The Safety and Efficacy of Propranolol in Reducing the Hypermetabolic Response in the Pediatric Burn Population.

Pediatric burn patients often have hypertension and tachycardia for several years post-injury. Propranolol has shown to be effective in treating the hypermetabolic state secondary to a major burn injury. This study was conducted to document a safe and effective dosing regimen for three different age groups. One hundred four burn-injured children with a 30% to 92% total body surface area burn were treated for 1 to 2 years with propranolol in the outpatient setting. Guardians of the patients were instructed on how to take and monitor the systolic blood pressure and heart rate, and document their vital signs several times a day. The documentation was reviewed with the guardian and patient, and based on age-specific vital sign parameters, propranolol dosing adjustment was done to measure at least 15% to 20% reduction in admission heart rate. Mean doses for the age groups were as follows: 0 to 3 years 5.2 ± 2.8 mg/kg/day, 4 to 10 years 4.2 ± 1.8 mg/kg/day, and 11 to 18 years 2.9 ± 1.4 mg/kg/day. The propranolol dose decreased as time post-burn increased. On selected patients, propranolol was stopped due to changes in the heart rate, but at all times, it was safe and effective. No adverse effects were noted. The dosing regimen was not affected by burn size or gender. Propranolol can be safely stopped abruptly with no rebound hypertension. Individuals older than 10 years required a lower dose per kilogram following the burn injury than prepubertal burn survivors. Propranolol proved to be both safe and effective in the management of cardiovascular changes occurring in the hypermetabolic state.

Adding value to daily chest X-rays in the ICU through education, restricted daily orders and indication-based prompting.

BACKGROUND: Chest X-rays (CXRs) are traditionally obtained daily in all patients on invasive mechanical ventilation (IMV) in the intensive care unit (ICU). We sought to reduce overutilisation of CXRs obtained in the ICU, using a multifaceted intervention to eliminate automated daily studies. METHODS: We first educated ICU staff about the low diagnostic yield of automated daily CXRs, then removed the 'daily' option from the electronic health records-based ordering system, and added a query (CXR indicated or not indicated) to the ICU daily rounding checklist to prompt a CXR order when clinically warranted. We built a report from billing codes, focusing on all CXRs obtained on IMV census days in the medical (MICU) and surgical (SICU) ICUs, excluding the day of admission and days that a procedure warranting CXR was performed. This generated the number of CXRs obtained every 1000 'included' ventilator days (IVDs), the latter defined as not having an 'absolute' clinical indication for CXR. RESULTS: The average monthly number of CXRs on an IVD decreased from 919±90 (95% CI 877 to 963) to 330±87 (95% CI 295 to 354) per 1000 IVDs in the MICU, and from 995±69 (95% CI 947 to 1055) to 649±133 (95% CI 593 to 697) in the SICU. This yielded an estimated 1830 to 2066 CXRs avoided over 2 years and an estimated annual savings of $191 600 to $224 200. There was no increase in reported adverse events. CONCLUSION: ICUs can safely transition to a higher value strategy of indication-based chest imaging by educating staff, eliminating the 'daily' order option and adding a simplified prompt to avoid missing clinically indicated CXRs.

Predictors of insulin resistance in pediatric burn injury survivors 24 to 36 months postburn.

Burn injury is a dramatic event with acute and chronic consequences including insulin resistance. However, factors associated with insulin resistance have not been previously investigated. The purpose of this study was to identify factors associated with long-term insulin resistance in pediatric burn injury survivors. The study sample consisted of 61 pediatric burn injury survivors 24 to 36 months after the burn injury, who underwent an oral glucose tolerance test. To assess insulin resistance, the authors calculated the area under the curve for glucose and insulin. The diagnostic criteria of the American Diabetes Association were used to define individuals with impaired glucose metabolism. Additional data collected include body composition, anthropometric measurements, burn characteristics, and demographic information. The data were analyzed using multivariate linear regression analysis. Approximately 12% of the patients met the criteria for impaired glucose metabolism. After adjusting for possible confounders, burn size, age, and body fat percentage were associated with the area under the curve for glucose (P < .05 for all). Time postburn and lean mass were inversely associated with the area under the curve for glucose (P < .05 for both). Similarly, older age predicted higher insulin area under the curve. The results indicate that a significant proportion of pediatric injury survivors suffer from glucose abnormalities 24 to 36 months postburn. Burn size, time postburn, age, lean mass, and adiposity are significant predictors of insulin resistance in pediatric burn injury survivors. Clinical evaluation and screening for abnormal glucose metabolism should be emphasized in patients with large burns, older age, and survivors with high body fat.

Reimbursement profile of a private toxicology practice.

This article presents two years of billing and collection data for a bedside toxicology consultation service. The collections rate was 34% or dollars 26.19 per hour of consultative time. There was an inverse correlation between collection rates and patient acuity.

The sensitivity and specificity of a red blood cell agglutination D-dimer assay for venous thromboembolism when performed on venous blood.

BACKGROUND: Studies evaluating the accuracy of the SimpliRED D-dimer assay for venous thromboembolism (VTE) have used a capillary fingerstick blood sample, which requires the test to be performed immediately at the bedside. Initial studies showed a sensitivity for VTE of 90% to 95% when the assay was performed by a finite number of experienced health care workers. However, because of the test's subjectivity, misinterpretation of the result is possible when performed by inexperienced staff. Recent reports by other investigators indicated a low sensitivity of this assay for VTE and noted a reduction in sensitivity (84%) for pulmonary embolism. OBJECTIVE: To determine the sensitivity and specificity of the D-dimer test performed in the laboratory by experienced technologists on venous whole-blood samples in routine collection tubes. If D-dimer testing results accurately detect VTE when performed in this manner, concerns about the sensitivity of this assay would be solved. METHODS: One hundred forty-eight consecutive patients with suspected VTE underwent D-dimer testing at the bedside using a fingerstick sample and venous blood collected into a plain tube. Venous blood was also collected into tubes containing tri-potassium EDTA, sodium citrate, or a combination of lithium and heparin for D-dimer testing in the laboratory. In addition, the EDTA tube was refrigerated overnight at 4 degrees C for retesting at approximately 24 hours. The presence or absence of VTE was determined by means of objective results of testing and a 3-month follow-up. RESULTS: Thirty-four subjects (23%) had confirmed VTE (25 with deep vein thrombosis; 9 with pulmonary embolism). All laboratory venous blood D-dimer results showed sensitivities of 97%, specificities of 61% to 64%, and negative predictive values of 99%, compared with 88%, 71%, and 95%, respectively, when the results were obtained by means of fingerstick at the bedside. CONCLUSIONS: The SimpliRED D-dimer assay performed in the laboratory on venous blood, collected into any of 3 routine laboratory tubes, is sensitive and moderately specific for VTE. Based on this study, immediate bedside testing (particularly by inexperienced personnel) under suboptimal conditions is unnecessary. Furthermore, the high sensitivity of refrigerated EDTA samples allows specimens to be stored or transported (on ice at 4 degrees C) for testing for 24 hours after collection.