Ultrasound-guided central venous catheter insertion in pediatric patients

In pediatric patients, central venous catheterization (CVC) is necessary for administration of fluids, drugs, high concentration electrolytes, vasopressors or inotropic drugs, transfusion, intravenous nutrition, and dialysis. Using an anatomical landmark for the CVC insertion may have a low success rate in children due to the positional variation between the deep vein and the landmarks, the small size of body and blood vessels, low insertion frequency, and operator skill. In order to improve the success rate, ultrasound guided CVC insertion is recommended in critically ill children. It is also expected to reduce mechanical complications, which are more common with subclavian CVC insertion. However, the association between the insertion site and the infection or thrombosis is unclear. Since thrombosis is relatively common, further studies are needed on the association between the incidence rate and insertion sites.

Factors Associated with Triage Modifications Using Vital Signs in Pediatric Triage: a NationwideCross-Sectional Study in Korea

Background@#Previous studies on inter-rater reliability of pediatric triage systems have compared triage levels classified by two or more triage providers using the same information about individual patients. This overlooks the fact that the evaluator can decide whether or not to use the information provided. The authors therefore aimed to analyze the differences in the use of vital signs for triage modification in pediatric triage. @*Methods@#This was an observational cross-sectional study of national registry data collected in real time from all emergency medical services beyond the local emergency medical centers (EMCs) throughout Korea. Data from patients under the age of 15 who visited EMC nationwide from January 2016 to December 2016 were analyzed. Depending on whether triage modifications were made using respiratory rate or heart rate beyond the normal range by age during the pediatric triage process, they were divided into down-triage and non-down-triage groups. The proportions in the down-triage group were analyzed according to the triage provider's profession, mental status, arrival mode, presence of trauma, and the EMC class. @*Results@#During the study period, 1,385,579 patients' data were analyzed. Of these, 981,281 patients were eligible for triage modification. The differences in down-triage proportions according to the profession of the triage provider (resident, 50.5%; paramedics, 47.7%; specialist, 44.9%; nurses, 44.2%) was statistically significant (P < 0.001). The triage provider's professional down-triage proportion according to the medical condition of the patients showed statistically significant differences except for the unresponsive mental state (P = 0.502) and the case of air transport (P = 0.468). @*Conclusion@#Down-triage proportion due to abnormal heart rates and respiratory rates was significantly different according to the triage provider's condition. The existing concept of inter-rater reliability of the pediatric triage system needs to be reconsidered.

Long-term changes in computed tomography and ultrasound utilization in a pediatric emergency department

OBJECTIVE: Many studies have proposed reducing unnecessary use of computed tomography (CT), and ongoing studies in pediatric populations are aiming to decrease radiation dosages whenever possible. We aimed to evaluate the long-term changes in the utilization patterns of CT and ultrasound (US) in pediatric emergency departments (PEDs). METHODS: This retrospective study reviewed the electronic medical data of patients who underwent CT and/or US in the PED of a tertiary referral hospital from 2000 to 2014. We compared the changes in utilization patterns of brain and abdominal CT scans in pediatric patients and analyzed changes in abdominal US utilization in the PED. RESULTS: During the study period, 196,371 patients visited the PED. A total of 12,996 brain and abdominal CT scans and 12,424 abdominal US were performed in the PED. Comparison of CT use in pediatric patients before and after 2007 showed statistically decreasing trends after 2007, expressed as the coefficient values of the differences in groups. The numbers of brain and abdominal CT scans showed a significant decreasing trend in children, except for abdominal CT in adolescents. The abdominal US/CT ratio in the PED showed a statistically significant increase (2.68; 95% confidence interval, 1.87 to 3.49) except for the adolescent group (5.82; 95% confidence interval, -2.06 to 13.69). CONCLUSION: Overall, CT use in pediatric patients has decreased since 2007. Pediatric US use has also shown a decreasing trend; however, the abdominal US/CT ratio in pediatric patients showed an increasing trend, except for adolescents.

Interfacility transport of critically ill children

Interfacility transport of critically ill children (transport) is a challenging component of pediatric critical care. The risk associated with the transport may be reduced by a specialized pediatric transport team, a screening tool for critically ill children, and a standardized handover between referring and referred physicians. Further research is necessary in Korea regarding the above measures for the safe and effective transport.

Changes in the Trend of the Imaging Study in Children with Acute Appendicitis in the Pediatric Emergency Department and Changes of the Negative Appendectomy Rate (NAR)

PURPOSE: We evaluated the relationship between changes in the trend of the utilization of diagnostic imaging studies and the rates of negative appendectomy, complications in pediatric patients with appendicitis. METHODS: This retrospective observational study was conducted at a pediatric emergency department (PED) of a tertiary university hospital. Patients who underwent imaging studies under the clinical impression of acute appendicitis and underwent appendectomy at the hospital from 2010 to 2013 were enrolled. We compared the percentages of imaging studies performed and negative appendectomy rate (NAR), complications between first two years (FTY) and second two years (STY). RESULTS: The total number of patients was 197 with a mean age of 9.68 (+/-3.17) years, and 66% were boys. The percentages of performed computed tomography (CT) of FTY and STY were 46.2% and 25.5% (p<0.05). Patients who were evaluated by ultrasound alone were 53.8% and 74.5%, respectively (p<0.05). The NARs of the two groups were 13.2% (FTY) and 8.0% (STY) (p=0.19). There was no significant difference in the number of hospital days, drainage insertion rates, duration of draining, and the rates of perforations between groups. The duration of antibiotics use was significantly longer only in the STY group than in the FTY group (6.20+/-3.95 vs. 6.94+/-3.41 days, p=0.04). CONCLUSION: Although the number of patients who underwent ultrasound without a CT scan for the diagnosis of acute appendicitis was increased, the NAR and clinically important complications were comparable from the preceding two years at a tertiary PED.

Unplanned Revisit to Pediatric Emergency Department: Patients' Characteristics and Relationship with Overcrowding

PURPOSE: Revisit to the pediatric emergency department (ED) in the short-term period may be due to inadequate evaluation during the previous visit, which may indicate a problem with quality in emergency care. The aims of this study are to analyze the characteristics of patients who revisited the pediatric ED within 48 hours after discharge and to evaluate the relation between overcrowding and revisit rates. METHODS: Retrospectively, we reviewed the charts of patients who returned within 48 hours after visiting a PED during a one-year period between June 1st, 2011 and December 31st, 2011. We determined the rate of return visits and review the characteristics of patients, emergency severity index (ESI) level at visits, cause of revisit, diagnosis, and crowding degree of the pediatric ED at the patient's first visit. RESULTS: A total of 16,688 patients visited the pediatric ED and 13,716 patients were discharged from the PED during the period. Of these discharged patients, 534 patients revisited inevitably within 48 hours. The most common cause of revisit was relapse or worsened symptoms (70.0%). There was no significant difference in sex, severity of patient, and crowding degree of the pediatric ED at the first visit, however, patients who revisited were younger than those who did not (p=0.005). The ESI level at the return visit was significantly higher irrespective of admission after revisit (p<0.001). In diagnosis grouping, patients with gastrointestinal diseases, respiratory diseases, and neoplastic diseases showed a higher rate of revisit. CONCLUSION: Approximately 4% of our pediatric ED visits were for children returning within 48 hours. Patients who revisited were younger and patients with gastrointestinal diseases, neoplastic diseases, and respiratory diseases were more likely to revisit. Careful explanation of the possibility of worsened symptoms is necessary for these patients.