Variations in sedating uncooperative, stable children for post-traumatic head CT

To the Editor. One of the areas of controversy in the practice of pediatric emergency medicine is the evaluation of the infant who presents with its first febrile seizure. I applaud the American Academy of Pediatrics (AAP) Provisional Committee on Quality Improvement's attempt to clarify the issues regarding the treatment of these infants. I must, however, question both the recommendations and the methods by which they were developed.Whenever a committee of the AAP presents practice parameters, recommendations must reflect the practice patterns of the medical community and the state of the art scientific evidence available to substantiate the recommendation. The Committee recommends “after the first seizure with fever in infants younger than 12 months, performance of a lumbar puncture must be strongly considered.” Neither the prevailing practice patterns of pediatric emergency physicians nor the most recent literature were considered. The makeup of the Committee as listed in the abstract lists general pediatricians and consultants in the field of neurology and epilepsy as the developers of this practice parameter. Absent from the Subcommittee on Febrile Seizures was any representation from the Section on Pediatric Emergency Medicine. The references used to support this recommendation cannot be considered contemporary. The most recent article quoted in references substantiating this recommendation is 13 years old.Pediatric emergency physicians manage fevers with seizures as a daily part of their clinical practice.1 If the child is previously healthy, has not been treated previously with an antibiotic, and has a simple febrile seizure, he/she is managed as any child with an acute fever. Simple febrile seizures are a normal variant. This question of lumbar puncture for the first febrile seizure was recently addressed in the pediatric emergency medicine literature.1A case study was presented, a simple febrile seizure in a previously healthy 8-month-old infant who was not currently on antibiotics and at the time of examination in the emergency department was alert, smiling, and had a normal white blood cell count. The pediatric emergency discussants indicated that lumbar puncture for such a case scenario would not be indicated. Studies have addressed the issue both retrospectively and prospectively.23 A recent review by Green et al2 found that all children who presented with fever, seizures, and meningitis either appeared extremely ill, had meningeal signs, or had febrile seizures with complex features. The authors conclude that lumbar puncture for simple febrile seizures was not indicated unless the child had an indication independent of the seizure for requiring the study.2Indications for lumbar puncture in a febrile child age 6 months to 5 years old include presence of meningeal signs and toxicity consistent with the diagnosis of meningitis. Lumbar puncture should be strongly considered in this age group for children who present with seizure activity at the time of arrival in the emergency department, or with findings on physical examination such as rash, cyanosis, hypotension, respiratory distress, or abnormal neurologic examination.4Children with complex febrile seizures should strongly be considered for performance of a lumbar puncture.3 The recommendation algorithm would be better served highlighting theseindications rather than their basis of particular age subgroups.Such practice parameter recommendations become significant medical legal literature. The Academy would have been better served if the recommendations regarding the evaluation of the child with a first simple febrile seizure reflected both current practice patterns in pediatric emergency departments and current contemporary pediatric literature.In Reply. The American Academy of Pediatrics (AAP) Subcommittee on Febrile Seizures thanks Dr Nozicka, Medical Director of Pediatric Services at the Columbia Hospital and State Medical Center, for his thoughtful comments. The Subcommittee members recognize that the most controversial area of the practice parameter on febrile seizures is the recommendation regarding lumbar punctures.It should be noted that these recommendations were developed only after an extensive review of the literature and consultation with 11 experts in the field, various AAP sections and committees including the Committee on Pediatric Emergency Medicine and Section on Emergency Medicine, the American Academy of Pediatrics' Board of Directors as well as committees from the American College of Emergency Physicians, Child Neurology Society, the American Academy of Family Physicians, the American Academy of Neurology, the American Neurologic Association, and the Epilepsy Foundation of America. As might be anticipated, there was a range of reactions to the practice parameter. Most reviewers were supportive of the recommendations but two groups had differing opinions. One society considered our recommendation “a lumbar puncture in children less than 12 months of age with first febrile seizure should be strongly considered” as too weak and wanted us to “strongly recommend” routine lumbar puncture in all children less than 18 months with a first febrile seizure. In contrast, another society thought that a lumbar puncture should not be recommended unless the child had definite signs of meningitis. It is the nature of this type of exercise that there will be differences of opinion. However, it should be stressed that our recommendations were based on a careful analytic review of the literature. Unfortunately, the technical report, which describes and analyzes each article we reviewed, was not published in its entirety in Pediatrics due to space considerations. The full technical report is available through the American Academy of Pediatrics' Division of Publications.As reported in the literature, between 1% and 5% of children with first febrile seizures may have abnormal cerebrospinal examinations. In some children (particularly the very young), the only presenting clinical sign is a seizure and fever. Therefore, young children are at high risk for undiagnosed meningitis. In Dr Nozicka's letter, young age at the time of the first febrile seizure is not considered high risk, but we do not feel that this view is supportable either based on the literature or on clinical experience.As noted in the technical report, clearly the clinical evaluation of young febrile children requires skills that vary between examiners. As such, the Subcommittee deliberately chose a conservative approach with an emphasis on the value of the lumbar puncture in diagnosing meningitis. Practice parameters are meant solely to give guidance and not to eliminate clinical judgment. Although this practice parameter states that a lumbar puncture should be “strongly considered” in certain situations, we are not suggesting it be mandated. If the pediatrician feels confident in his examination of the child, is comfortable that he/she will have adequate follow-up of the patient over the next 24 hours, and it is in her/his judgment that a lumbar puncture is not indicated, this practice parameter would not presume to change that approach. Alternatively, in situations that are not optimal, ie, a young child with a first febrile seizure seen in an emergency department by physicians who may be less experienced and where follow-up is likely to be less than ideal, it would appear that a lumbar puncture would be the appropriate diagnostic approach.

The restlessness of young children often causes motion artifacts on CT images. We devised a new animation projector system (CT Theater) that enables a child to view an animation during a pediatric head CT examination. The purpose of this study is to assess the usefulness on a children of a video viewed during a head CT scan. Children of 3-10 years old who underwent head CT (SOMATOM Definition Flash, SOMATOM Force; Siemens) were analyzed for a period from 6 months before, to 6 months after, introduction of the projector system (before: n=46, after: n=29). Mobile projector (MP-CL1; Sony) connected with tablet device (iPad; Apple) was put on the CT table near the child's head. An animation was projected on the child's line of sight inside the gantry. The animation is projected on the line of sight of the child such that the projector moves with the child on the table. The number of requests for use made by children was 28/29 (96.6%). The presence of images without motion artifacts decreased significantly after introduction (before/after introduction: 84.8% vs 100%, p=0.03). The overall examination success rate tended to increase after introduction (84.8% vs 92.9%, p=0.26). The overall examination time was significantly reduced (92.4±42.4 s vs 65.1±47.3 s, p<0.001). We developed an animation projector system that shortened examination time and decreased motion artifacts in pediatric head CT.

Medical radiation from CT should be kept as low as reasonably achievable (ALARA), particularly in young patients. To examine radiation dose from head CT in children in a trauma center (TC) and a regional children's hospital (RCH). A random sample of 240 children (0-3, 4-9, 10-14 years of age) from the TC were compared with a similar cohort from the RCH. All children had undergone at least one head CT scan without contrast enhancement; data from PACS and Department of Radiology Information System were used to estimate normalized effective dose (ED). Lifetime attributable risk of cancer incidence was estimated using the Biologic Effects of Ionizing Radiation (BEIR) VII report. The mean normalized ED was significantly higher in the youngest children at the TC (2.74 mSv in those aged 0-3 years vs. 2.23 mSv in those aged 10-14 years; P<0.001) and at the RCH (2.44 mSv in those aged 0-3 years vs. 1.71 mSv in those aged 10-14 years; P<0.001). Each decreasing year of age was independently associated with a 0.06 mSv higher mean normalized ED (P<0.001). After adjusting for the age difference between the institutions, the mean normalized ED was 0.44 mSv lower at the RCH than at the TC across all ages (95% CI 0.31-0.58, P<0.001). A higher lifetime attributable risk of cancer was associated with younger age. The radiation dose from head CT in children as defined by the normalized ED was highest in the youngest children and varied significantly between institutions in this bi-institutional study.

The appropriate management of anxiety and pain for diagnostic and therapeutic procedures in children frequently requires the administration of drugs with sedative properties. Sedation for these procedures has been associated with considerable risk for adverse events (1–3). In light of reports of lifethreatening adverse events, the American Academy of Pediatrics (AAP) (4), American Society of Anesthesiologists (ASA) (5), and Joint Commission on the Accreditation of Health Care Organizations (JCAHO) (6) have mandated guidelines in order to reduce continuing variability in practice, and the risk associated with sedation. These guidelines, as detailed in Chapter 2, emphasize the importance of uniformity of monitoring and care for sedated children, regardless of the nature of the procedure and the setting in which it is performed or the intended depth of sedation. Despite the availability of nationally publicized guidelines, there is great variability in sedation practice.

Radiation dose comparison in brain CT examinations among 3 public hospitals

The creation of formal planning guidelines for newborn intensive care units (NICUs) first occurred when Toward Improving the Outcome of Pregnancy was published in 1976. This landmark publication, written by a multidisciplinary committee and published by the March of Dimes, provided a rationale for planning and policy for regionalized perinatal care, as well as details of roles and facility design. Since then, the American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG) have published several editions of their comprehensive Guidelines for Perinatal Care, and the American Institute of Architects has likewise published several editions of their Guidelines for Construction of Hospital and Healthcare Facilities. In 1993, Toward Improving the Outcome of Pregnancy was revised. The second Toward Improving the Outcome of Pregnancy reviewed medical and societal changes since the original document and formulated new recommendations in recognition of these developments, particularly the ascendance of managed care. The purpose of this committee is to complement the above documents by providing health-care professionals, architects, interior designers, state health-care facility regulators and others involved in the planning of NICUs with a comprehensive set of standards based on clinical experience and an evolving scientific database. With the support of Ross Products Division/Abbott Laboratories, a multidisciplinary team of physicians, nurses, state health planning officials, consultants and architects reached consensus on the first edition of these recommendations in January 1992. The document was then sent to all members of the American Academy of Pediatrics Section on Perinatal Pediatrics to solicit their comments, and we also sought input from participants at the 1993 Parent Care Conference and at an open, multidisciplinary conference on newborn ICU design held in Orlando in 1993. Subsequent editions of these recommended standards were then developed by the consensus committees in 1993, 1996, 1999, 2002 and 2006 under the auspices of the Physical and Developmental Environment of the High-Risk Infant Project. Various portions of these recommended standards have now been adopted by the American Institute of Architects’ Guidelines, the AAP/ACOG Guidelines and by standards documents in several other countries. In the future, we will continue to update these recommendations on a regular basis, incorporating new research findings, experiences and suggestions. It is our hope that this document will continue to provide the basis for a consistent set of standards that can be used by all states and endorsed by appropriate national organizations, and that it will also continue to be useful in the international arena. While many of these standards are minimums, the intent is to optimize design within the constraints of available resources, and to facilitate excellent health care for the infant in a setting that supports the central role of the family and the needs of the staff. Decision makers may find that these standards do not go far enough and resources may be available to push further toward the ideal.

The establishment of local diagnostic reference levels for pediatric CT

Patients with acute neurologic injury require a specialized approach to critical care, particularly with regard to sedation and analgesia. This article reviews the most recent advances in methodology, pharmacology, and best practices of sedation and analgesia for the neurocritical care population. In addition to established agents such as propofol and midazolam, dexmedetomidine and ketamine are two sedative agents that play an increasingly central role, as they have a favorable side effect profile on cerebral hemodynamics and rapid offset can facilitate repeated neurologic exams. Recent evidence suggests that dexmedetomidine is also an effective component when managing delirium. Combined analgo-sedation with low doses of short-acting opiates is a preferred sedation strategy to facilitate neurologic exams as well as patient-ventilator synchrony. Optimal care for patients in the neurocritical care population requires an adaptation of general ICU strategies that incorporates understanding of neurophysiology and the need for close neuromonitoring. Recent data continues to improve care tailored to this population.

Purpose:To ascertain and implement the maximum level of adaptive statistical iterative reconstruction (ASiR) that can be used to establish dose reduced pediatric head CT protocols.Methods:Noise power spectrum (NPS), modulation transfer function (MTF), and qualitative visual assessment were used as image quality metrics to calculate image quality based on filtered back projection (FBP) and ASiR reconstruction. The effect on image quality as a function of level of ASiR implementation and tube current reduction was analyzed by comparing image noise magnitude and frequency, and spatial resolution with similar measured image quality for FBP. Relative patient dose reduction was estimated using both CTDIvol and effective dose calculated using pediatric sized physical anthropomorphic phantoms. Dose reduced protocols were investigated for CT head examinations (i.e. brain, orbits, sinus, maxillary and temporal bones) by implementing ASiR and lowering CT tube current.Results:An analysis of the effects on noise texture from implementation of statistical iterative reconstruction determined that the level of ASiR that correlated closest with FBP for the GE soft reconstruction kernel (for both 100 and 120 kVp) was determined to be 30%, and for the GE standard reconstruction kernel at 100 kVp was 20% ASiR. However, implementation of 60% ASiR (GE soft reconstruction kernel) and 30% ASiR (GE standard reconstruction kernel) led to an average relative reduction in CTDIvol by 40% (range: 30%‐47%) and effective dose by 36% (range: 12%‐54%) while maintaining the same overall noise magnitude and improving the CNR of the image as compared to FBP. A coarser noise texture was visualized at 60% ASiR.Conclusion:The data in this study are provided to allow customized selection of ASiR implementation relating to acceptable tolerance for change in noise texture appearance in reconstructed images, and level of relative dose reduction for a pediatric population undergoing head CT examination.

Head CT scans are considered the imaging modality of choice to screen patients with head trauma for neurocranial injuries; however, widespread CT imaging is not recommended and much research has been conducted to establish objective clinical predictors of intracranial injury (ICI) in order to optimize the use of neuroimaging in children with minor head trauma. To evaluate whether a strict application of the New Orleans Criteria (NOC), Canadian CT Head Rule (CCHR) and National Emergency X-Radiography Utilization Study II (NEXUS II) in pediatric patients with head trauma presenting to a non-trauma center (level II) could reduce the number of cranial CT scans performed without missing clinically significant ICI. We conducted an IRB-approved retrospective analysis of pediatric patients with head trauma who received a cranial CT scan between Jan. 1, 2001, and Sept. 1, 2008, and identified which patients would have required a scan based on the criteria of the above listed decision instruments. We then determined the sensitivities, specificities and negative predictive values of these aids. In our cohort of 2,101 patients, 92 (4.4%) had positive head CT findings. The sensitivities for the NOC, CCHR and NEXUS II were 96.7% (95%CI 93.1-100), 65.2% (95%CI 55.5-74.9) and 78.3% (95%CI 69.9-86.7), respectively, and their negative predictive values were 98.7%, 97.6% and 97.2%, respectively. In contrast, the specificities for these aids were 11.2% (95%CI 9.8-12.6), 64.2% (95%CI 62.1-66.3) and 34.2% (95%CI 32.1-36.3), respectively. Therefore, in our population it would have been possible to scan at least 10.9% fewer patients. The number of cranial CT scans conducted in our pediatric cohort with head trauma would have been reduced had any of the three clinical decision aids been applied. Therefore, we recommend that further validation and adoption of pediatric head CT decision aids in non-trauma centers be considered to ultimately increase patient safety while reducing medical expense.

Together with quantile regression methods, such a model would have the potential for clinical utility through automated quantitative comparison of individual cases relative to their age and gender-matched peer group. Our aim was to demonstrate the automated processing of digital clinical head CT data in the development of a clinically useful model of age-related changes of the brain in the first 2 decades of life. A total of 415 (209 female) consecutive, clinical head CTs with radiographically normal findings from patients from birth through 20 years of age were retrospectively selected and subjected to automated segmentation. Brain volume, brain parenchymal fraction, brain radiodensity, and brain radiomass were assessed as a function of patient age. Statistical modeling and quantile regression were performed. Brain volume increased from 400 cm3 at birth to 1350 cm3 at 20 years of age (>3-fold). Males had a slightly steeper growth trajectory than females, with approximately 8% difference in volume between the sexes established in the first few years of life. Brain parenchymal fraction was variable at younger than 2 years of age, stabilizing between 0.85 and 0.92 at 2-3 years of age. Brain mean radiodensity was lower at birth (24 HU) and increased through 3 years of age, after which it stabilized near 30 HU, an approximately 25% increase. The product of brain volume and mean brain radiodensity (radiomass), increased from 700 HU × mL at birth to 3900 HU × mL, a 5.6-fold increase, with approximately 5% difference between males and females at 20 years. Quantile regression enables a given metric to be interpreted relative to an age- and sex-matched peer group. Automated segmentation of clinical head CT images permitted the generation of a reference database for quantitative analysis of pediatric and adolescent brains. Quantile regression facilitates clinical application.

The close relationship between clinical outcomes and sedation strategies in critically ill patients strongly supports the need for a rigorous and systematic approach to analgesia, sedation, and delirium (ASD) management in those patients. In the last decade, several high-quality evidence-based clinical practice guidelines, including substantial new elements for ASD treatment, have been published. They strongly support a light rather than deep level of sedation with a general retreat from benzodiazepines; an appropriate monitoring of analgesia, sedation, and delirium; and the use of nonpharmacological interventions. Nevertheless, national and international surveys highlighted the gap existing between clinical practice and current recommendations, revealing low implementation of screening tools and remarkable variations in the definition and assessment of optimal sedation. The development of institutionally specific patient-centered protocols, using an interdisciplinary team approach, may facilitate the transfer of evidence-based “best practices” to the bedside, limit practice variation, and reduce treatment delays, with improvement in overall quality of care in ICU patients and cost reduction. An integrated bundle approach, focusing on assessing, treating, and preventing pain, agitation, and delirium in an integrated manner and connecting ASD management to other evidence-based ICU practices, has been proposed. Although the true effects are not well defined, the application of individual elements of the bundle, or the combination of more of them, appeared to significantly improve outcomes and significantly reduce costs both in short- and long-term critically ill patients.

Analgesia and sedation play important roles in the overall treatment of critically burned adult patients. According to clinical actual situation of critically burned adult patients, a set of analgesic and sedative practices, including analgesia-based sedation, scientifically reasonable sedation status monitoring, early goal-directed sedation strategy, standardized and individualized strategy for analgesia and sedation, and early comfort using analgesia, minimal sedative, maximal human care strategy are recommended and widely implemented nowadays. However, guideline or consensus about how to provide analgesia and sedation treatment for critically burned adult patients is lacking. In this article, we discuss strategy for analgesic and sedative management in critically burned adult patients, with preexisting ideas in critical care medicine, pathophysiological characteristics of critically burned patients, and our clinical practice for reference.

Our aim in the study was to assess the eye lens dose reduction resulting from the use of radioprotective bismuth garments to shield the eyes of pediatric patients undergoing head CT. The Monte Carlo N-particle transport code and mathematical humanoid phantoms representing the average individual at different ages were used to determine eye lens dose reduction accomplished with bismuth shielding of the eye in the following simulated CT scans: (a) scanning of the orbits, (b) scanning of the whole head, and (c) 20 degrees angled scanning of the brain excluding the orbits. The effect of bismuth shielding on the eye lens dose was also investigated using an anthropomorphic phantom and thermoluminescence dosimetry (TLD). Eye lens dose reduction achieved by bismuth shielding was measured in 16 patients undergoing multiphase CT scanning of the head. The patient's scans were divided in the following: CT examinations where the eye globes were entirely included (n=5), partly included (n=6) and excluded (n=5) from the scanned region. The eye lens dose reduction depended mainly on the scan boundaries set by an operator. The average eye lens dose reduction determined by Monte Carlo simulation was 38.2%, 33.0% and <1% for CT scans of the orbits, whole head, and brain with an angled gantry, respectively. The difference between the Monte Carlo derived eye lens dose reduction factor values and corresponding values determined directly by using the anthropomorphic phantom head was found less than 5%. The mean eye lens dose reduction achieved by bismuth shielding in pediatric patients were 34%, 20% and <2% when eye globes were entirely included, partly included and excluded from the scanned region, respectively. A significant reduction in eye lens dose may be achieved by using superficial orbital bismuth shielding during pediatric head CT scans. However, bismuth garments should not be used in children when the eyes are excluded from the primarily exposed region.

Patient- and family-centered care is an approach to health care that recognizes the role of the family in providing medical care; encourages collaboration between the patient, family, and health care professionals; and honors individual and family strengths, cultures, traditions, and expertise. Although there are many opportunities for providing patient- and family-centered care in the emergency department, there are also challenges to doing so. The American Academy of Pediatrics and the American College of Emergency Physicians support promoting patient dignity, comfort, and autonomy; recognizing the patient and family as key decision-makers in the patient's medical care; recognizing the patient's experience and perspective in a culturally sensitive manner; acknowledging the interdependence of child and parent as well as the pediatric patient's evolving independence; encouraging family-member presence; providing information to the family during interventions; encouraging collaboration with other health care professionals; acknowledging the importance of the patient's medical home; and encouraging institutional policies for patient- and family-centered care.