Journal Feed Weekly Wrap-Up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 
Originally published at JournalFeed, a site that provides daily or weekly literature updates. 
Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.

#1: How High-Risk is a High-Risk BRUE?

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Presence of AAP high-risk BRUE criteria do not accurately predict the presence of a serious underlying diagnosis. Abnormal medical history, history of similar event, event duration >1 minute, and altered responsiveness increased the odds of a serious underlying diagnosis.

Why does this matter?
The absence of high-risk criteria is an effective risk stratification tool to reduce unnecessary workup and admission in BRUE. However, does the presence of these criteria predict outcomes that warrant more than education and discharge, and if not, what does?

Trouble BRUEing?
This was a multicenter retrospective cohort of 2,036 children who met criteria for BRUE (formally ALTE) at ED presentation via a heroic chart review of 4,446 patients identified through ICD-10 codes. Primary endpoint was the diagnosis of a serious condition explaining the index ED visit, which occurred in 82 (4%) cases, with 37 occurring after ED discharge. AAP high-risk criteria (see MDCalc here) were used as covariates for multivariate regression. While the absence of AAP high risk criteria had a robust NPV (97%) for underlying serious condition, presence of criteria did not have a strong PPV (4%). Abnormal medical history (OR 7.3, 95%CI 2.4-21.8), history of similar event (OR 4.1, 95%CI 1.3-12.8), event duration > 1 min (OR 3.6, 95%CI 1.2-10.3), and altered responsiveness (OR 3.6, 95%CI 1.3-10) were associated with increased odds of a serious underlying condition.

This study supports AAP recommendations that in the absence of high-risk criteria further workup can be deferred. However, the decision to pursue admission or further workup should be in the greater context of the patient’s history rather than BRUE screening criteria alone, as their presence is not predictive of a serious underlying diagnosis. Seizure disorder and abusive head trauma were the serious conditions most frequently missed in those discharged from the ED with BRUE, and it may be prudent to focus additional resources towards these conditions and, of course, document these have been considered.

Risk Factors and Outcomes After a Brief Resolved Unexplained Event: A Multicenter Study. Pediatrics. 2021 Jun 24;e2020036095. doi: 10.1542/peds.2020-036095. Online ahead of print.

Edited by Aaron Lacy

For more, see the emDocs Pediatric Small Talk on BRUE.

#2: Should We Use Bronchodilators for Bronchiolitis?

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For infants <12 months diagnosed with bronchiolitis, bronchodilators did not improve hospital or ICU admission numbers, ED return visits, or noninvasive or invasive ventilation requirement.

Why does this matter?
COVID has altered the typical summer respite from RSV, and cases have risen, leading to crowding in pediatric hospitals due to bronchiolitis in infants <12 months. Bronchiolitis is the most commonly diagnosed lower respiratory infection in infants, accounting for up to 300,000 visits per year in EDs. The American Academy of Pediatrics (AAP) recommendation from 2014 does not endorse the use of bronchodilators as part of routine treatment for bronchiolitis. Currently, there are no recommended interventions that are known to be effective at reducing hospital admission for bronchiolitis, which accounts for up to 18% of all pediatric admissions.

No summer break this year
This multicenter, retrospective, cross-sectional study reviewed over 445,000 ED visits between 2010-2018 to see if there was any clinical or statistical difference in outcomes regarding bronchiolitis with bronchodilator use. When comparing hospitals with the highest vs lowest rates of bronchodilator use, there was no difference in, “hospital admissions (OR: 0.93; 95% CI 0.7–1.3), ICU admissions (OR: 1.5; 95%CI 0.7–3.1), ED return visits after initial ED discharge (OR: 1.2; 95%CI 0.99–1.4), noninvasive ventilation (OR: 3.5; 95%CI 0.7–19.1), and invasive ventilation (OR: 8.2; 95% CI 0.99–67.5).” In addition, over the study period, hospital admissions decreased from 34.4% to 33.1% (OR 0.98, 95%CI 0.98-0.99) and ED return visits within 3 days decreased from 5.9% to 5.2% (OR 098, CI 95%CI 0.98-0.99) while ICU admissions increased from 2.4% to 4.3% (OR 1.06, 95%CI 1.05-1.06); noninvasive ventilation increased from 1% to 2.9% (OR 1.15, 95%CI 1.14-1.16), and invasive ventilation increased from 0.7% to 1.5% (OR 1.06, 95%CI 1.04-1.07).

In summary, supportive care and noninvasive or invasive ventilatory support, in conjunction with suctioning, are considered first-line therapies for bronchiolitis, and bronchodilators have not shown any clinically significant benefit in these patients.

Early Use of Bronchodilators and Outcomes in Bronchiolitis. Pediatrics. 2021 Jul 6;e2020040394. doi: 10.1542/peds.2020-040394. Online ahead of print.

Spoon Feed
Ondansetron reduced the odds of young children needing IV fluid during their index ED visit but didn’t seem to reduce hospitalization or other short term outcomes.

Why does this matter?
Ondansetron is safe in children with mild AGE. Safety, with regard to QT interval, is not as clear in critically ill children. Although we use a lot of ondansetron, does its use impact any clinically meaningful outcomes, like need for IV fluid, hospitalization, or frequency of vomiting?

The AGE old problem

I’m trying something a little different with this summary.* Let me know if you like it or not.

  • Data were initially collected prospectively; this was a planned secondary analysis and is considered retrospective. This cohort included 794 children 3-48 months of age with ≥3 episodes of vomiting. Half of these children were given ondansetron solely at the discretion of the provider. From the 794 kids, they selected 528 (half got ondansetron, half did not) and propensity matched them for relevant clinical characteristics except ondansetron use.

  • With propensity matching, there was a 50% lower odds of IV fluid at the index visit, but there was no decrease in index visit hospitalization rate, 72-hour hospitalization rate, or frequency of vomiting and diarrhea in the 24 hours after the ED visit.

  • Ondansetron reduced the odds of young children needing IV fluid administration, so I plan to keep using it, but it doesn’t appear to have much additional short-term impact.

  • There is certainly some selection bias since ondansetron use was non-randomized and subject to provider discretion. Propensity analysis helped mitigate this to some degree.

Oral Ondansetron Administration in Children Seeking Emergency Department Care for Acute Gastroenteritis: A Patient-Level Propensity-Matched Analysis. Ann Emerg Med. 2021 Aug 11;S0196-0644(21)00478-9. doi: 10.1016/j.annemergmed.2021.06.003. Online ahead of print.

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