July 27, 2017

Background: Fluid resuscitation with crystalloid is one of the most basic initial management approaches to adult and pediatric patients with severe sepsis and septic shock. However, which fluid should we be giving, and does it matter?  Should we give an unbalanced, chloride rich solution such as normal saline or a balanced, chloride restrictive fluid, such as lactated ringers, Plasma-Lyte, or Normasol? Interestingly, the 2016 Surviving Sepsis Guidelines, added resuscitation with balanced fluids into the guidelines, although a weak recommendation with low quality of evidence. This recommendation was based on some growing adult data, albeit retrospective, showing that resuscitation strategies using normal saline may be harmful and associated with increased risk of AKI (1), need for CRRT (1) and increased mortality (2-3). The effects of balanced fluids however, have not been studied in the resuscitation of children in severe sepsis and septic shock.

May 11, 2017

Background: Fever without source in infants less than three months old presents a difficult diagnostic dilemma for ED physicians.  Over the past 25 years several algorithms have been developed to help guide clinicians, most notably the Rochester, Philadelphia and Boston Criteria, in determining which infants require admission vs. outpatient management.  These studies were designed published between 1992 and 1994 prior to the wide spread use of HiB and pneumococcal vaccines in children, maternal GBS screening and the development of many new biomarkers. 

The Step-by-Step approach to febrile infants was developed by a European group of pediatric emergency physicians with the objective of identifying low risk infants who could be safely managed as outpatients without lumbar puncture or empiric antibiotic treatment. The algorithm was designed using retrospective data and this study attempts to prospectively validate it.

March 6, 2017

Pediatric Septic Hip Definition: Bacterial infection of the hip joint space and synovial fluid

Background:

  • Causes
    • Hematogenous spread in bacteremia
    • Local spread (i.e. from osteomyelitis)
    • Direct inoculation (traumatic or surgical)
  • High-Risk Subgroups
    • Age < 2 years (peak incidence 6 - 24 months)
    • Immunocompromised state (i.e. AIDS, active cancer, etc)
    • Functional asplenia (i.e. sickle cell disease)
  • Complications
    • Sepsis
    • Osteomyelitis
    • Chronic arthritis
    • Osteonecrosis
    • Capsule damage

June 2, 2016

BACKGROUND: Every year in the United States there are an estimated 178.8 million episodes of acute gastroenteritis resulting in 473,832 hospitalizations.  Most of the evidence surrounding oral rehydration centers around Oral Rehydration Therapy (ORT) studies in low-income countries where children suffer from more extensive gastrointestinal losses.  Theoretically, electrolyte maintenance solutions are recommended in order to prevent increasing diarrheal losses through the osmotic diuresis that can occur with glucose-rich drinks like juice.  However, these electrolyte maintenance solutions can cost up to $10 for a 1-liter bottle and are unpalatable to some children.  Refusal to drink often results in the need for IV hydration and can potentially result in disease progression and hospitalization.  This study attempted to look at whether a dilute apple juice solution or preferred fluids was equal to, if not superior to oral hydration with an electrolyte maintenance solution.

August 17, 2015

Welcome to the August 2015 REBEL Cast, where Swami, Matt, and I are going to tackle a couple of topics. First topic: renal colic. Renal colic is a commonly seen condition encountered in emergency departments and the use of medical expulsive therapy (MET) is commonly recommended by our urology colleagues. Proponents of MET in the treatment of ureteric colic advocate for them due to their potential ability to increase stone passage, reduce pain medication use, and reduce urologic interventions. Second topic: pediatric weights. In pediatric resuscitations many of use the Broselow tape to predict weights for dosing of medications.  With the increasing weights in pediatric patients seen in developed countries around the world, does the commonly used Broselow tape accurately predict weights?   So with that introduction today we are going to specifically tackle:

Topic #1: MET for Renal Colic Topic #2: Use of the Broselow Tape to Estimate Pediatric Weights

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