Category: PEM Journal Club

PEM JOURNAL CLUB: SICKLE CELL With FEVER PROTOCOL

11/30/2016

Hello!
This journal club we reviewed the PED sickle cell with fever protocol. Below are the highlights from that protocol that we found to be the most important steps of the protocol that also had some evidence behind them in the articles listed below. (BTW in the first article Gibbs is one of the authors!)

Hope you enjoy!
- Kat

Labs
- PEM Consensus:
  - CBC, Retic panel to evaluate for aplastic crisis or splenic sequestration
  - Blood culture
Treatment
- PEM Consensus:
  - Avoid oxygen unless in respiratory distress
  - IV bolus ONLY if clinically dehydrated/hypotensive
    - Excess IVF are associated with atelectasis formation, which is a risk factor for acute chest syndrome
  - Early administration of IV antibiotics covering Strep pneumoniae crucial
    - Majority of bacterial infections from encapsulated bacteria
    - Use high dose Ceftriaxone (75mg/kg – 100mg/kg, Max 2G) for higher serum levels
      - SCD patient with higher risk for antibiotic resistance
      - If (true) PCN allergy: Clindamycin 15mg/kg (Max 600mg)
      - If severe illness or meningitis: add Vancomycin (15mg/kg)
Disposition
- PEM Consensus:
  - Higher likelihood of admission based on age and ability for follow-up
  - Contact Hematologist for disposition joint decision
Strength of recommendations
- PEM Consensus:
  - WEAK
    - SCD severely underfunded
    - Large portion of research preformed before wide availability of Pneumococcal vaccine
    - No high powered studies performed/published in several decades
Articles
- Glassberg, J. "Evidence-based management of sickle cell disease in the emergency department." Emergency medicine practice 13.8 (2011): 1-20.
- Yawn, Barbara P., et al. "Management of sickle cell disease: summary of the 2014 evidence-based report by expert panel members." Jama 312.10 (2014): 1033-1048.
- Powars, Darleen, et al. "Pneumococcal septicemia in children with sickle cell anemia: changing trend of survival." JAMA 245.18 (1981): 1839-1842.
- Overturf, Gary D., Darleen Powars, and Larry J. Baraff. "Bacterial meningitis and septicemia in sickle cell disease." American Journal of Diseases of Children 131.7 (1977): 784-787.
- Yusuf HR, Atrash HK, Grosse SD, Parker CS, Grant AM. Emergency department visits made by patients with sickle cell disease: a descriptive study, 1999–2007. American journal of preventive medicine. 2010;38(4):S536-S41.
- Yawn BP, Buchanan GR, Afenyi-Annan AN, Ballas SK, Hassell KL, James AH, et al. Management of sickle cell disease: summary of the 2014 evidence-based report by expert panel members. JAMA. 2014;312(10):1033-48.

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PEM journal club: Asthma protocol

9/15/2016

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Hey everyone,
This year the PEM fellows have decided to do PEM Journal club a little differently from last year. Periodically we will critically appraise the evidence behind the clinical protocols that we currently use in our Pediatric ED to better understand why we do what we do.

For our first protocol, we reviewed the new Peds ED Asthma Pathway. Below are the take home points for the main topics that we discussed.

Enjoy!
- Kat Bryant

Dexamethasone vs Prednisolone:

PEM Consensus:
- Dexamethasone was shown to be better tolerated, cheaper, has better patient/parent satisfaction with less concern for compliance issues
- No difference was found in relapse rate or incidence of vomiting with 1-2 doses of Dexamethasone compared to 3-day course of Prednisolone
- Dexamethasone is likely non-inferior to Prednisolone for the treatment of acute asthma exacerbations
Articles:
- Altamimi, S., et al., Single-dose oral dexamethasone in the emergency management of children with exacerbations of mild to moderate asthma. Pediatr Emerg Care, 2006. 22(12): p. 786-93.
- Cronin, J.J., et al., A Randomized Trial of Single-Dose Oral Dexamethasone Versus Multidose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department. Ann Emerg Med, 2016. 67(5): p. 593-601 e3.
- Greenberg, R.A., G. Kerby, and G.E. Roosevelt, A comparison of oral dexamethasone with oral prednisone in pediatric asthma exacerbations treated in the emergency department. Clin Pediatr (Phila), 2008. 47(8): p. 817-23.
- Qureshi, F., A. Zaritsky, and M.P. Poirier, Comparative efficacy of oral dexamethasone versus oral prednisone in acute pediatric asthma. J Pediatr, 2001. 139(1): p. 20-6.

When to add anticholinergics to short acting beta agonists:

PEM Consensus
- Children with moderate to severe asthma exacerbations benefited from receiving anticholinergics with decreased stay duration and decreased number of subsequent interventions
- Anticholinergics haven’t been shown to be beneficial in mild exacerbations
- Data suggests, but has not proven, that multiple doses of anticholinergics are more beneficial
Articles:
- Griffiths, B. and F.M. Ducharme, Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children. Paediatr Respir Rev, 2013. 14(4): p. 234-5.
- Rodrigo, G.J. and J.A. Castro-Rodriguez, Anticholinergics in the treatment of children and adults with acute asthma: a systematic review with meta-analysis. Thorax, 2005. 60(9): p. 740-6.
- Zorc, J.J., et al., Ipratropium bromide added to asthma treatment in the pediatric emergency department. Pediatrics, 1999. 103(4 Pt 1): p. 748-52.

Why use Magnesium:

PEM Consensus:
- Magnesium’s exact mechanism of action for bronchodilation unclear
- Magnesium may be beneficial for decreased severity of exacerbation, may prevent hospital admission/ICU admission
- Magnesium requires monitoring for hypotension, but has not been shown to cause significant harm
Articles:
- Alansari, K., et al., Nebulized magnesium for moderate and severe pediatric asthma: A randomized trial. Pediatr Pulmonol, 2015. 50(12): p. 1191-9.
- Colleti, J., Jr. and W.B. de Carvalho, Magnesium Sulfate for Acute Asthma in Children: A Good Option, but How to Use It? Pediatr Crit Care Med, 2016. 17(5): p. 477-8.
- Kokotajlo, S., et al., Use of intravenous magnesium sulfate for the treatment of an acute asthma exacerbation in pediatric patients. J Pediatr Pharmacol Ther, 2014. 19(2): p. 91-7

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PEM JOURNAL CLUB: SICKLE CELL With FEVER PROTOCOL

PEM journal club: Asthma protocol

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PEM JOURNAL CLUB: SICKLE CELL With FEVER PROTOCOL

﻿P﻿EM journal club: Asthma protocol﻿

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PEM journal club: Asthma protocol