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Uber AM, Han J, Grimm P, Montez-Rath ME, Chaudhuri A. Defining systolic blood pressure normative values in hospitalized pediatric patients: a single center experience. Pediatr Res 2024; 95:1860-1867. [PMID: 38326477 DOI: 10.1038/s41390-024-03059-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/12/2023] [Accepted: 01/15/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Normative blood pressure (BP) values and definition of hypertension (HTN) in children in outpatient setting cannot be reliably used for inpatient therapy initiation. No normative exists to describe HTN in hospitalized pediatric populations. We aimed to study the prevalence of hypertension and produce normative BP values in hospitalized children. METHODS Cross sectional observational study of all children hospitalized on acute care floors, ≥2 and <18 years age, at Stanford Children's Hospital, from Jan-01-2014 to Dec-31-2018. Cohort included 7468 hospital encounters with a total of 118,423 automated, oscillometric, BPs measured in the upper extremity during a hospitalization of >24 hours. RESULTS Overall prevalence of HTN, defined by outpatient guidelines, was 12-48% in boys and 6-39% in girls, stage 1 systolic HTN in 12-38% of boys and 6-31% of girls, stage 2 systolic HTN in 3-10% of boys and 1-8% of girls. Centile curves were derived demonstrating overall higher BP reading for hospitalized patients compared to the outpatient setting. CONCLUSION Higher blood pressures are anticipated during hospitalization. Thresholds provided by the centile curves generated in this study may provide the clinician with some guidance on how to manage hospitalized pediatric patients based on clinical circumstances. IMPACT Hospitalized children have higher blood pressures compared to patients in the ambulatory setting, hence outpatient normative blood pressure values cannot be reliably used for inpatient therapy initiation. No normative exists to describe hypertension in hospitalized pediatric populations. The thresholds provided by the centile curves generated in this study may provide the clinician with some guidance on how to manage hospitalized pediatric patients based on clinical circumstances.
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Affiliation(s)
- Amanda M Uber
- Department of Nephrology, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Jialin Han
- Department of Nephrology, Stanford University School of Medicine, Stanford, CA, USA
| | - Paul Grimm
- Department of Pediatrics (Nephrology), Stanford University School of Medicine, Stanford, CA, USA
| | - Maria E Montez-Rath
- Department of Nephrology, Stanford University School of Medicine, Stanford, CA, USA
| | - Abanti Chaudhuri
- Department of Pediatrics (Nephrology), Stanford University School of Medicine, Stanford, CA, USA.
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Measuring the association between temperature and heart rate in children: be aware of the uncertainties. Eur J Emerg Med 2023; 30:147-148. [PMID: 36815480 DOI: 10.1097/mej.0000000000000998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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Dang R, Schroeder AR, Weng Y, Wang ME, Patel AI. A Cross-sectional Study Characterizing Pediatric Temperature Percentiles in Children at Well-Child Visits. Acad Pediatr 2023; 23:287-295. [PMID: 35914730 DOI: 10.1016/j.acap.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Temperature measurement plays a central role in determining pediatric patients' disease risk and management. However, current pediatric temperature thresholds may be outdated and not applicable to children. OBJECTIVE To characterize pediatric temperature norms and variation by patient characteristics, time of measurement, and thermometer route. METHODS In this cross-sectional study, we analyzed 134,641 well-child visits occurring between 2014-2019 at primary care clinics that routinely measured temperature. We performed bivariate and multivariable quantile regressions with clustered standard errors to determine temperature percentiles and variation by age, sex, time of measurement, and thermometer route. We performed sensitivity analyses: 1) using a cohort that excluded visits with infectious diagnoses that could explain temperature aberrations and 2) including clinic as a fixed effect. RESULTS The median rectal temperature for visits of infants ≤12 months old was 37.2˚C, which was 0.4˚C higher than the median axillary temperature. The median axillary temperature for children 1-18 years old was 36.7˚C, which was 0.1˚C lower than the median values of all other routes. The 99th percentile for rectal temperatures in infants was 37.8˚C and the 99.9th percentile for axillary temperatures in children was 38.5˚C. Adjusted analyses did not demonstrate clinically significant variation in temperature by sex, age, or time of measurement. CONCLUSIONS These updated temperature norms can serve as reference values in clinical practice and should be considered in the context of thermometer route used and the clinical condition being evaluated. Variations in temperature values by sex, age, and time of measurement were not clinically significant.
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Affiliation(s)
- Rebecca Dang
- Department of Pediatrics (R Dang, AR Schroeder, ME Wang, AI Patel), Stanford University School of Medicine, Palo Alto, Calif.
| | - Alan R Schroeder
- Department of Pediatrics (R Dang, AR Schroeder, ME Wang, AI Patel), Stanford University School of Medicine, Palo Alto, Calif
| | - Yingjie Weng
- Department of Medicine - Quantitative Sciences Unit (Y Weng), Stanford University School of Medicine, Palo Alto, Calif
| | - Marie E Wang
- Department of Pediatrics (R Dang, AR Schroeder, ME Wang, AI Patel), Stanford University School of Medicine, Palo Alto, Calif
| | - Anisha I Patel
- Department of Pediatrics (R Dang, AR Schroeder, ME Wang, AI Patel), Stanford University School of Medicine, Palo Alto, Calif
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Capua M, Amlicke M, Esposito E, Belfer J, Bellis M, Falkowitz D, Teng D. Time of Observation in Xenobiotic Ingestions in Children: Is 6 Hours Too Long? Pediatr Emerg Care 2023; 39:e24-e29. [PMID: 35439241 DOI: 10.1097/pec.0000000000002707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Children endure a prolonged observation after xenobiotic ingestions, despite low associated morbidity and mortality. The primary objective was to describe the management and outcomes of acute xenobiotic exposures in asymptomatic pediatric patients presenting to the emergency department (ED). A secondary objective was to explore the impact of vital signs on the patients' management and outcomes. METHODS We conducted a retrospective review of asymptomatic children (younger than 18 years) presenting to a pediatric ED after a toxic ingestion from 2014 to 2018. Ingestions of hydrocarbons, acetaminophen, salicylates, sulfonylureas, caustic, and/or extended release agents were excluded. Demographic and clinical data were abstracted. RESULTS Of 2817 charts, we identified 109 asymptomatic patients with a mean age of 4.7 years. The average observation from registration to disposition was 4.06 hours. Five patients were admitted and were subsequently discharged within 24 hours. Of the discharged patients, 2 returned within 72 hours and were subsequently discharged home. A total of 321 asymptomatic patients presented with ≥1 abnormal vital signs (mean age, 6.6 years) and were observed in the ED for an average of 4.54 hours. They had a higher percentage of ingestions related to suicide attempts (odds ratio, 6.8). Twenty-two were admitted. Of those discharged home, 11 returned to the ED within 72 hours; all were subsequently discharged home. CONCLUSIONS Prolonged observations may not be necessary after ingestions in asymptomatic children. Vital sign abnormalities at presentation did not impact disposition. Prospective studies are needed to determine the safety and efficacy of this shortened observation.
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Affiliation(s)
- Maya Capua
- From the Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maire Amlicke
- Division of Pediatric Emergency Medicine, Cohen Children's Medical Center, New Hyde Park, NY
| | - Emily Esposito
- St. George's University Medical School, West Indies, Grenada
| | - Joshua Belfer
- Division of Pediatric Emergency Medicine, Cohen Children's Medical Center, New Hyde Park, NY
| | - Mitchell Bellis
- New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
| | | | - David Teng
- Division of Pediatric Emergency Medicine, Cohen Children's Medical Center, New Hyde Park, NY
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Jiang P, Gao F, Liu S, Zhang S, Zhang X, Xia Z, Zhang W, Jiang T, Zhu JL, Zhang Z, Shu Q, Snyder M, Li J. Longitudinally tracking personal physiomes for precision management of childhood epilepsy. PLOS DIGITAL HEALTH 2022; 1:e0000161. [PMID: 36812648 PMCID: PMC9931296 DOI: 10.1371/journal.pdig.0000161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 11/13/2022] [Indexed: 12/24/2022]
Abstract
Our current understanding of human physiology and activities is largely derived from sparse and discrete individual clinical measurements. To achieve precise, proactive, and effective health management of an individual, longitudinal, and dense tracking of personal physiomes and activities is required, which is only feasible by utilizing wearable biosensors. As a pilot study, we implemented a cloud computing infrastructure to integrate wearable sensors, mobile computing, digital signal processing, and machine learning to improve early detection of seizure onsets in children. We recruited 99 children diagnosed with epilepsy and longitudinally tracked them at single-second resolution using a wearable wristband, and prospectively acquired more than one billion data points. This unique dataset offered us an opportunity to quantify physiological dynamics (e.g., heart rate, stress response) across age groups and to identify physiological irregularities upon epilepsy onset. The high-dimensional personal physiome and activity profiles displayed a clustering pattern anchored by patient age groups. These signatory patterns included strong age and sex-specific effects on varying circadian rhythms and stress responses across major childhood developmental stages. For each patient, we further compared the physiological and activity profiles associated with seizure onsets with the personal baseline and developed a machine learning framework to accurately capture these onset moments. The performance of this framework was further replicated in another independent patient cohort. We next referenced our predictions with the electroencephalogram (EEG) signals on selected patients and demonstrated that our approach could detect subtle seizures not recognized by humans and could detect seizures prior to clinical onset. Our work demonstrated the feasibility of a real-time mobile infrastructure in a clinical setting, which has the potential to be valuable in caring for epileptic patients. Extension of such a system has the potential to be leveraged as a health management device or longitudinal phenotyping tool in clinical cohort studies.
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Affiliation(s)
- Peifang Jiang
- National Clinical Research Center for Child Health, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Feng Gao
- National Clinical Research Center for Child Health, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Sixing Liu
- SensOmics, Inc. Burlingame, California, United States of America
| | - Sai Zhang
- SensOmics, Inc. Burlingame, California, United States of America
| | - Xicheng Zhang
- National Clinical Research Center for Child Health, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Genetics, Center for Genomics and Personalized Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Zhezhi Xia
- National Clinical Research Center for Child Health, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weiqin Zhang
- National Clinical Research Center for Child Health, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tiejia Jiang
- National Clinical Research Center for Child Health, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jason L. Zhu
- SensOmics, Inc. Burlingame, California, United States of America
| | - Zhaolei Zhang
- SensOmics, Inc. Burlingame, California, United States of America
- Donnelly Centre, Department of Computer Science and Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
- * E-mail: (ZZ); (QS); (MS); (JL)
| | - Qiang Shu
- National Clinical Research Center for Child Health, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- * E-mail: (ZZ); (QS); (MS); (JL)
| | - Michael Snyder
- SensOmics, Inc. Burlingame, California, United States of America
- * E-mail: (ZZ); (QS); (MS); (JL)
| | - Jingjing Li
- SensOmics, Inc. Burlingame, California, United States of America
- * E-mail: (ZZ); (QS); (MS); (JL)
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Relationship Between Body Temperature and Heart Rate in Children With No Other Apparent Cause of Tachycardia. Pediatr Emerg Care 2022; 38:644-649. [PMID: 35786789 DOI: 10.1097/pec.0000000000002617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to investigate the normal heart rate range for each body temperature in patients visiting the emergency department (ED) with no other, apparent, coexisting factors causing tachycardia. METHODS This was an observational study conducted in the ED at a single children's hospital between April 1, 2014, and March 31, 2017. Data on all visits were extracted from the electronic triage system and were excluded if they indicated the presence of factors other than body temperature potentially increasing the heart rate. We created age-dependent heart rate percentile curves for body temperature in 6 age categories: 0 to younger than 3 months, 3 to younger than 12 months, 1 to younger than 2 years, 2 to younger than 5 years, 5 to younger than 10 years, and 10 years or older. The curves were created for the body temperatures of 36.0°C to 38.0°C for the 0 to younger than 3 months age group and for body temperatures of 36.0°C to 40.5°C for the other age groups. RESULTS Of the 113,242 patients included, 61,321 were analyzed. The percentile curves across all age groups were similar despite differences in the baseline heart rate. Heart rate increase was steepest between 37.0°C and 38.0°C at a rate of approximately 20 beats per minute per degree Celsius for all groups. Compared with previous studies in the outpatient setting, including the ED, heart rate was lower in younger patients and was similar among older patients. CONCLUSIONS We created new, age-dependent heart rate percentile curves for body temperature for use in the ED setting. In outpatients, the effect of coexisting factors affecting heart rate, such as crying, may be higher among younger patients.
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Heal C, Harvey A, Brown S, Rowland AG, Roland D. The association between temperature, heart rate, and respiratory rate in children aged under 16 years attending urgent and emergency care settings. Eur J Emerg Med 2022; 29:413-416. [PMID: 35679531 PMCID: PMC9605188 DOI: 10.1097/mej.0000000000000951] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/10/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND IMPORTANCE Body temperature is considered an independent determinant of respiratory rate and heart rate; however, there is limited scientific evidence regarding the association. This study aimed to assess the association between temperature, and heart rate and respiratory rate in children. OBJECTIVE The objective of this study was to validate earlier findings that body temperature causes an increase of approximately 10 bpm rise in heart rate per 1 °C rise in temperature, in children aged under 16 years old. DESIGN A prospective study using anonymised prospectively collected patient data of 188 635 attendances, retrospectively extracted from electronic patient records. SETTINGS AND PARTICIPANTS Four Emergency or Urgent Care Departments in the North West of England. Participants were children and young people aged 0-16 years old who attended one of the four sites over a period of 3 years. OUTCOME MEASURES AND ANALYSIS Multiple linear regression models, adjusted for prespecified confounders (including oxygen saturation, heart rate, respiratory rate, site of attendance, age), were used to examine the influence of various variables on heart rate and respiratory rate. MAIN RESULTS Among the 235 909 patient visits (median age 5) included, the mean temperature was 37.0 (SD, 0.8). Mean heart rate and respiratory rate were 115.6 (SD, 29.0) and 26.9 (SD, 8.3), respectively. For every 1 °C increase in temperature, heart rate will on average be 12.3 bpm higher (95% CI, 12.2-12.4), after accounting for oxygen saturation, location of attendance, and age. For every 1 °C increase in temperature, there is on average a 0.3% decrease (95% CI, 0.2-0.4%) in respiratory rate. CONCLUSION In this study on children attending urgent and emergency care settings, there was an independent association between temperature and heart rate but not between temperature and respiratory rate.
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Affiliation(s)
- Calvin Heal
- Centre for Biostatistics, The University of Manchester
| | - Anna Harvey
- North Manchester General Hospital, Manchester University NHS Foundation Trust, Manchester
| | | | - Andrew Graeme Rowland
- North Manchester General Hospital, Manchester University NHS Foundation Trust, Manchester
- School of Health and Society, The University of Salford, Salford
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children’s Emergency Department, Leicester Royal Infirmary
- SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
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Vital sign predictors of severe influenza among children in an emergent care setting. PLoS One 2022; 17:e0272029. [PMID: 35960719 PMCID: PMC9374253 DOI: 10.1371/journal.pone.0272029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/12/2022] [Indexed: 11/19/2022] Open
Abstract
Background Decisions regarding the evaluation of children with influenza infection rely on the likelihood of severe disease. The role of early vital signs as predictors of severe influenza infection in children is not well known. Our objectives were to determine the value of vital signs in predicting hospitalization/recurrent emergency department (ED) visits due to influenza infection in children. Methods We conducted a prospective study of children aged 6 months to 8 years of age with influenza like illness evaluated at an ED/UC from 2016–2018. All children underwent influenza testing by PCR. We collected heart rate, respiratory rate and temperature, and converted heart rate (HR) and respiratory rate (RR) to z-scores by age. HR z scores were further adjusted for temperature. Our primary outcome was hospitalization/recurrent ED visits within 72 hours. Vital sign predictors with p< 0.2 and other clinical covariates were entered into a multivariable logistic regression model to determine odds ratios (OR) and 95% CI; model performance was assessed using the Brier score and discriminative ability with the C statistic. Results Among 1478 children, 411 (27.8%) were positive for influenza, of which 42 (10.2%) were hospitalized or had a recurrent ED visit. In multivariable analyses, adjusting for age, high-risk medical condition and school/daycare attendance, higher adjusted respiratory rate (OR 2.09, 95%CI 1.21–3.61, p = 0.0085) was a significant predictor of influenza hospitalization/recurrent ED visits. Conclusions Higher respiratory rate adjusted for age was the most useful vital sign predictor of severity among young children with PCR-confirmed influenza.
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Eşki A, Öztürk GK, Turan C, Özgül S, Gülen F, Demir E. High-flow nasal cannula oxygen in children with bronchiolitis: A randomized controlled trial. Pediatr Pulmonol 2022; 57:1527-1534. [PMID: 35293153 DOI: 10.1002/ppul.25893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 01/22/2022] [Accepted: 03/14/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To determine whether high-flow nasal cannula oxygen (HFNCO) provided enhanced respiratory support in bronchiolitis than low-flow oxygen (LFO). METHODS We conducted a prospective, randomized controlled trial in children between 1 and 24 months diagnosed with moderate-to-severe bronchiolitis requiring oxygen therapy. Participants received LFO via face mask (6-10 L/min) or HFNCO (2 L/kg/min). Primary outcomes were the time that heart rate (HR) and respiratory rate (RR) return to their normal range for age and the time that baseline clinical respiratory score (CRS) regress to a lower severity score. Secondary outcomes were changes in HR, RR, and CRS over time, length of stay (LOS), duration of oxygen requirement, treatment failure, and adverse event (AE). RESULTS Eighty-seven children were enrolled (48 in LFO; 39 in HFNCO). The time that HR and RR baseline values reached their normal range for age was shorter in HFNCO therapy (2.0 h [1.0-4.0] vs. 12.0 h [2.0-24.0], and 4.0 h [2.0-12.0] vs. 24.0 h [4.0-48.0], respectively; p < 0.001); additionally, the improvement in CRS emerged more quickly in children treated with HFNCO (2.0 h [1.0-4.0] vs. 4.0 h [2.0-24.0]; p = 0.003). While the duration of oxygen requirement (19.0 h [4.0-30.0] vs. 29.5 h [14.0-45.7]; p = 0.009) and treatment failure (3% vs. 21%) was statistically lower in children who received HFNCO, there were no differences in LOS and AE between groups. CONCLUSION HFNCO may provide enhanced respiratory support with a notable improvement in HR, RR, and CRS than LFO. Comprehensive studies are needed to assess the clinical efficacy of HFNCO therapy.
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Affiliation(s)
- Aykut Eşki
- Division of Pediatric Pulmonology, Department of Pediatrics, Gazi Yaşargil Gynecology, Child Health, and Diseases Training and Research Hospital, University of Health Sciences, Diyarbakır, Turkey
| | - Gökçen Kartal Öztürk
- Division of Pediatric Pulmonology, Department of Pediatrics, Ege University Medical Faculty, Ege University Children Hospital, Izmir, Turkey
| | - Caner Turan
- Division of Emergency Medicine, Department of Pediatrics, Ege University Medical Faculty, Ege University Children Hospital, Izmir, Turkey
| | - Semiha Özgül
- Department of Medical Informatics, School of Medicine, Ege University, Izmir, Turkey
| | - Figen Gülen
- Division of Pediatric Pulmonology, Department of Pediatrics, Ege University Medical Faculty, Ege University Children Hospital, Izmir, Turkey
| | - Esen Demir
- Division of Pediatric Pulmonology, Department of Pediatrics, Ege University Medical Faculty, Ege University Children Hospital, Izmir, Turkey
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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 2022; 38:195-200. [PMID: 34711757 DOI: 10.1097/pec.0000000000002554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aims of the study were to evaluate the diagnostic performance of Pediatric Early Warning Score (PEWS) to predict occult invasive bacterial infection (IBI) in well-appearing pediatric emergency department (PED) patients without known risk factors for bacterial infection and to compare PEWS to heart rate (HR) and Emergency Severity Index (ESI). METHODS We performed a retrospective case-control analysis of febrile PED patients aged 60 days to 18 years over a 2-year period. Subjects were excluded if they were ill appearing, admitted to an intensive care unit, or had a known high-risk condition. Cases of occult IBI were included if they had a noncontaminant positive culture other than an isolated positive urine culture. Two febrile control subjects were identified for each case. Odds ratios and receiver operating characteristic curves were evaluated to determine performance characteristics of PEWS at triage and disposition, age-adjusted HR at triage and disposition, and ESI at triage. RESULTS Compared with 178 controls, 89 cases had higher disposition PEWS, higher disposition HR, lower ESI, and higher rate of hospital admission. Disposition PEWS ≥3 (odds ratio, 2.57; 95% confidence interval, 1.08-6.18), disposition HR > 99th percentile, and ESI demonstrated increased odds of occult IBI. Area under the receiver operating characteristic curve for disposition PEWS (0.56) was similar to triage PEWS (0.54), triage HR (0.54), disposition HR (0.58), and ESI (0.65). CONCLUSIONS Subjects with PEWS ≥3 at PED disposition have increased odds of occult IBI; however, PEWS has poor discriminative ability at all cutoffs. We cannot recommend PEWS used in isolation to predict occult IBI.
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Affiliation(s)
- Michael A Gardiner
- From the Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, CA
| | | | - Nidhi V Singh
- Department of Pediatrics, Baylor College of Medicine, Houston
| | - Erin Tresselt
- Department of Pediatrics, University of Texas Southwestern Medical School, Dallas, TX
| | - Andrew Young
- Department of Anesthesia, University of Colorado School of Medicine, Denver, CO
| | - Kara K Hurley
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, TX
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Kurosawa H, Shiima Y, Miyakoshi C, Nezu M, Someya M, Yoshida M, Nagase H, Nozu K, Kosaka Y, Iijima K. The association between prehospital vital signs of children and their critical clinical outcomes at hospitals. Sci Rep 2022; 12:5199. [PMID: 35338242 PMCID: PMC8956615 DOI: 10.1038/s41598-022-09271-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/21/2022] [Indexed: 11/08/2022] Open
Abstract
Vital signs are important for patient assessment, but little is known about interpreting those of children in prehospital settings. We conducted an observational study to investigate the association between prehospital vital signs of children and their clinical outcomes in hospitals. We plotted the data of patients with critical outcomes on published reference ranges, such as those of healthy children to evaluate the clinical relevance. Of the 18,493 children screened, 4477 transported to tertiary hospitals were included in the analysis. The outcomes 12 h after being transported to a tertiary hospital were as follows: deceased, 41; hospitalization with critical deterioration events, 65; hospitalization without critical deterioration events, 1086; returned home, 3090; and unknown, 195. The reference ranges of the heart rates (sensitivity: 57.7%, specificity: 67.5%) and respiratory rates (sensitivity: 54.5%, specificity: 67.7%) of healthy children worked best to detect the critical outcomes. Therefore, the reference ranges of healthy children were concluded to be suitable in prehospital settings; however, excessive reliance on vital signs carried potential risks due to their limited sensitivities and specificities. Future studies are warranted to investigate indicators with higher sensitivities and specificities.
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Affiliation(s)
- Hiroshi Kurosawa
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan.
- Department of Advanced Pediatric Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan.
- Division of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, 1-6-7, Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Yuko Shiima
- Division of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, 1-6-7, Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Chisato Miyakoshi
- Department of Research Support, Center for Clinical Research and Innovation, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Mari Nezu
- Department of Pediatrics, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Maki Someya
- Division of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, 1-6-7, Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Minae Yoshida
- Division of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, 1-6-7, Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Hiroaki Nagase
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Yoshiyuki Kosaka
- Department of Advanced Pediatric Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
- Department of Advanced Pediatric Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
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Eisenberg M, Puder M, Hudgins J. Prediction of the Development of Severe Sepsis Among Children With Intestinal Failure and Fever Presenting to the Emergency Department. Pediatr Emerg Care 2021; 37:e1366-e1372. [PMID: 32149998 DOI: 10.1097/pec.0000000000002048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Children with intestinal failure (IF) and fever are frequently bacteremic, but risk factors for development of sepsis in this population are not well delineated. Our objective was to determine what clinical factors available on arrival to the emergency department (ED), including commonly used vital sign thresholds, predicted the subsequent development of severe sepsis in children with IF and fever. STUDY DESIGN This was a retrospective cohort study of children younger than 21 years with IF presenting to a tertiary care ED between 2010 and 2016 with fever who did not have hypotensive septic shock on arrival. The primary outcome was development of severe sepsis within 24 hours of ED arrival, as defined by consensus criteria. We identified predictors of severe sepsis using both univariate and multivariate models and calculated the test characteristics of 3 different sets of vital sign criteria in determining risk of severe sepsis. RESULTS In 26 (9.4%) of 278 encounters, the patient developed severe sepsis within 24 hours of arrival to the ED; 3 were excluded due to hypotensive shock on arrival. Predictors of severe sepsis included history of intestinal pseudo-obstruction (odds ratio, 8.2; 95% confidence interval, 2.3-30.2) and higher initial temperature (odds ratio, 1.7; 95% confidence interval, 1.2-2.3). The 3 sets of vital sign criteria had widely varying sensitivity and specificity in identifying development of severe sepsis. CONCLUSIONS History of intestinal pseudo-obstruction and higher fever predicted increased risk of severe sepsis among children with IF and fever presenting to an ED. No single set of vital sign criteria had both high sensitivity and specificity for this diagnosis.
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Daymont C, Balamuth F, Scott HF, Bonafide CP, Brady PW, Depinet H, Alpern ER. Elevated Heart Rate and Risk of Revisit With Admission in Pediatric Emergency Patients. Pediatr Emerg Care 2021; 37:e185-e191. [PMID: 30020247 PMCID: PMC6335199 DOI: 10.1097/pec.0000000000001552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to identify emergency department (ED) heart rate (HR) values that identify children at elevated risk of ED revisit with admission. METHODS We performed a retrospective cohort study of patients 0 to 18 years old discharged from a tertiary-care pediatric ED from January 2013 to December 2014. We created percentile curves for the last recorded HR for age using data from calendar year 2013 and used receiver operating characteristic (ROC) curves to characterize the performance of the percentiles for predicting ED revisit with admission within 72 hours. In a held-out validation data set (calendar year 2014 data), we evaluated test characteristics of last-recorded HR-for-age cut points identified as promising on the ROC curves, as well as those identifying the highest 5% and 1% of last recorded HRs for age. RESULTS We evaluated 183,433 eligible ED visits. Last recorded HR for age had poor discrimination for predicting revisit with admission (area under the curve, 0.61; 95% confidence interval, 0.58-0.63). No promising cut points were identified on the ROC curves. Cut points identifying the highest 5% and 1% of last recorded HRs for age showed low sensitivity (10.1% and 2.5%) with numbers needed to evaluate of 62 and 50, respectively, to potentially prevent 1 revisit with admission. CONCLUSIONS Last recorded ED HR discriminates poorly between children who are and are not at risk of revisit with admission in a pediatric ED. The use of single-parameter HR in isolation as an automated trigger for mandatory reevaluation prior to discharge may not improve revisit outcomes.
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Affiliation(s)
- Carrie Daymont
- Departments of Pediatrics and Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Fran Balamuth
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Halden F Scott
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christopher P Bonafide
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Holly Depinet
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Distribution of Pediatric Vital Signs in the Emergency Department: A Nationwide Study. CHILDREN 2020; 7:children7080089. [PMID: 32764263 PMCID: PMC7465456 DOI: 10.3390/children7080089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 11/16/2022]
Abstract
To effectively use vital signs as indicators in children, the magnitude of deviation from expected vital sign distribution should be determined. The purpose of this study is to derive age-specific centile charts for the heart rate and respiratory rate of the children who visited the emergency department. This study used the Korea’s National Emergency Department Information System dataset. Patients aged <16 years visiting the emergency department between 1 January 2016 and 31 December 2017 were included. Heart rate and respiratory rate centile charts were derived from the population with normal body temperature (36 to <38 °C). Of 1,901,816 data points retrieved from the database, 1,454,372 sets of heart rates and 1,458,791 sets of respiratory rates were used to derive centile charts. Age-specific centile charts and curves of heart rates and respiratory rates showed a decline in heart rate and respiratory rate from birth to early adolescence. There were substantial discrepancies in the reference ranges of Advanced Paediatric Life Support and Pediatric Advanced Life Support guidelines. Age-based heart rate and respiratory rate centile charts at normal body temperature, derived from children visiting emergency departments, serve as new evidence-based data and can be used in follow-up studies to improve clinical care for children.
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The Role of Viral Coinfection in Bronchiolitis Treated With High-Flow Nasal Cannula at Pediatric Emergency Department During 2 Consecutive Seasons: An Observational Study. Pediatr Infect Dis J 2020; 39:102-107. [PMID: 31725117 DOI: 10.1097/inf.0000000000002512] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND The role of multiple respiratory viruses in bronchiolitis treated with high-flow nasal cannula (HFNC) has not been thoroughly investigated. We evaluated the contribution of coinfection on clinical course of bronchiolitis treated with HFNC and on response to this treatment. METHODS We selected 120 children with bronchiolitis, younger than 12 months, admitted to Emergency Department between 2016 and 2018 and treated with HFNC. We compared single and multiple virus infections in relation to specific outcomes such as the clinical response to HFNC and the HFNC failure. The multiple virus infection was defined by the detection of 2 or more viruses in nasopharyngeal aspirates. The HFNC failure was defined as escalation to higher level of care, including Helmet-Continuous Positive Airway Pressure, invasive ventilation or transfer to pediatric intensive care unit within 48 hours from the time of HFNC initiation. We also performed a comparison between HFNC failure and HFNC not-failure groups according to the number of virus and the type of virus. RESULTS The severity score post-HFNC initiation was significantly associated with coinfection [odds ratio (OR): 1.361; 95% confidence interval (CI): 1.036-1.786; P = 0.027]. The likelihood of coinfection decreased by 23.1% for each increase of saturation O2 after HFNC initiation (OR: 0.769; 95% CI: 0.609-0.972; P = 0.028). Atelectasis was more likely to occur in coinfection (OR: 2.923; 95% CI: 1.049-8.148; P = 0.04). The duration of HFNC treatment increased significantly in coinfection (OR: 1.018; 95% CI: 1.006-1.029; P = 0.002). No significant differences were described between HFNC failure and the number and the type of detected viruses. CONCLUSIONS The detection of multiple viruses and the type of virus did not influence the HFNC failure, although the coinfection was associated with a deterioration of severity score, a longer HFNC treatment and a major presence of atelectasis. The role of coinfection on HFNC treatment might subtend a complex interplay between multiple viruses and host susceptibility.
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Dagdanpurev S, Tsogzolmaa U, Sun G, Choimaa L, Abe S, Matsui T. Development of a low-cost, portable, pediatric infection screening system using simultaneous measurement of multiple vital signs. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:7181-7184. [PMID: 31947491 DOI: 10.1109/embc.2019.8857689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The primary cause of death among children under age 5 years is acute respiratory infection, such as pneumonia. Detection of infection at the earliest point of contagion is necessary, to reduce morbidity and prevent infectious disease epidemics; therefore, identifying abnormal vital signs is essential. For early detection of pediatric infections, we developed a low-cost, portable, rapid screening system of pediatric infection. The system simultaneously measures three vital signs: heart rate (HR), respiration rate (RR), and body temperature (Temp) within 10 seconds using a pulse sensor, Doppler radar, and an infrared thermopile. Vital sign signal processing and computation are conducted using an Arduino Nano microprocessor, enabling the small, lightweight, and portable design of this system. Moreover, the cost-effectiveness of the system facilitates system applications in developing countries, which have the highest levels of pediatric mortality. We conducted trial measurement in Bayangol Health Center, Ulaanbaatar, Mongolia in 2019. A total of 50 children (age 1-14 years, 26 boys/24 girls) were enrolled in this study. Bland-Altman plot and Pearson correlation methods were used to evaluate the accuracy of the proposed system. The correlation coefficients were calculated as HR: r=0.92, RR: r=0.8, and Temp: r=0.82, with p<; 0.01. The system appears promising for rapid and convenient detection of infection in children.
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Temporal Variability in the Sampling of Vital Sign Data Limits the Accuracy of Patient State Estimation. Pediatr Crit Care Med 2019; 20:e333-e341. [PMID: 31162373 DOI: 10.1097/pcc.0000000000001984] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Physiologic signals are typically measured continuously in the critical care unit, but only recorded at intermittent time intervals in the patient health record. Low frequency data collection may not accurately reflect the variability and complexity of these signals or the patient's clinical state. We aimed to characterize how increasing the temporal window size of observation from seconds to hours modifies the measured variability and complexity of basic vital signs. DESIGN Retrospective analysis of signal data acquired between April 1, 2013, and September 30, 2015. SETTING Critical care unit at The Hospital for Sick Children, Toronto. PATIENTS Seven hundred forty-seven patients less than or equal to 18 years old (63,814,869 data values), within seven diagnostic/surgical groups. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Measures of variability (SD and the absolute differences) and signal complexity (multiscale sample entropy and detrended fluctuation analysis [expressed as the scaling component α]) were calculated for systolic blood pressure, heart rate, and oxygen saturation. The variability of all vital signs increases as the window size increases from seconds to hours at the patient and diagnostic/surgical group level. Significant differences in the magnitude of variability for all time scales within and between groups was demonstrated (p < 0.0001). Variability correlated negatively with patient age for heart rate and oxygen saturation, but positively with systolic blood pressure. Changes in variability and complexity of heart rate and systolic blood pressure from time of admission to discharge were found. CONCLUSIONS In critically ill children, the temporal variability of physiologic signals supports higher frequency data capture, and this variability should be accounted for in models of patient state estimation.
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Lockwood J, Reese J, Wathen B, Thomas J, Brittan M, Iwanowski M, McLeod L. The Association Between Fever and Subsequent Deterioration Among Hospitalized Children With Elevated PEWS. Hosp Pediatr 2019; 9:170-178. [PMID: 30760491 PMCID: PMC6391037 DOI: 10.1542/hpeds.2018-0187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To evaluate the association between fever and subsequent deterioration among patients with Pediatric Early Warning Score (PEWS) elevations to ≥4 to inform improvements to care escalation processes at our institution. METHODS We performed a cohort study of hospitalized children at a single quaternary children's hospital with PEWS elevations to ≥4 between January 1, 2014 and March 31, 2014. Bivariable analysis was used to compare characteristics between patients with and without unplanned ICU transfers and critical deterioration events (CDEs) (ie, unplanned ICU transfers with life-sustaining interventions initiated in the first 12 ICU hours). A multivariable Poisson regression was used to assess the relative risk of unplanned ICU transfers and CDEs. RESULTS The study population included 220 PEWS elevations from 176 unique patients. Of those, 33% had fever (n = 73), 40% experienced an unplanned ICU transfer (n = 88), and 19% experienced CDEs (n = 42). Bivariable analysis revealed that febrile patients were less likely to experience an unplanned ICU transfer than those without fever. The same association was found in multivariable analysis with only marginal significance (adjusted relative risk 0.68; 95% confidence interval 0.45-1.01; P = .058). There was no difference in the CDE risk for febrile versus afebrile patients (adjusted relative risk 0.79; 95% confidence interval 0.43-1.44; P = .44). CONCLUSIONS At our institution, patients with an elevated PEWS appeared less likely to experience an unplanned ICU transfer if they were febrile. We were underpowered to evaluate the effect on CDEs. These findings contributed to our recognition that (1) PEWS may not include all relevant clinical factors used for clinical decision-making regarding care escalation and (2) further study is needed in this area.
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Affiliation(s)
- Justin Lockwood
- Section of Hospital Medicine, Department of Pediatrics, School of Medicine, and
- Children's Hospital Colorado, Aurora, Colorado
| | - Jennifer Reese
- Section of Hospital Medicine, Department of Pediatrics, School of Medicine, and
- Children's Hospital Colorado, Aurora, Colorado
| | - Beth Wathen
- PICU and
- Children's Hospital Colorado, Aurora, Colorado
| | - Jacob Thomas
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado; and
- Children's Hospital Colorado, Aurora, Colorado
| | - Mark Brittan
- Section of Hospital Medicine, Department of Pediatrics, School of Medicine, and
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado; and
- Children's Hospital Colorado, Aurora, Colorado
| | - Melissa Iwanowski
- Children's Hospital Colorado, Aurora, Colorado
- Quality and Patient Safety
| | - Lisa McLeod
- Section of Hospital Medicine, Department of Pediatrics, School of Medicine, and
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado; and
- Children's Hospital Colorado, Aurora, Colorado
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Miyakoshi C, Yamamoto Y, Yamakawa M, Fukuhara S. Heart Rate, Responsiveness to Intravenous Immunoglobulin, and Coronary Artery Aneurysms in Kawasaki Disease. J Pediatr 2018; 200:160-165.e5. [PMID: 29793867 DOI: 10.1016/j.jpeds.2018.04.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 04/02/2018] [Accepted: 04/17/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate whether heart rate (HR) was associated with intravenous immunoglobulin (IVIG) responsiveness or development of coronary artery lesions (CALs) in patients with Kawasaki disease. STUDY DESIGN We conducted a retrospective cohort study using data from in patients with Kawasaki disease who were hospitalized in our institution from 2006 to 2016. The patients were divided into 5 groups according to the age- and temperature-adjusted HR z score (HRZage/temp) just before IVIG administration. The ORs of outcomes were estimated by using logistic regression models, with the middle group set as the reference. RESULTS Of the 322 patients, a total of 98 patients (30%) were refractory to initial IVIG treatment. The patients whose HRZage/temp belonged to the lowest group were at the highest risk of being refractory to the initial IVIG treatment (OR 2.10 [95% CI 1.01-4.37]). Multivariable analyses showed the same trend, though this was not statistically significant. The patients with the highest HRZage/temp were most likely to develop CALs (OR 2.61 [95%CI 0.86-7.92]). CONCLUSIONS In patients with Kawasaki disease , HRs has a different relationship with IVIG responsiveness and CALs. Low HRZage/temp might be associated with high risk of being refractory to the initial IVIG treatment, while the risk of developing CALs increased among those whose HRs were high. Further studies are necessary to investigate the mechanisms regarding HR and these outcomes in Kawasaki disease.
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Affiliation(s)
- Chisato Miyakoshi
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Pediatrics, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Masaru Yamakawa
- Department of Pediatrics, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan; Center for Innovative Research for Communities and Clinical Excellence (CIRC2LE), Fukushima Medical University, Fukushima, Japan
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Harju J, Kalliomäki ML, Leppikangas H, Kiviharju M, Yli-Hankala A. Surgical pleth index in children younger than 24 months of age: a randomized double-blinded trial. Br J Anaesth 2018; 117:358-64. [PMID: 27543530 DOI: 10.1093/bja/aew215] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The surgical pleth index (SPI) is a measurement of intraoperative nociception. Evidence of its usability in children is limited. Given that the autonomic nervous system is still developing during the first years of life, the performance of the SPI on small children cannot be concluded from studies carried out in older age groups. METHODS Thirty children aged <2 yr, planned for elective open inguinal hernia repair or open correction of undescended testicle, were recruited. The children were randomized into two groups; the saline group received ultrasound-guided saline injection in the ilioinguinal and iliohypogastric nerve region before surgery and ropivacaine after surgery, whereas the block group received the injections in the opposite order. The SPI was recorded blinded and was analysed at the time points of intubation, incision, and when signs of inadequate anti-nociception were observed. RESULTS There was a significant increase in the SPI after intubation (P=0.019) and after incision in the saline group (P=0.048), but not at the time of surgical incision in the block group (P=0.177). An increase in the SPI was also seen at times of clinically apparent inadequate anti-nociception (P=0.008). The between-patient variability of the SPI was large. CONCLUSIONS The SPI is reactive in small children after intubation and after surgical stimuli, but the reactivity of the SPI is rather small, and there is marked inter-individual variability in reactions. The reactivity is blunted by the use of ilioinguinal and iliohypogastric nerve block. CLINICAL TRIAL REGISTRATION NCT02045810.
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Affiliation(s)
- J Harju
- Department of Anaesthesia, Tampere University Hospital, PL2000, Tampere 33521, Finland
| | - M-L Kalliomäki
- Department of Anaesthesia, Tampere University Hospital, PL2000, Tampere 33521, Finland
| | - H Leppikangas
- Department of Anaesthesia, Tampere University Hospital, PL2000, Tampere 33521, Finland
| | - M Kiviharju
- Department of Anaesthesia, Tampere University Hospital, PL2000, Tampere 33521, Finland
| | - A Yli-Hankala
- Department of Anaesthesia, Tampere University Hospital, PL2000, Tampere 33521, Finland Medical School, University of Tampere, Tampere, Finland
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Tipene-Leach D, Baddock SA, Williams SM, Tangiora A, Jones R, McElnay C, Taylor BJ. The Pēpi-Pod study: Overnight video, oximetry and thermal environment while using an in-bed sleep device for sudden unexpected death in infancy prevention. J Paediatr Child Health 2018; 54:638-646. [PMID: 29357197 DOI: 10.1111/jpc.13845] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 10/22/2017] [Accepted: 12/21/2017] [Indexed: 11/29/2022]
Abstract
AIM The aim of this study was to identify the potential risks and benefits of sleeping infants in a Pēpi-Pod distributed to families with high risk of sudden unexpected death in infancy compared to a bassinet. METHODS Forty-five mostly indigenous Māori mothers who were referred by local health providers to receive a Pēpi-Pod were surveyed at recruitment, 1 and 3 months. A sleep study at 1 month included infrared video, oximetry and temperature measures. RESULTS When compared with 89 historical bassinet controls, an intention-to-treat analysis of questionnaires showed no increase in direct bed sharing but demonstrated significantly less sharing of the maternal bedroom at both interviews, with the majority of those not sleeping in the maternal bedroom, actually sleeping in the living room. The 1 month 'as-used' analysis showed poorer maternal sleep quality. The 'as-used' analysis of video data (24 Pēpi-Pod and 113 bassinet infants) also showed no increase in direct bed sharing, head covering or prone/side sleep position. Differences in oxygen saturation were not significant, but heart rate was higher in the Pēpi-Pod infants by 8.37 bpm (95% confidence interval 4.40, 12.14). Time in the thermal comfort zone was not different between groups despite Pēpi-Pod infants being situated in significantly warmer rooms. CONCLUSIONS Overall, we found that most differences in infant risk behaviours in a Pēpi-Pod compared to a bassinet were small, with confidence intervals excluding meaningful differences. We noted poorer maternal sleep quality at 1 month. Higher infant heart rates in the Pēpi-Pod group may be related to higher room temperatures. The Pēpi-Pod appears physiologically safe but is associated with lower reported maternal sleep quality.
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Affiliation(s)
- David Tipene-Leach
- Department of Women's and Children's Health, and, University of Otago, Dunedin, New Zealand.,Faculty of Education, Humanities and Health Sciences, Eastern Institute of Technology, Napier, New Zealand
| | - Sally A Baddock
- School of Midwifery, Otago Polytechnic, Dunedin, New Zealand
| | - Sheila M Williams
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Angeline Tangiora
- Department of Women's and Children's Health, and, University of Otago, Dunedin, New Zealand
| | - Raymond Jones
- Department of Women's and Children's Health, and, University of Otago, Dunedin, New Zealand
| | - Caroline McElnay
- Population Health, Hawke's Bay District Health Board, Hastings, New Zealand
| | - Barry J Taylor
- Department of Women's and Children's Health, and, University of Otago, Dunedin, New Zealand
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Abstract
OBJECTIVES Define the distributions of heart rate and intraarterial blood pressure in children at admission to an ICU based on admission diagnosis and examine trends in these physiologic signs over 72 hours from admission (or to discharge if earlier). DESIGN A retrospective analysis of continuously acquired signals. SETTING A quaternary and primary referral children's hospital with a general PICU and cardiac critical care unit. PATIENTS One thousand two hundred eighty-nine patients less than 18 years old were analyzed. Data from individual patient admissions were divided into 19 groups by primary admission diagnosis or surgical procedure. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS Distributions at admission are dependent on patient age and admission diagnosis (p < 10(-6)). Heart rate decreases over time, whereas arterial blood pressure is relatively stable, with differences seen in the directions and magnitude of these trends when analyzed by diagnosis group (p < 10(-6)). Multiple linear regression analysis shows that patient age, diagnosis group, and physiologic vital sign value at admission explain 50-63% of the variation observed for that physiologic signal at 72 hours (or at discharge if earlier) with admission value having the greatest influence. Furthermore, the variance of either heart rate or arterial blood pressure for the individual patient is smaller than the variance measured at the level of the group of patients with the same diagnosis. CONCLUSIONS This is the first study reporting distributions of continuously measured physiologic variables and trends in their behavior according to admission diagnosis in critically ill children. Differences detected between and within diagnostic groups may aid in earlier recognition of outliers as well as allowing refinement of patient monitoring strategies.
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Sepanski RJ, Godambe SA, Zaritsky AL. Pediatric Vital Sign Distribution Derived From a Multi-Centered Emergency Department Database. Front Pediatr 2018; 6:66. [PMID: 29629363 PMCID: PMC5876311 DOI: 10.3389/fped.2018.00066] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 03/08/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND We hypothesized that current vital sign thresholds used in pediatric emergency department (ED) screening tools do not reflect observed vital signs in this population. We analyzed a large multi-centered database to develop heart rate (HR) and respiratory rate centile rankings and z-scores that could be incorporated into electronic health record ED screening tools and we compared our derived centiles to previously published centiles and Pediatric Advanced Life Support (PALS) vital sign thresholds. METHODS Initial HR and respiratory rate data entered into the Cerner™ electronic health record at 169 participating hospitals' ED over 5 years (2009 through 2013) as part of routine care were analyzed. Analysis was restricted to non-admitted children (0 to <18 years). Centile curves and z-scores were developed using generalized additive models for location, scale, and shape. A split-sample validation using two-thirds of the sample was compared with the remaining one-third. Centile values were compared with results from previous studies and guidelines. RESULTS HR and RR centiles and z-scores were determined from ~1.2 million records. Empirical 95th centiles for HR and respiratory rate were higher than previously published results and both deviated from PALS guideline recommendations. CONCLUSION Heart and respiratory rate centiles derived from a large real-world non-hospitalized ED pediatric population can inform the modification of electronic and paper-based screening tools to stratify children by the degree of deviation from normal for age rather than dichotomizing children into groups having "normal" versus "abnormal" vital signs. Furthermore, these centiles also may be useful in paper-based screening tools and bedside alarm limits for children in areas other than the ED and may establish improved alarm limits for bedside monitors.
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Affiliation(s)
- Robert J Sepanski
- Department of Quality Improvement, Children's Hospital of The King's Daughters, Norfolk, VA, United States
| | - Sandip A Godambe
- Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, Norfolk, VA, United States
| | - Arno L Zaritsky
- Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, Norfolk, VA, United States
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Abstract
BACKGROUND Although technological advances have improved devices used to maintain the temperatures of 500- to 1500-g infants, managing the thermal environment remains challenging. PURPOSE To evaluate the effects of 2 methods of thermal support provided by a hybrid incubator during routine care in the first week of life. METHODS This descriptive, comparative study evaluates changes in temperature, humidity, heart rate, and oxygen saturation in the incubator versus radiant warmer (canopy) modes of hybrid warmers using data downloaded from the incubator and the monitor. The impact of the Boost Curtain on temperature when opening the portholes during the incubator mode was also examined. Mixed-effects linear models and the log-rank test were used to analyze patient data to determine the effect of thermal support on temperature and humidity changes during care, as well as during the postcare period. RESULTS Entering the incubator through the portholes improved temperature control compared with using the canopy mode. The Boost Curtain resulted in an overall temperature stability and heat gain. IMPLICATIONS FOR PRACTICE Nurses caring for premature infants in hybrid incubators should minimize incubator openings and utilize portholes rather than the canopy whenever practical. The Boost Curtain should be used when opening the portholes during the incubator mode. IMPLICATIONS FOR RESEARCH Comparing time, accuracy, and tolerance of procedures in the canopy versus incubator modes would improve nurses' ability to determine the best approach for different clinical scenarios.
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Eytan D, Goodwin AJ, Greer R, Guerguerian AM, Laussen PC. Heart Rate and Blood Pressure Centile Curves and Distributions by Age of Hospitalized Critically Ill Children. Front Pediatr 2017; 5:52. [PMID: 28367430 PMCID: PMC5355490 DOI: 10.3389/fped.2017.00052] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 02/28/2017] [Indexed: 11/13/2022] Open
Abstract
Heart rate (HR) and blood pressure (BP) form the basis for monitoring the physiological state of patients. Although norms have been published for healthy and hospitalized children, little is known about their distributions in critically ill children. The objective of this study was to report the distributions of these basic physiological variables in hospitalized critically ill children. Continuous data from bedside monitors were collected and stored at 5-s intervals from 3,677 subjects aged 0-18 years admitted over a period of 30 months to the pediatric and cardiac intensive care units at a large quaternary children's hospital. Approximately 1.13 billion values served to estimate age-specific distributions for these two basic physiological variables: HR and intra-arterial BP. Centile curves were derived from the sample distributions and compared to common reference ranges. Properties such as kurtosis and skewness of these distributions are described. In comparison to previously published reference ranges, we show that children in these settings exhibit markedly higher HRs than their healthy counterparts or children hospitalized on in-patient wards. We also compared commonly used published estimates of hypotension in children (e.g., the PALS guidelines) to the values we derived from critically ill children. This is a first study reporting the distributions of basic physiological variables in children in the pediatric intensive care settings, and the percentiles derived may serve as useful references for bedside clinicians and clinical trials.
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Affiliation(s)
- Danny Eytan
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Department of Pediatric Critical Care, Rambam Medical Center, Haifa, Israel
| | - Andrew J Goodwin
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto , Toronto, ON , Canada
| | - Robert Greer
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto , Toronto, ON , Canada
| | - Anne-Marie Guerguerian
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Neuroscience and Mental Health Program, Research Institute, Toronto, ON, Canada
| | - Peter C Laussen
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Department of Anaesthesia, University of Toronto, Toronto, ON, Canada
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Arrêt cardiaque du nourrisson et de l’enfant. ANNALES FRANCAISES DE MEDECINE D URGENCE 2016. [DOI: 10.1007/s13341-016-0683-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Long E, Oakley E, Babl FE, Duke T. An observational study using ultrasound to assess physiological changes following fluid bolus administration in paediatric sepsis in the emergency department. BMC Pediatr 2016; 16:93. [PMID: 27421648 PMCID: PMC4946151 DOI: 10.1186/s12887-016-0634-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 07/09/2016] [Indexed: 12/31/2022] Open
Abstract
Background Fluid bolus administration is widely recommended as part of the initial treatment of paediatric sepsis, though the physiological benefits and harms are unclear. The primary aim of this study is to determine the effect of fluid bolus administration on cardiac index (CI). Secondary aims are to determine the effect of fluid bolus administration on extra-vascular lung water (EVLW), whether fluid responsiveness can be predicted by inferior vena cava (IVC) collapsibility, and whether fluid responsiveness correlates with changes in vital signs. Methods/design A prospective observational study of children presenting to the Emergency Department of The Royal Children’s Hospital with clinically diagnosed sepsis requiring fluid bolus administration. Prior to fluid bolus administration, an echocardiogram, lung ultrasound, and IVC ultrasound will be performed, and vital signs recorded. These will be repeated 5 min after and 60 min after fluid bolus administration. Recorded echocardiograms and lung/IVC ultrasound will be evaluated independently by a paediatric cardiologist and paediatric emergency physician, respectively, blinded to the patient identity and time of examination relative to time of fluid bolus administration. Fifty patients will be enrolled in the study based on a precision based sample size calculation. Results will be analysed for change in CI and change in EVLW 5 min after and 60 min after fluid bolus administration compared to baseline, IVC collapsibility as a predictor of fluid responsiveness, and the relationship between fluid responsiveness and changes in vital signs. Discussion This study will explore assumptions about the effect of fluid boluses on CI in children with sepsis, and will provide evidence for secondary effects on other organ systems. This may lead to novel methods for assessment and decision making in the initial resuscitation of paediatric sepsis in clinical and research settings, and will likely influence the design of future interventional studies in this arena. Trial registration The study is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12614000824662; 04 August 2014).
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Affiliation(s)
- Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, 50 Flemington Road, 3052, Parkville, VIC, Australia. .,Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Australia. .,Department of Paediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Victoria, Australia.
| | - Ed Oakley
- Department of Emergency Medicine, The Royal Children's Hospital, 50 Flemington Road, 3052, Parkville, VIC, Australia.,Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital, 50 Flemington Road, 3052, Parkville, VIC, Australia.,Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Victoria, Australia
| | - Trevor Duke
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Victoria, Australia.,Paediatric Intensive Care Unit, The Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, Australia
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Sutherland SM, Kaelber DC, Downing NL, Goel VV, Longhurst CA. Electronic Health Record-Enabled Research in Children Using the Electronic Health Record for Clinical Discovery. Pediatr Clin North Am 2016; 63:251-68. [PMID: 27017033 DOI: 10.1016/j.pcl.2015.12.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Initially described more than 50 years ago, electronic health records (EHRs) are now becoming ubiquitous throughout pediatric health care settings. The confluence of increased EHR implementation and the exponential growth of digital data within them, the development of clinical informatics tools and techniques, and the growing workforce of experienced EHR users presents new opportunities to use EHRs to augment clinical discovery and improve pediatric patient care. This article reviews the basic concepts surrounding EHR-enabled research and clinical discovery, including the types and fidelity of EHR data elements, EHR data validation/corroboration, and the steps involved in analytical interrogation.
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Affiliation(s)
- Scott M Sutherland
- Department of Pediatrics, Stanford University School of Medicine, 300 Pasteur Drive, Room G-306, Stanford, CA 94304, USA; Department of Clinical Informatics, Stanford Children's Health, 1265 Welch Road, MSOB XIC65A, Stanford, CA 94305, USA.
| | - David C Kaelber
- Departments of Information Services, Internal Medicine, Pediatrics, Epidemiology and Biostatistics, Center for Clinical Informatics Research and Education, The MetroHealth System, Case Western Reserve University, 2500 MetroHeatlh Drive, Cleveland, OH 44109, USA
| | - N Lance Downing
- Department of Clinical Informatics, Stanford Children's Health, 1265 Welch Road, MSOB XIC65A, Stanford, CA 94305, USA
| | - Veena V Goel
- Department of Pediatrics, Stanford University School of Medicine, 300 Pasteur Drive, Room G-306, Stanford, CA 94304, USA; Department of Clinical Informatics, Stanford Children's Health, 1265 Welch Road, MSOB XIC65A, Stanford, CA 94305, USA
| | - Christopher A Longhurst
- Department of Biomedical Informatics, UC San Diego School of Medicine, 9560 Towne Centre Drive, San Diego, CA 92121, USA
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