Inhaled nitrous oxide for painful procedures in children and youth: a systematic review and meta-analysis

OBJECTIVES

The objective of this study was to synthesize indication-based evidence for N₂O for distress and pain in children.

STUDY DESIGN

We included trials of N₂O in participants 0-21 years, reporting distress or pain for emergency department procedures. The primary outcome was procedural distress. Where meta-analysis was not possible, we used Tricco et al.'s classification of "neutral" (p ≥ 0.05), "favorable," or "unfavorable" (p < 0.05, supporting N₂O or comparator, respectively). We used the Cochrane Collaboration's Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system to evaluate risk of bias and quality of evidence, respectively.

RESULTS

We included 30 trials. For pain using the Visual Analog Scale (0-100 mm) during IV insertion, 70% N₂O (delta:-16.5; 95%CI:-28.6 to -4.4; p = 0.008; three trials; I² = 0%) and 50% N₂O plus eutectic mixture of local anesthetics (EMLA) (delta:-1.2; 95%CI:-2.1 to -0.3; p = 0.007; two trials; I² = 43%) were superior to EMLA. 50% N₂O was not superior to EMLA (delta:-0.4; 95%CI:-1.2 to 0.3; p = 0.26; two trials; I² = 15%). For distress and pain during laceration repair, N₂O was "favorable" versus each of SC lidocaine, oxygen, and oral midazolam but "neutral" versus IV ketamine (five trials). For distress and pain during fracture reduction (three trials), N₂O was "neutral" versus each of IM meperidine plus promethazine, regional anesthesia, and IV ketamine plus midazolam. For distress and pain during lumbar puncture (one trial), N₂O was "favorable" versus oxygen. For distress and pain during urethral catheterization (one trial), N₂O was "neutral" versus oral midazolam. For pain during intramuscular injection (one trial), N₂O plus EMLA was "favorable" versus N₂O and EMLA alone. Common adverse effects of N₂O included nausea (4.4%), agitation (3.7%), and vomiting (3.6%) AEs were less frequent with N₂O alone (278/1147 (24.2%)) versus N₂O plus midazolam (48/52 (92.3%)) and N₂O plus fentanyl (123/201 (61.2%)).

CONCLUSIONS

There is sufficient evidence to recommend N₂O plus topical anesthetic for IV insertion and laceration repair. Adverse effects are greater when combined with other sedating agents.

Development and implementation of an end-of-shift clinical debriefing method for emergency departments during COVID-19

BACKGROUND

Multiple guidelines recommend debriefing after clinical events in the emergency department (ED) to improve performance, but their implementation has been limited. We aimed to start a clinical debriefing program to identify opportunities to address teamwork and patient safety during the COVID-19 pandemic.

METHODS

We reviewed existing literature on best-practice guidelines to answer key clinical debriefing program design questions. An end-of-shift huddle format for the debriefs allowed multiple cases of suspected or confirmed COVID-19 illness to be discussed in the same session, promoting situational awareness and team learning. A novel ED-based clinical debriefing tool was implemented and titled Debriefing In Situ COVID-19 to Encourage Reflection and Plus-Delta in Healthcare After Shifts End (DISCOVER-PHASE). A facilitator experienced in simulation debriefings would facilitate a short (10-25 min) discussion of the relevant cases by following a scripted series of stages for debriefing. Data on the number of debriefing opportunities, frequency of utilization of debriefing, debriefing location, and professional background of the facilitator were analyzed.

RESULTS

During the study period, the ED treated 3386 suspected or confirmed COVID-19 cases, with 11 deaths and 77 ICU admissions. Of the 187 debriefing opportunities in the first 8-week period, 163 (87.2%) were performed. Of the 24 debriefings not performed, 21 (87.5%) of these were during the four first weeks (21/24; 87.5%). Clinical debriefings had a median duration of 10 min (IQR 7-13). They were mostly facilitated by a nurse (85.9%) and mainly performed remotely (89.8%).

CONCLUSION

Debriefing with DISCOVER-PHASE during the COVID-19 pandemic were performed often, were relatively brief, and were most often led remotely by a nurse facilitator. Future research should describe the clinical and organizational impact of this DISCOVER-PHASE.

Review of 14 drowning publications based on the Utstein style for drowning

BACKGROUND

The Utstein style for drowning (USFD) was published in 2003 with the aim of improving drowning research. To support a revision of the USFD, the current study aimed to generate an inventory of the use of the USFD parameters and compare the findings of the publications that have used the USFD.

METHODS

A search in Pubmed, Embase, the Cochrane Library, Web of Science and Scopus was performed to identify studies that used the USFD and were published between 01-10-2003 and 22-03-2015. We also searched in Pubmed, Embase, the Cochrane Library, Web of Science, and Scopus for all publications that cited the two publications containing the original ILCOR advisory statement introducing and recommending the USFD. In total we identified 14 publications by groups that explicitly used elements of the USFD for collecting and reporting their data.

RESULTS

Of the 22 core and 19 supplemental USFD parameters, 6-19 core (27-86%) and 1-12 (5-63%) supplemental parameters were used; two parameters (5%) have not been used in any publication. Associations with outcome were reported for nine core (41%) and five supplemental (26%) USFD parameters. The USFD publications also identified non-USFD parameters related to outcome: initial cardiac rhythm, time points and intervals during resuscitation, intubation at the drowning scene, first hospital core temperature, serum glucose and potassium, the use of inotropic/vasoactive agents and the Paediatric Index of Mortality 2-score.

CONCLUSIONS

Fourteen USFD based drowning publications have been identified. These publications provide valuable information about the process and quality of drowning resuscitation and confirm that the USFD is helpful for a structured comparison of the outcome of drowning resuscitation.

Implementation of a Novel Conference Series on Clinical Practice Variations Provides an Opportunity for Constructive Discussion of Faculty Practice Patterns: Do as We Say? … or Do as We Do?

BACKGROUND

Although evidence-based medicine (EBM) is routinely used to guide management in the emergency department, there is still considerable variation in clinical practice. Trainees may not fully appreciate the reasons for these clinical practice variations (CPVs) and may find it frustrating when they encounter them. We used areas of CPV among our faculty as the basis for resident educational sessions and assessed the perceived utility of these sessions.

METHODS

Topics were identified when residents noticed significant variability among the faculty in their management of particular clinical presentations. Sessions were conducted by facilitator-led reviews of EBM guidelines, by faculty panel discussions of their management rationale where EBM guidelines are not available, or by pro-con debates. Residents were surveyed after the initial sessions to assess the utility of this series and changes in their understanding of CPV.

RESULTS

There was a 72% response rate. The percentage of residents who were frustrated with CPV decreased from 64% to 35%; the percentage who felt that the presence of CPV enhanced their learning increased from 19% to 48%. Sixty-five percent felt that the educational series contributed to decreased frustration, 77% felt that the sessions helped them understand why CPV occurs, and 93% felt that they helped their overall learning.

CONCLUSION

Explicit discussion and exploration of CPV in an educational setting can provide multiple benefits. Trainees may gain a better understanding of why CPV occurs and of the rationale behind practice variations. Faculty may benefit from analyzing CPV to determine whether these truly represent the "art of medicine."

Feasibility of Automatic Extraction of Electronic Health Data to Evaluate a Status Epilepticus Clinical Protocol

Status epilepticus is a common neurologic emergency in children. Pediatric medical centers often develop protocols to standardize care. Widespread adoption of electronic health records by hospitals affords the opportunity for clinicians to rapidly, and electronically evaluate protocol adherence. We reviewed the clinical data of a small sample of 7 children with status epilepticus, in order to (1) qualitatively determine the feasibility of automated data extraction and (2) demonstrate a timeline-style visualization of each patient's first 24 hours of care. Qualitatively, our observations indicate that most clinical data are well labeled in structured fields within the electronic health record, though some important information, particularly electroencephalography (EEG) data, may require manual abstraction. We conclude that a visualization that clarifies a patient's clinical course can be automatically created using the patient's electronic clinical data, supplemented with some manually abstracted data. Future work could use this timeline to evaluate adherence to status epilepticus clinical protocols.

Portrait of rural emergency departments in Québec and utilization of the provincial emergency department management Guide: cross sectional survey

Background

Rural emergency departments (EDs) constitute crucial safety nets for the 20 % of Canadians who live in rural areas. Pilot data suggests that the province of Québec appears to provide more comprehensive access to services than do other provinces. A difference that may be attributable to provincial policy/guidelines “the provincial ED management Guide”. The aim of this study was to provide a detailed description of rural EDs in Québec and utilization of the provincial ED management Guide.

Methods

We selected EDs offering 24/7 medical coverage, with hospitalization beds, located in rural or small towns. We collected data via telephone, paper, and online surveys with rural ED/hospital staff. Data were also collected from Québec’s Ministry of Health databases and from Statistics Canada. We computed descriptive statistics, ANOVA and t-tests were used to examine the relationship between ED census, services and inter-facility transfer requirements.

Results

A total of 23 of Québec’s 26 rural EDs (88 %) consented to participate in the study. The mean annual ED visits was 18 813 (Standard Deviation = 6 151). Thirty one percent of ED physicians were recent graduates with fewer than 5 years of experience. Only 6 % had residency training or certification in emergency medicine. Teams have good local access (24/7) to diagnostic equipment such as CT scanner (74 %), intensive unit care (78 %) and general surgical services (78 %), but limited access to other consultants. Sixty one percent of participants have reported good knowledge of the provincial ED management Guide, but only 23 % of them have used the guidelines. Furthermore, more than 40 % of EDs were more than 300 km from levels 1 to 2 trauma centers, and only 30 % had air transport access.

Conclusions

Rural EDs in Québec are staffed by relatively new graduates working as solo physicians in well-resourced and moderately busy (by rural standards) EDs. The provincial ED management Guide may have contributed to this model of service attribution. However, the majority of rural ED staff report limited knowledge or use of the provincial ED management Guide and increased efforts at disseminating this Guide are warranted.

A majority of rural emergency departments in the province of Quebec use point-of-care ultrasound: a cross-sectional survey

BACKGROUND

Point-of-care ultrasound (POCUS) can be used to provide rapid answers to specific and potentially life-threatening clinical questions, and to improve the safety of procedures. The rate of POCUS access and use in Canada is unclear. The objective of this study was to examine access to POCUS and potential barriers/facilitators to its use among rural physicians in Quebec.

METHODS

This descriptive cross-sectional study used an online survey. The 30-item questionnaire is an adapted and translated version of a questionnaire used in a prior survey conducted in rural Ontario, Canada. The questionnaire was pre-tested for clarity and relevance. The survey was sent to non-locum physicians working either full- or part-time in rural emergency departments (EDs) (n = 206). All EDs were located in rural and small towns and provided 24/7 medical coverage with acute care hospitalization beds.

RESULTS

In total, 108 surveys were completed (participation rate = 52.4%). Of the individuals who completed surveys, ninety-three percent were family physicians, and seven percent had Canadian College of Family Physicians - Emergency Medicine (CCFP-EM) certification. The median number of years of practice was seven. A bedside ultrasound device was available in 95% of rural EDs; 75.9% of physicians reported using POCUS on a regular basis. The most common indications for POCUS use were to rule out abdominal aortic aneurysm (70.4%) and to evaluate presence of free fluid in trauma and intrauterine pregnancy (60%). The most common reason (73%) for not using POCUS was limited access to POCUS training programs. Over 40% of POCUS users received training in POCUS during medical school or residency. Sixty-four percent received training from the Canadian Emergency Ultrasound Society, 13% received training from the Canadian Association of Emergency Physicians, and 23% were trained in another course. Finally, 95% of respondents reported that POCUS skills are essential for rural ED practice.

CONCLUSIONS

POCUS use in rural EDs in the province of Quebec appears to be relatively widespread. Access to training programs is a barrier to greater use.

Factors Influencing the Decision to Attend a Pediatric Emergency Department for Nonemergent Complaints

OBJECTIVE

The objective of this study was to explore the factors associated with parents' decisions to bring their children to the pediatric emergency department (PED) for nonemergent concerns.

METHODS

We conducted a cross-sectional survey at a tertiary-care, pediatric referral center emergency department. We surveyed caregivers of children triaged to low-acuity levels using the Pediatric Canadian Triage and Acuity Scale. We used descriptive statistics to report the proportion of patients who have a primary care physician, who attempted to contact any health care providers prior to coming to the PED, and other factors surrounding the decision to come to the PED.

RESULTS

We approached 340 families, of which 300 were enrolled (uptake rate, 88.2%). We found that 32% (95% confidence interval, 0.26-0.37) attempted to contact another health care provider prior to coming to the PED, and 59% (95% confidence interval, 0.48-0.69) of those respondents were specifically instructed to come to the PED. The top 3 reasons for coming to the British Columbia Children's Hospital PED were (1) that it specializes in children, (2) child has medical issues previously managed at the same hospital, and (3) closest location to patient.

CONCLUSIONS

Despite the majority of patients having a primary care physician, less than half of them actually contacted these providers (or another health care provider) before presenting to the PED for their nonurgent illness or injury. Of these, nearly two thirds were specifically instructed to come to the PED by the health care provider in the community.

National Survey of Pediatric Emergency Medicine Fellows on Debriefing After Medical Resuscitations

BACKGROUND

Medical resuscitations of critically ill children in the emergency department are stressful events requiring a coordinated team effort. Current guidelines recommend debriefing after such events to improve future performance. Debriefing practices within pediatric emergency departments by pediatric emergency medicine (PEM) fellows in the United States has not been studied.

OBJECTIVE

The aim of this study was to describe the current debriefing experience of PEM fellows in the United States.

METHODS

A 10-item, anonymous questionnaire regarding debriefing characteristics was distributed to fellows in US Accreditation Council for Graduate Medical Education-accredited PEM programs via e-mail and paper format from December 2011 to March 2012. Results were summarized using descriptive statistics.

RESULTS

Of 393 eligible PEM fellows, 201 (51.1%) completed the survey. The 201 respondents included 82 first-year fellows (40.8%), 71 second-year fellows (35.3%), and 48 third-year fellows (23.9%). Ninety-nine percent had participated in medical resuscitations during their fellowship training, yet 88.0% reported no formal teaching on how to debrief. There was wide variability in the format and timing of debriefings. The majority of debriefings were led by PEM attending physicians (65.5%) and PEM fellows (19.6%). Most (91.5%) of the fellows indicated they would like further education about debriefing.

CONCLUSIONS

The majority of PEM fellows do not receive formal training on how to debrief after a critical event and may have limited experience in leading debriefings. Debriefing training should be considered part of the educational curriculum during PEM fellowship.

Holospinal epidural abscess of the spinal axis: two illustrative cases with review of treatment strategies and surgical techniques

Despite the increasing prevalence of spinal infections, the subcategory of holospinal epidural abscesses (HEAs) is extremely infrequent and requires unique management. Panspinal imaging (preferably MRI), modern aggressive antibiotic therapy, and prompt surgical intervention remain the standard of care for all spinal axis infections including HEAs; however, the surgical decision making on timing and extent of the procedure still remain ill defined for HEAs. Decompression including skip laminectomies or laminoplasties is described, with varied clinical outcomes. In this review the authors present the illustrative cases of 2 patients with HEAs who were treated using skip laminectomies and epidural catheter irrigation techniques. The discussion highlights different management strategies including the role of conservative (nonsurgical) management in these lesions, especially with an already identified pathogen and the absence of mass effect on MRI or significant neurological defects. Among fewer than 25 case reports of HEA published in the past 25 years, the most important aspect in deciding a role for surgery is the neurological examination. Nearly 20% were treated successfully with medical therapy alone if neurologically intact. None of the reported cases had an associated cranial infection with HEA, because the dural adhesion around the foramen magnum prevented rostral spread of infection. Traditionally a posterior approach to the epidural space with irrigation is performed, unless an extensive focal ventral collection is causing cord compression. Surgical intervention for HEA should be an adjuvant treatment strategy for all acutely deteriorating patients, whereas aspiration of other infected sites like a psoas abscess can determine an infective pathogen, and appropriate antibiotic treatment may avoid surgical intervention in the neurologically intact patient.

Extracorporeal cardiopulmonary resuscitation

PURPOSE OF REVIEW

To discuss the role of extracorporeal membrane oxygenation (ECMO) in patients with cardiac arrest.

RECENT FINDINGS

Return to spontaneous circulation dramatically decreases with the duration of cardiopulmonary resuscitation (CPR). In this context, it has been proposed to implement venoarterial ECMO in order to assist CPR (ECPR) both in inhospital cardiac arrest (IHCA) and in out-of-hospital cardiac arrest (OHCA).

SUMMARY

This review highlights that ECPR is feasible for both IHCA and OHCA. In the recent series, the outcome of ECPR in IHCA is satisfactory, with survival rates good with neurologic outcome reaching the 40-50% range. All series converge in highlighting that time from cardiac arrest to ECMO flow is a critical determinant of outcome, with survival rates of 50% when initiated within 30 min of IHCA, 30% between 30 and 60 min, and 18% after 60 min. Results of ECPR in OHCA are more challenging. Recent series suggest that good outcome can be obtained in 15-20% of the patients, provided that time from arrest to ECMO is shorter than 60 min. Duration of cardiac arrest seems to be more important than location of cardiac arrest. ECPR thus seems to be a valuable option in selected cases.

Return to system within 30 days of discharge following pediatric shunt surgery

OBJECT

The rate of readmission after CSF shunt surgery is significant and has caught the attention of purchasers of health care. However, a detailed description of clinical scenarios that lead to readmissions and reoperations after index shunt surgery is lacking in the medical literature.

METHODS

This study included 1755 shunt revision and insertion surgeries that were performed at a single institution between May 1, 2009, and April 30, 2013. Demographic, socioeconomic, and clinical characteristics were prospectively collected in the administrative, business, and operating room databases. Clinical events within the 30 days following discharge were reviewed and analyzed. Two events of interest, Emergency Department (ED) utilization and reoperation, were further analyzed for risk factor associations by using multivariate logistic regression.

RESULTS

There were 290 readmissions within 30 days of discharge (16.5%). Admission sources included ED (n = 216), hospital transfers (n = 23), and others. Of the 290 readmissions, 184 were associated with an operation, but only 165 of these were performed by the neurosurgical service. These included surgeries for shunt occlusion and externalization (n = 150), wound revision (n = 7), and other neurosurgical procedures that were not shunt related (n = 8). The remaining readmissions (n = 106) were not associated with an operation, and only 59 patients were admitted for issues related to the index shunt surgery. When return to the ED was the dependent variable in a multivariate regression model, patients who returned to the ED were more likely to be from the Atlanta metropolitan area and to be either uninsured or insured with public assistance. When reoperation was the dependent variable, patients whose surgery started after 3 p.m. were more likely to undergo subsequent CSF shunt revision surgery on readmission.

CONCLUSIONS

Of the readmissions within 30 days of shunt surgery, 74.5% were related to the index shunt surgery. Whether and to what extent these readmissions are preventable continues to be controversial. Further study is needed to identify modifiable risk factors that may eventually improve patient care.

Identification of differentially expressed serum proteins in infectious purpura fulminans

Purpura fulminans (PF) is a life-threatening hemorrhagic condition. Because of the rarity and randomness of the disease, no improvement in treatment has been made for a long time. In this study, we assessed the serum proteome response to PF by comparing serum proteins between healthy controls and PF patient. Liquid chromatography with tandem mass spectrometry (LC-MS/MS) approach was used after depleting 6 abundant proteins of serum. In total, 262 proteins were confidently identified with 2 unique peptides, and 38 proteins were identified significantly up- (≥2) or downregulated (≤0.5) based on spectral counting ratios (SpC_PF/N). In the 38 proteins with significant abundance changes, 11 proteins were previously known to be associated with burn or sepsis response, but 27 potentially novel proteins may be specifically associated with PF process. Two differentially expressed proteins, alpha-1-antitrypsin (SERPINA1) and alpha-2 antiplasmin (SERPINF2), were validated by Western blot. This is the first study where PF patient and healthy controls are compared in a proteomic study to elucidate proteins involved in the response to PF. This study provides an initial basis for future studies of PF, and the differentially expressed proteins might provide new therapeutic targets to decrease the mortality of PF.