Little Big Med Little Big Med

In this episode host Jason Woods talks with Corrie Chumpitazi and Pradip Kamat about the general trends in pediatric sedation (outside of the operating room) over the last decade, centered on a paper they co-authored. The discussion focuses on changing distribution of WHO is doing sedations, medications used, and safety measures.







Highlighted paper: Kamat PP, McCracken CE, Simon HK, et al. Trends in Outpatient Procedural Sedation: 2007-2018. Pediatrics. 2020;145(5):e20193559. doi:10.1542/peds.2019-3559







DISCLOSURE: We will be discussing sedation medications, which are commonly used but not FDA approved for children for this indication. 







Guests







Corrie E. Chumpitazi MD, MS, Associate Professor of Pediatrics, Baylor College of Medicine/Texas Children’s Hospital







Director of Sedation, Associate Chief of Research, Sedation Oversight Committee Chair, Section of Emergency Medicine, Baylor College of Medicine/Texas Children’s Hospital







Site Principal Investigator, National EMS for Children Innovation and Improvement Center







Society for Pediatric Sedation Provider Course Chair







Pradip P. Kamat MD, MBA Associate Professor of Pediatrics/Pediatric Critical Care Medicine Children’s Heathcare of Atlanta/Emory University School of Medicine







Director Children’s Sedation Services At Egleston, Children’s Healthcare of Atlanta/Emory University School of Medicine







Society for Pediatric Sedation, Chair of Membership Committee, President-Elect







Additional Resources







* Texas Children’s Hospital Procedural Sedation Evidence Based Guideline







Bibliography







* Kamat PP, McCracken CE, Simon HK, et al. Trends in Outpatient Procedural Sedation: 2007-2018. Pediatrics. 2020;145(5):e20193559. doi:10.1542/peds.2019-3559* Bhatt M, Kennedy RM, Osmond MH, Krauss B, McAllister JD, Ansermino JM, Evered LM, Roback MG; Consensus Panel on Sedation Research of Pediatric Emergency Research Canada (PERC) and the Pediatric Emergency Care Applied Research Network (PECARN). Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children. Ann Emerg Med. 2009 Apr;53(4):426-435.e4. doi: 10.1016/j.annemergmed.2008.09.030. Epub 2008 Nov 20. PMID: 19026467.* Roback MG, Green SM, Andolfatto G, Leroy PL, Mason KP. Tracking and Reporting Outcomes Of Procedural Sedation (TROOPS): Standardized Quality Improvement and Research Tools from the International Committee for the Advancement of Procedural Sedation. Br J Anaesth. 2018 Jan;120(1):164-172. doi: 10.1016/j.bja.2017.08.004. Epub 2017 Nov 23. PMID: 29397125.* Grunwell JR, Travers C, McCracken CE, Scherrer PD, Stormorken AG, Chumpitazi CE, Roback MG, Stockwell JA, Kamat PP. Procedural Sedation Outside of the Operating Room Using Ketamine in 22,645 Children: A Report From the Pediatric Sedation Research Consortium. Pediatr Crit Care Med. 2016 Dec;17(12):1109-1116. doi: 10.1097/PCC.0000000000000920.*  Mallory MD, Baxter AL, Yanosky DJ, Cravero JP; Pediatric Sedation Research Consortium. Emergency physician-administered propofol sedation: a report on 25,433 sedations from the pediatric sedation research consortium. Ann Emerg Med. 2011;57(5):462-8.e1. * Jenkins E, Hebbar KB, Karaga KK, et al. Experience with the use of propofol for radiologic imaging in infants younger than 6 months of age. Pediatr Radiol. 2017;47(8):974-983.

In this episode of Little Big Med, host Jason Woods talked with Mark Piehl, pediatric intensivist and founder and CMO of 410 Medical Innovation, about his journey with taking an idea for a medical innovation from concept the entire way to commercial production. Mark is co-inventor of the LifeFlow device and has specific interest in improving resuscitation in pediatric shock, sepsis, and trauma.







Key Points:







Guest: Mark Piehl MD, MPH – Founder and CMO of 410 Medical Innovation, Medical Director WakeMed Mobile Pediatric Critical Care Transport Team, pediatric intensivist at WakeMed in Raleigh, NC







Twitter – @markpiehl







Audio Editor – Kellen Vu







Additional Resources:







* 410 Medical Innovation* Publications relating to the LifeFlow device

In this episode of Little Big Med, host Jason Woods talks with Dr. Stefanie Ames about the paper she first-authored titled “Emergency Department Pediatric Readiness and Mortality in Critically Ill Children”.







Key Points







* Retrospective study, data from Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project, 2013* Included 20483 patients from 426 hospitals in Florida, Iowa, Massachusetts, Nebraska, and New York* Mortality decreased with increasing readiness score* Adjusted OR also showed that the highest “readiness” hospitals had the lowest mortality in this cohort* Some concern remains that the difference is at least partially related to case definition – ICU admission was included as an inclusion criteria, which may have falsely lowered the overall level of illness of patients admitted to an institution with a PICU. HOWEVER – * Cases were also followed through time – so patients that were transferred to a hospital with an ICU from a hospital without one had their data linked together. * In that case the presence or absence of an ICU at the index hospital would not have “counted against” the index hospital, unless that hospital were inappropriately admitting critical ill patients to a general ward instead of transferring to a facility with a PICU* The authors feel they addressed this by also considering PECARN illness severity scores, most of which were 4 or 5 (most severe illness)* Most deaths in this cohort occurred in the ED rather than in the ICU/floor, arguing that the ICU admission criteria itself did not drive mortality rates. * Another analysis of this article from EMA exists but comes to a different conclusion about the impact of this article. I’m linking here so you can listen to the differing viewpoints.







Guest







Stefanie Ames, Assistant Professor, Pediatric Critical Care Medicine, University of Utah







Audio Editor – Kellen Vu







References







* Ames SG, Davis BS, Marin JR, Fink EL, Olson LM, Gausche-Hill M, Kahn JM. Emergency Department Pediatric Readiness and Mortality in Critically Ill Children. Pediatrics. 2019 Sep;144(3):e20190568. doi: 10.1542/peds.2019-0568. Erratum in: Pediatrics. 2020 May;145(5): PMID: 31444254; PMCID: PMC6856787.* Alessandrini EA, Alpern ER, Chamberlain JM, Shea JA, Holubkov R, Gorelick MH; Pediatric Emergency Care Applied Research Network. Developing a diagnosis-based severity classification system for use in emergency medical services for children. Acad Emerg Med. 2012 Jan;19(1):70-8. doi: 10.1111/j.1553-2712.2011.01250.x. PMID: 22251193.

This is part 2 of a 2 part episode. Please see part 1 for full show notes, guest information, and references.

This is part 1 of a 2 part series. Please be sure to listen to part 2!







In this episode, host Jason Woods speaks with Dr. Daniel Tsze and Child Life Specialist Hilary Woodward about how to approach pain in the pediatric patient. This could be pain from the presenting complaint or from the procedure being performed. The discussion focusses primarily on the non-pharmacologic techniques that have been shown to improve the experience for patients, caregivers, and care providers.







Dan and Hilary are both part of the PECARN (Pediatric Emergency Care Applied Research Network) and this episode is published in partnership with the PECARN Dissemination Working Group.







Guests







Hilary Woodward MS, CCLS -New York-Presbyterian Morgan Stanley Children’s Hospital at Columbia University Medical Center







Daniel Tsze MD, MPH – Associate Professor of Pediatrics (Emergency Medicine), New York-Presbyterian Morgan Stanley Children’s Hospital at Columbia University Medical Center







Show Notes







* Techniques – non pharmacologic* Environment – Remember that the environment can have a huge impact not he patient! (I.e. colors on the walls, pictures/posters, cartoons). The attitude and approach from the caregivers and clinical providers also contributes. * Before procedure* Opportunities for patient to interact (safely) with procedure materials. Can use either (or both) of the techniques below:* Medical play – free play with safe procedure materials, possibly with some child-centered narration as patient manipulates what is provided (i.e. “you’re putting that on the doll’s arm”); helps with desensitization & child-directed understanding (figuring out organically how the materials work) and increases patient’s opportunities for control. * Developmentally appropriate teaching – practice procedure on stuffed animal/doll etc., while explaining what will happen and clarifying patient’s questions/misconceptions as needed. May consider hand-over-hand techniques to give patients some knowledge/experience with sharps (if caregiver consent provided, safety guidelines in place, patient assessed by clinician to be an appropriate candidate developmentally and in regards to temperament)* Explanation of what you are going to do. How much do you tell a child and how does this change based on * Can start with “small spoonfuls” of info, focusing on what the patient’s sensory experience will likely be (i.e. how will it feel, what will they see/smell/taste; “some kids say it’s like _______”). Monitor verbal/non-verbal cues to guide when/if/how to share more* Patient and caregiver input is vital – ask what they would like to know more about, and offer choices of coping techniques (consider needs of self-identified “attenders” vs. “distractors”)* Don’t forget the basis like splinting, ice packs, which also have analgesic effects* Positioning for comfort* Chest to chest in a chair for scalp lacs, procedures on extremities* Parent sitting in a chair works well – make sure that patient’s feet are dangling so that they don’t have leverage to push up* Make sure to brace the extremity you are working with (rest extremity on the bed or on a bedside table, ideally at close to a 90 degree angle)* Consider asking a “helper” to hold head or extremity steady* Patient’s back against parent’s chest for facial lacs, procedures on extremities* Have parent lay on stretcher with their whole body (feet included) on the bed; child lays or sits between parent’s legs, with their bottom on the stretcher (NOT on parent’s lap) – then parent can cross their legs over child’s legs* As with chest-to-chest, make sure to use appropriate bracing and a “helper” as needed for steadying* Do you talk with parents ...

In this episode, host Jason Woods speaks with Emma Harding and Laura Bricklin about drowning in children. The discussion covers prevention (specifically parental and patient education) and management, as well as the current terminology and existing data.







This episode is produced in conjunction with Drs. Emma Harding and Laura Bricklin as part of their worth on an AAP CATCH grant.  







The following show notes were authored by Drs. Bricklin and Harding and provide a fantastic review.







Take-Home Points







* Drowning is the #1 cause of preventable death in children age 1-4* You can’t drown-proof a child – multiple layers of protection help prevent drowning* Providers are a major source of water-safety education for most families







Major Data Points







Drowning claimed the lives of nearly 1,000 children (under 20 years old) in 2017, and an estimated 8,700 children visited a hospital emergency department for a drowning.







Two age groups have the highest risk of drowning – toddlers, and teens. Teens of color are at especially high risk. 







The highest rate of drowning is among children under age 4, with children 12 to 36 months of age being at the highest risk. 







* Most infants drown in bathtubs and buckets. * Most preschool-aged children drown in swimming pools. * CPSC found that 69% of children under 5 who drowned were not expected to be at or near a pool when the drowned. 







Teens ages 15-19 years have the second-highest fatal drowning rate. Every year, about 370 children ages 10-19 drown.







* Among teens, half of all drownings occur in natural water settings like lakes, rivers or oceans. * Among teens, drowning is due to a variety of factors, but alcohol is often involved. 







Layers of Protection







* All children and adults should learn to swim. If swim lessons are suspended in your area due to coronavirus, it is important to add other layers of protection until your child can access lessons.







* Close, constant, attentive supervision around water is important. Assign an adult ‘water watcher,’ who should not be distracted by work, socializing, or chores.







* Around the house, empty all buckets, bathtubs, and wading pools immediately after use. If you have young children, keep the bathroom door closed, and use toilet locks to prevent access.







* Pools should be surrounded by a four-sided fence, with a self-closing and self-latching gate. Research shows pool fencing can reduce drowning risk by 50%. Additional barriers can include door locks, window locks, pool covers, and pool alarms.







* Adults and older children should learn CPR. 







* Everyone, children and adults, should wear US Coast Guard-approved life jackets whenever they are in open water, or on watercraft.







* Parents and teens should understand how using alcohol and drugs increase the risk of drowning while swimming or boating.















Pathophysiology







* Fatal and nonfatal drowning typically begins with a period of panic, loss of the normal breathing pattern, breath-holding, air hunger, and a struggle by the victim to stay above the water. 







* Reflex inspiratory efforts eventually occur, leading to hypoxemia by means of either aspiration or reflex laryngospasm that occurs when water contacts the lower respiratory tract







* Results in decreased lung compliance, ventilation-perfusion mismatching,