in ED was shown to be a stronger predictor of serious illness.

Why does it matter? 

It is well known that febrile infants less than 60 days old are at higher risk of serious infection and therefore require a cautious approach to their clinical work-up. While infrared thermometers are not recommended over direct axillary or rectal methods, the devices are increasingly used to measure fever at home as they are affordable and popular. This can cause preventable parental distress and presents a challenge to ED clinicians and decision making about the need for further investigations, prolonged observations, and admissions, particularly in well-appearing infants. (Check out DFTB’s post on the management of febrile infants in the emergency department here and this post on well-appearing febrile infants.)

Clinically Relevant Bottom Line:

Most parents use infrared thermometers. Given fever at home from infrared thermometers are poorly correlated with subsequent fever measured in ED (22%), the authors highlight the need to educate the public, merchants, and healthcare providers to change the type of thermometer used. 

The weaknesses of this study were its single-centre, tertiary-level setting which may limit its transferability to other ED environments. In addition, its retrospective nature studied over a short one-year duration may limit its generalizability. It was interesting to note the author’s pragmatic definition of “serious illness” as infants who require pro-active investigation and treatment, highlighted a clear rationale in including UTI in the definition compared to previous studies.

Reviewed by:  Ivy Jiang

Article 2: Corticosteroids in the Treatment of Pediatric Retropharyngeal and Parapharyngeal Abscesses

Do steroids make a difference in treating retropharyngeal and parapharyngeal abscesses? Goenka PK, Hall M, Shah SS, et al. Corticosteroids in the treatment of pediatric retropharyngeal and parapharyngeal abscesses. Pediatrics. 2021;148(5):e2020037010.

What’s it about? 

Retropharyngeal abscesses (RPA) and parapharyngeal abscesses (PPA) are deep neck infections that may arise from preceding infection or inflammation. They are treated with antibiotics and possible operative drainage. The authors sought to evaluate the association of corticosteroid administration as part of initial medical management and rate of operative drainage and length of stay for RPAs and PPAs.

They conducted a multi-center, retrospective study involving 2259 children, 2 months to 8 years of age, over 3 years using administrative data from the Pediatric Health Information System (PHIS). This contains data from 46 tertiary care paediatric hospitals. They included patients with a discharge diagnosis of RPA or PPA. Patients were excluded if they had incomplete data, were transferred from another institution, had complex chronic conditions, congenital airway malformations, trauma, or previous diagnoses requiring corticosteroids.

The primary exposure was whether or not corticosteroids (including oral or parenteral dexamethasone, prednisone, prednisolone, or methylprednisolone) were administered prior to any surgical intervention. The primary outcome was surgical drainage. The secondary outcomes assessed included various aspects of a diagnostic evaluation, medical management, and health care use.

2259 patients were included in the study with 1677 (74.2%) designated to the noncorticosteroid group and 582 (25.8%) were designated to the corticosteroid group. Corticosteroid administration varied across study hospitals with the most common being parenteral dexamethasone. Patients in the corticosteroid group underwent surgical intervention less frequently compared to those in the noncorticosteroid group (22.2% vs 51.5%, p<0.001). Patients in the corticosteroid group often had more CT images performed (9.8% vs 6.4%, p=0.006).  Antibiotic therapy also differed between groups with the corticosteroid group more frequently receiving clindamycin compared to ꞵ-lactam and/or ꞵ-lactamase inhibitors in the noncorticosteroid group. Those in the corticosteroid group also received opioid analgesia less frequently (45.2% vs 54.4%, p<0.001). There was no significant difference in median length of stay in risk-adjusted analysis, but hospital costs were lower in the corticosteroid group. The corticosteroid group also had greater odds of all-cause 7-day emergency department revisit. Rates of 30-day hospital readmission did not differ between groups. Of the 16 patients who were initially medically managed then readmitted and underwent subsequent surgical drainage, 8 (0.5%) were from the noncorticosteroid group and 8 (1.3%) were from the corticosteroid group.

There are some important things to highlight:

  • Database Studies: While PHIS allows for the collection of a wide swath of information from multiple institutions, it doesn’t provide details regarding severity of patient presentation or help us understand a clinician’s rationale for using corticosteroids. 
  • Corticosteroid vs noncorticosteroid group allocation: patients who received corticosteroids on the day of or after surgery were included in the noncorticosteroid group under the assumption that these were used for peri-or postoperative care. This overlap in exposure may muddy the data.
  • Balancing act: The group that received corticosteroids had lower hospital costs (likely due to no operative time) but were exposed to more CT scans and had greater odds of 7-day emergency department revisit (uncertain if attributable to corticosteroid course).

Why does it matter? 

There is marked variation amongst clinicians on the use of corticosteroids in the medical management of children with RPAs and PPAs. While corticosteroids may lower the odds of surgical drainage and save on health care costs, there are limitations to this study.

Clinically Relevant Bottom Line:

There is potentially a role for corticosteroids in the medical management of RPAs and PPAs by decreasing the need for surgical intervention. However, more prospective studies should be performed before the adoption of corticosteroids in the treatment of RPAs/PPAs into standard practice.

Reviewed by: Dennis Ren

Article 3: Bier’s Block vs Ketamine sedation for closed fracture reduction- which gets you out of hospital faster?

Kwong A, Aldridge E, Jayawardana R, et al Length of stay outcomes in patients receiving ketamine sedation versus Bier’s block anaesthesia for procedural fracture reduction: A retrospective audit of paediatric emergency department patients. Emerg Med Australas. 2021 Aug 29

What’s it all about?

This paper retrospectively compared the length of stay in patients receiving ketamine sedation versus those undergoing Bier’s block for closed forearm fracture reduction. A retrospective audit of 449 ED patients presenting to three Australian hospitals 2012-2017. 379 received ketamine 73 underwent Bier’s block. The median post-procedural length of stay was 75 minutes shorter in the group receiving Bier’s block. Those receiving ketamine were nine times more likely to require admission. There were no major adverse events in either group. Limitations: Bier’s block requires more cooperation which may prove problematic in younger patients and is a more complicated procedure that not all departments will have as part of their offerings. There were much fewer patients in the Bier’s Block treatment arm and the authors commented on issues with being able to access all of the documentation specifically timings as this was a retrospective review.

Why does it matter?

Forearm fractures are a common presentation in paediatric EDs, and closed fractures are often reduced in the department. Bier’s block is a form of intravenous regional anaesthesia (administered with a tourniquet in place to prevent systemic administration). Ketamine is a safe well-tolerated means of sedation that can be delivered intravenously or intramuscularly but it does require a period of observation following administration as well as a competent practitioner with specific training and airway skills. (For more information check out DFTB’s post on ketamine and procedural sedation.

The Bottom Line:

In ED we should be considering using Bier’s block for procedural sedation for fracture reduction of closed fractures in older and more cooperative patients. The skills required for this should be gained and maintained.

Reviewed by: Sarah Reynolds

Article 4: Evaluation of a Paediatric Early Warning Score as a Predictor of Occult Invasive Bacterial Infection in the Paediatric Emergency Department

Gardiner MA, Allen CH, Singh NV, Tresselt E, Young A, Hurley KK, Wilkinson MH. Evaluation of a Pediatric Early Warning Score as a Predictor of Occult Invasive Bacterial Infection in the Pediatric Emergency Department. Pediatr Emerg Care. 2021 Oct 26. doi: 10.1097/PEC.0000000000002554.

What’s it about?

This study primarily aimed to evaluate the diagnostic performance of a Paediatric Early Warning Score (PEWS) to predict an occult invasive bacterial infection (IBI) in well-appearing febrile paediatric emergency department (PED) patients without known risks for bacterial infection. Secondary aims were to assess the predictive characteristics of PEWS compared to heart rate (HR) and Emergency Severity Index (ESI) at PED triage and disposition. 

The authors performed a 3-year single-centre retrospective case-control analysis recruiting 267 febrile (fever above 38 degrees at triage or within the preceding 48 hours) PED patients (178 controls and 89 cases of occult IBI) aged 60 days to 18 years old. Exclusion criteria included if they were ill-appearing, admitted to ICU, or had a known high-risk condition. Occult IBI was defined as having a non-contaminant positive culture (bacterial Ag test, PCR or bacterial culture growth) other than an isolated positive urine culture. The primary outcome was the predictive characteristic of PEWS at ED disposition to identify occult IBI. Secondary outcomes were the predictive characteristics of triage PEWS, triage HR for age, disposition HR for age, and ESI. Compared with 178 controls, the 89 cases had a higher disposition PEWS, higher disposition HR for age, lower ESI and higher rate of hospital admission. Specifically, disposition PEWS ≥3, disposition HR > 99th percentile, ESI ≤3 and ESI ≤2 all demonstrated statistically significant increased odds of occult IBI. However, disposition PEWS demonstrated a low sensitivity at all cut-offs with 73% (65/89) occult IBI cases having a PEWS of zero at disposition. Disposition PEWS had a sensitivity ranging from 27% to 4.5%, and specificity ranging from 82.6% to 100%, for PEWS ≥1 and PEWS ≥4 scores respectively.

Why does it matter?

Although the incidence of occult IBI in previously healthy, well-appearing children is rare, accurate identification of these patients remains a difficult task. Having an accurate clinical decision tool to facilitate identification would help clinicians form a proper evaluation and disposition for these patients, and potentially avoid delay in treatment and subsequent complications.

The PEWS is a multi-faceted assessment that predicts a patient’s severity of illness or likelihood of decompensation based on a total score from 0 to 12, and has been previously validated to predict patients at risk of deterioration resulting in cardiopulmonary arrest and in an inpatient setting to predict the requirement for escalation of care or ICU admission.

The bottom line

PEWS score at ED disposition is an inadequate screening tool to predict occult IBI in previously healthy PED patients, and clinicians should maintain a high index of suspicion for occult IBI with a thorough clinical workup and their own clinical gestalt applied.

Reviewed by: Emma Chan

Article 5: Ultrasound to diagnose midgut volvulus/ rotation?

Nguyen, H.N., Kulkarni, M., Jose, J., Sisson, A., Brandt, M.L., Sammer, M.B. and Pammi, M., 2021. Ultrasound for the diagnosis of malrotation and volvulus in children and adolescents: a systematic review and meta-analysis. Archives of Disease in Childhood.

What’s it about?

This paper is the first systematic review of the diagnostic accuracy of USS in midgut malrotation with, or without volvulus, in children. Electronic database searches were completed over a 2-year period.  This provided 17 cohort cross-sectional studies and a grand total of 2257 participants. They found a summary sensitivity of 94% and specificity of 100% (moderate certainty evidence) when ultrasound was used for the diagnosis of malrotation when compared with the reference standard. The authors state that one of their limitations was the heterogeneity of studies. They have explored this further in a sub-group analysis.

Why does it matter?

Midgut malrotation, complicated by volvulus, is an acute surgical emergency. This may lead to midgut necrosis, with a high degree of morbidity and mortality. 75% of children will be asymptomatic but may present acutely unwell before five years of age. Since the late 1960s, upper GI contrast studies have been used, with varying success to achieve a 2D image of a 3D structure. This technique relies on a radiologist, an enteric tube, and the evaluation of the duodenal jejunal junction. Ultrasound has been used since 1987 to look for the ‘whirlpool’ sign. This is direct visualisation of the SMV (superior mesenteric vein) with proximal small bowel swirling around the SMA (superior mesenteric artery)- a reversal of the normal SMA-SMV relationship.

Clinically Relevant Bottom Line:

Ultrasound is portable, gives off no ionising radiation and no enteric tube is needed. It is, however, operator dependent and may be disrupted by the air interface (air in between bowel walls). There is also, unfortunately, no consensus between radiologists and surgeons on the clinical signs that correlate with positive findings at laparotomy.  This being said, a positive test on ultrasound increases the probability of having malrotation, with or without volvulus, to 98%. A negative test decreases the probability to 1%. More formal studies are needed, but this is a massive step in the right direction and may be able to be brought into an emergency department near you, very soon.

Reviewed by: Sam Danaher

If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments!

That’s it for this month. Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to.

All articles reviewed and edited by Vicki Currie

About the authors

  • Vicki is a Paediatric Registrar in the West Midlands in the UK , starting PEM in September 2021. Vicki is passionate about good communication in teams and with patients along with teaching at undergraduate and postgraduate level. When not editing Bubble wrap Vicki can be found running with her cocker spaniel Scramble or endlessly chatting with friends.

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