Nebulized Tranexamic Acid for Pediatric Post-tonsillectomy Hemorrhage: A Report of Two Cases.

INTRODUCTION: Tranexamic acid (TXA) use in pediatrics to control hemorrhage has gained interest in recent years, but there is limited literature on nebulized TXA especially regarding dosing and adverse effects. Tranexamic acid has anti-fibrinolytic properties via competitive inhibition of plasminogen activation making it a logical approach to promote hemostasis in cases of post-tonsillectomy hemorrhage. CASE REPORT: We describe two cases of post-tonsillectomy hemorrhage managed with nebulized TXA. In both cases, bleeding was stopped after TXA administration. CONCLUSION: To our knowledge, this is the first case report to describe the use of nebulized TXA without an adjunct pharmacotherapy. Our two cases add additional reportable data on the safety of nebulized TXA and possible effectiveness on post-tonsillectomy hemorrhage.

Point-of-Care Ultrasound for Confirmation of Nasogastric and Orogastric Tube Placement in Pediatric Patients.

OBJECTIVES: The aim of the study was to investigate the role of point-of-care ultrasound (POCUS) as an alternative imaging modality to confirm proper placement for nasogastric tubes (NGTs) and orogastric tubes (OGTs) in pediatric patients. METHODS: This was a prospective descriptive study performed at a tertiary care free-standing children's hospital. Patients 21 years and younger requiring radiographic confirmation of NGT or OGT placement were eligible for enrollment. Bedside ultrasonography examination of the epigastric area was performed by a blinded pediatric emergency medicine physician. An abdominal radiograph was obtained to confirm NGT or OGT placement in all patients. RESULTS: A total of 26 patients with a mean age of 2.6 years (standard deviation, 3.9 years) were enrolled. All 26 patients had x-ray confirmation of NGT and OGTs correctly placed in the stomach. Confirmation of NGT or OGT placement by ultrasound was obtained in 23 patients. For these 23 patients, POCUS agreed with radiographic findings. For 3 patients, the NGT and OGT was unable to be identified by ultrasound. The sensitivity of ultrasound for detecting a properly placed tube was 88% (95% confidence interval, 70.0%-97.6%). CONCLUSIONS: This pilot study described ultrasound confirmation of NGT or OGT placement. If confirmed in larger studies, POCUS can be used as an objective tool for the confirmation of NGT or OGT placement in pediatric patients and limit the need for routine x-ray confirmation.

Trends in adult patients presenting to pediatric emergency departments.

OBJECTIVE: Adults presenting to pediatric emergency departments (PEDs) include those with complex chronic conditions (CCCs) often still followed by pediatric providers, and those without CCCs (non-CCCs). This paper describes recent trends in adults seen within PEDs, both by age subgroups and CCC status. METHODS: Data were retrospectively reviewed from the Pediatric Health Information System for PED visits between Jan 1, 2013 and Dec 31, 2017. Yearly visit rates were trended for all adult visits, age subgroups (18-21, 22-25, 26-40, and 41-95 years), and by CCC status. The most frequent diagnoses were reviewed for each adult age group and CCC category. RESULTS: Rates of adult PED visits significantly increased from 3.7% in 2013 to 4.2% in 2017 (P < 0.0001). While the overall majority (88% overall and >70% for each age group) of adult PED patients were non-CCC, the rate of CCC patients increased overall (P < 0.0001), especially among older patients (41-95 years) from 8.7% in 2013 to 29% in 2017 (P < 0.0001). The most frequent CCC diagnoses were sickle cell disease (18-21 and 22-25 years), cardiac pathology (26-40 years), and hyperlipidemia (41-95 years). The most frequent non-CCC diagnoses were abdominal pain (18-21 years), pregnancy-related (22-25 and 26-40 years), and chest pain (41-95 years). CONCLUSION: Visits to PEDs by adult patients have increased over time, with the majority of the population being represented by non-CCC adults. The results of this study can be used to guide specifics in adult medicine training during Pediatric Emergency Medicine fellowship and assist in continuing education efforts.

How Much Drool Is Too Much?

A 3-year-old boy presented to the emergency department with a chief complaint of "lethargy" and was found to have ptosis with eventual respiratory failure and need for emergent intubation. There is a broad differential for a patient with respiratory failure, and careful physical examination and history are imperative to reduce morbidity and prevent mortality. After further evaluation and workup, the diagnosis is ultimately revealed.

Influence of Clinical Competency Committee Review Process on Summative Resident Assessment Decisions.

BACKGROUND: Clinical Competency Committees (CCCs) are charged with making summative assessment decisions about residents. OBJECTIVE: We explored how review processes CCC members utilize influence their decisions regarding residents' milestone levels and supervisory roles. METHODS: We conducted a multisite longitudinal prospective observational cohort study at 14 pediatrics residency programs during academic year 2015-2016. Individual CCC members biannually reported characteristics of their review process and Accreditation Council for Graduate Medical Education milestone levels and recommended supervisory role categorizations assigned to residents. Relationships among characteristics of CCC member reviews, mean milestone levels, and supervisory role categorizations were analyzed using mixed-effects linear regression, reported as mean differences with 95% confidence intervals (CIs), and Bayesian mixed-effects ordinal regression, reported as odds ratios (ORs) and 95% credible intervals (CrIs). RESULTS: A total of 155 CCC members participated. Members who provided milestones or other professional development feedback after CCC meetings assigned significantly lower mean milestone levels (mean 1.4 points; CI -2.2 to -0.6; P < .001) and were significantly less likely to recommend supervisory responsibility in any setting (OR = 0.23, CrI 0.05-0.83) compared with CCC members who did not. Members recommended less supervisory responsibility when they reviewed more residents (OR = 0.96, 95% CrI 0.94-0.99) and participated in more review cycles (OR = 0.22, 95% CrI 0.07-0.63). CONCLUSIONS: This study explored the association between characteristics of individual CCC member reviews and their summative assessment decisions about residents. Further study is needed to gain deeper understanding of factors influencing CCC members' summative assessment decisions.

Thresholds and interpretations: How clinical competency committees identify pediatric residents with performance concerns.

BACKGROUND: Clinical competency committee (CCC) identification of residents with performance concerns is critical for early intervention. METHODS: Program directors and 94 CCC members at 14 pediatric residency programs responded to a written survey prompt asking them to describe how they identify residents with performance concerns. Data was analyzed using thematic analysis. RESULTS: Six themes emerged from analysis and were grouped into two domains. The first domain included four themes, each describing a path through which residents could meet or exceed a concern threshold:1) written comments from rotation assessments are foundational in identifying residents with performance concerns, 2) concerning performance extremes stand out, 3) isolated data points may accumulate to raise concern, and 4) developmental trajectory matters. The second domain focused on how CCC members and program directors interpret data to make decisions about residents with concerns and contained 2 themes: 1) using norm- and/or criterion-referenced interpretation, and 2) assessing the quality of the data that is reviewed. CONCLUSIONS: Identifying residents with performance concerns is important for their education and the care they provide. This study delineates strategies used by CCC members across several programs for identifying these residents, which may be helpful for other CCCs to consider in their efforts.