Premedication with midazolam for urethral catheterization of febrile infants.

Febrile infants undergoing urethral catheterization (UC) are often not treated for pain and distress. The aim was to evaluate the effectiveness of midazolam premedication. We compared a convenience sample of infants who underwent UC with midazolam with those who did not receive midazolam. Outcome measures were Visual Analog Scale assessment, duration of cry, and emergency department length of stay. Thirty-two study participants and 18 controls were prospectively enrolled. Midazolam premedication showed a 53% decrease in the mean Visual Analog Scale score when parents assessed distress (33.6 vs. 71.7, P<0.0001) and a 48% decrease when nurses assessed distress (28.7 vs. 55.5, P<0.0002); the median cry duration was significantly shorter (0 vs. 240 s). Serious adverse events were not observed during sedation and at 48 h after discharge. Study participants had longer emergency department length of stay compared with the controls (191.5 vs. 139 min, P<0.017). In this cohort, midazolam significantly reduced the distress associated with UC without causing serious adverse events.

Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study.

BACKGROUND: Limited data are available on adverse events among children admitted to hospital. The Canadian Paediatric Adverse Events Study was done to describe the epidemiology of adverse events among children in hospital in Canada. METHODS: We performed a 2-stage medical record review at 8 academic pediatric centres and 14 community hospitals in Canada. We reviewed charts from patients admitted from April 2008 through March 2009, evenly distributed across 4 age groups (0 to 28 d; 29 to 365 d; > 1 to 5 yr and > 5 to 18 yr). In stage 1, nurses and health records personnel who had received training in the use of the Canadian Paediatric Trigger Tool reviewed medical records to detect triggers for possible adverse events. In stage 2, physicians reviewed the charts identified as having triggers and described the adverse events. RESULTS: A total of 3669 children were admitted to hospital during the study period. The weighted rate of adverse events was 9.2%. Adverse events were more frequent in academic pediatric centres than in community hospitals (adjusted odds ratio [OR] 2.98, 95% confidence interval [CI] 1.65-5.39). The incidence of preventable adverse events was not significantly different between types of hospital, but nonpreventable adverse events were more common in academic pediatric centres (adjusted OR 4.39, 95% CI 2.08-9.27). Surgical events predominated overall and occurred more frequently in academic pediatric centres than in community hospitals (37.2% v. 21.5%, relative risk [RR] 1.7, 95% CI 1.0-3.1), whereas events associated with diagnostic errors were significantly less frequent (11.1% v. 23.1%, RR 0.5, 95% CI 0.2-0.9). INTERPRETATION: More children have adverse events in academic pediatric centres than in community hospitals; however, adverse events in the former are less likely to be preventable. There are many opportunities to reduce harm affecting children in hospital in Canada, particularly related to surgery, intensive care and diagnostic error.

Current advances in intraosseous infusion - a systematic review.

OBJECTIVES: To describe the advancement of Intraosseous (IO) infusion in the spectrum of resuscitative protocols and to provide a systematic review on currently used semi-automatic IO infusion devices. The specific question addressed was: "In patients undergoing resuscitation, does the use of semi-automatic IO infusion devices compared to manual needles influence IO placement success rate, time for IO placement, and ease-of-use and user preference?" METHODS: The electronic databases PubMed and Embase were searched for articles published from 1997 to 2010 using the search terms ("intraosseous") AND ("needle" or "device" or "technique") AND ("infusion" or "injection" or "access"). The Internet search engine Google Scholar was searched using the search term "intraosseous infusion device" to identify articles published in electronic journals, books, and scientific websites. Articles were included only if they compared at least two types of semi-automatic devices, or compared one or more semi-automatic device with one or more manual needles. Reviews, editorials, surveys, and case reports were excluded. RESULTS: The search strategy yielded 179 papers. Ten studies met full criteria for further review. Of these, two were LOE 1 (randomized controlled trials), one was LOE 2 (non-randomized, concurrent controls), one was LOE 3 (retrospective controls), and six were LOE 5 (simulation-based study). One of the six LOE 5 studies was a non-peer reviewed article. CONCLUSIONS: Only a few studies compared the performance of different types of IO infusion devices, most of them have a low level of evidence. These studies suggested a superiority of the battery-powered IO driver over manual needles, and other semi-automatic IO infuson devices.

Comparison of two mechanical intraosseous infusion devices: a pilot, randomized crossover trial.

INTRODUCTION: Administration of medications via the intraosseous (IO) route has proven to be a lifesaving procedure in critically ill or injured children. Two mechanical IO infusion devices have been approved for use in children, the spring-loaded IO infusion device (Bone Injection Gun, BIG) and the battery-powered IO infusion drill (EZ-IO). The objective of this pilot study was to compare the success rates for insertion and the ease-of-use of the two devices. PATIENTS AND METHODS: A randomized crossover study was conducted in a local paramedic training course with 29 paramedic students participating. Participants watched two videos describing the use of the two devices, followed by a demonstration on how to use each device on a turkey bone model. Then subjects were divided into two study groups: BIG-first or EZ-IO-first. Each participant performed one insertion attempt with each device independently. All attempts were filmed by a video camera. Successful placement was defined as the visualization of fluid flow from the marrow cavity. Following the study procedure, participants completed a two-item questionnaire recording their ranking of the ease-of-use of each device and their "first choice device". RESULTS: Participants had a significantly higher one-attempt success rate with the EZ-IO than with the BIG (28/29 vs 19/29, p=0.016), and selected the EZ-IO as their first choice (20/29). Participants of the EZ-IO-first group assessed the EZ-IO as easier to use than the BIG (p=0.0039). The subjects of the BIG-first group found no difference in the ease-of-use between the two devices (p=0.32). CONCLUSIONS: As tested by paramedic students on a turkey bone model, the EZ-IO demonstrated higher success rates than the BIG and was the preferred device. Future studies are planned to determine which of the two devices is more appropriate for obtaining IO access in the setting of paediatric emergencies.

Application of topical analgesia in triage: a potential for harm.

To reduce the overall time spent in the ED, triage nurses are encouraged to treat patients with a topical anesthetic cream, eutectic mixture of local anesthetics (EMLA). We present a case in which a 28-day-old neonate who was treated with EMLA cream in triage developed severe methemoglobinemia 18 hours post admission to the pediatric ward. This case demonstrates that there may be some risks associated with this approach, and that protocols for the use of EMLA at triage should include not only the indications for its use, but also need to ensure that there is a process to have the EMLA removed before patient discharge or transfer.

A novel imaging technique to measure capillary-refill time: improving diagnostic accuracy for dehydration in young children with gastroenteritis.

BACKGROUND: Assessment of dehydration in young children currently depends on clinical judgment, which is relatively inaccurate. By using digital videography, we developed a way to assess capillary-refill time more objectively. OBJECTIVE: Our goal was to determine whether digitally measured capillary-refill time assesses the presence of significant dehydration (> or = 5%) in young children with gastroenteritis more accurately than conventional capillary refill and overall clinical assessment. METHODS: We prospectively enrolled children with gastroenteritis, 1 month to 5 years of age, who were evaluated in a tertiary-care pediatric emergency department and judged by a triage nurse to be at least mildly dehydrated. Before any treatment, we measured the weight and digitally measured capillary-refill time of these children. Pediatric emergency physicians determined capillary-refill time by using conventional methods and degree of dehydration by overall clinical assessment by using a 7-point Likert scale. Postillness weight gain was used to estimate fluid deficit; beginning 48 hours after assessment, children were reweighed every 24 hours until 2 sequential weights differed by no more than 2%. We compared the accuracy of digitally measured capillary-refill time with conventional capillary refill and overall clinical assessment by determining sensitivities, specificities, likelihood ratios, and area under the receiver operator characteristic curves. RESULTS: A total of 83 patients were enrolled and had complete follow-up; 13 of these patients had significant dehydration (> or = 5% of body weight). The area under the receiver operator characteristic curves for digitally measured capillary-refill time and overall clinical assessment relative to fluid deficit (< 5% vs > or = 5%) were 0.99 and 0.88, respectively. Positive likelihood ratios were 11.7 for digitally measured capillary-refill time, 4.5 for conventional capillary refill, and 4.1 for overall clinical assessment. CONCLUSIONS: Results of this prospective cohort study suggest that digitally measured capillary-refill time more accurately predicts significant dehydration (> or = 5%) in young children with gastroenteritis than overall clinical assessment.

Sonography of the hip-joint by the emergency physician: its role in the evaluation of children presenting with acute limp.

OBJECTIVE: To describe a new imaging bedside test called Sonography of the Hip-joint by the Emergency Physician (SHEP) and to examine if its use as a triage tool for the presence of fluid in the hip joint can guide the emergency physician to the right diagnosis. METHODS: Case series of 5 children presented to the ED with an acute onset of limp. In addition to a careful clinical history and physical examination, each child received SHEP. RESULTS: Follow-up confirmed that the presumptive diagnosis made in the ED was correct. The SHEP tests were found helpful in diagnosing transient synovitis (3 cases), septic arthritis (1 case), and osteomyelitis of the femur (1 case). CONCLUSIONS: The SHEP tests provided additional information that narrowed the differential diagnosis, and minimized unnecessary blood tests and diagnostic imaging studies.