Pediatric patients undergoing diagnostic tests in the pediatric emergency room are frequently sedated. Although efforts are made to prevent adverse events, no sedation protocol has specified the optimal regimen, dosage, and interval of medication to prevent adverse events. This study analyzed the safety and efficacy of sequential pediatric sedation protocols for pediatric patients undergoing diagnostic tests in the pediatric emergency room of a single tertiary medical center. The medical records of patients aged < 18 years who visited the pediatric emergency room of Seoul Asan Medical Center between January and December 2019 for diagnostic testing were retrospectively reviewed. Sedation protocols consisted of 50 mg/kg and 25 mg/kg chloral hydrate, 0.1 mg/kg and 0.1 mg/kg midazolam, and 1 mg/kg and 0.5 to 1 mg/kg ketamine, administered sequentially at intervals of 30, 20, 10, 10, and 10 minutes, respectively. Patients were assessed prior to sedation, and adverse events were investigated. Of the 289 included patients, 20 (6.9%) experienced adverse events, none serious, and nine (3.1%) failed to reach the depth of sedation required to complete the test. The regimen (P = .622) and dosage (P = .777) of the sedatives were unrelated to the occurrence of adverse events when sedation was performed according to protocol. The sedation protocol used in these patients, consisting of sequential administration of minimum dosages, achieved a sufficient depth of sedation with relatively few adverse events, indicating that this protocol can be used safely and effectively for painless sedation in pediatric patients undergoing diagnostic testing.
Purpose The more younger the child, the more complications of endotracheal intubation are likely, such as deep intubation, extubation, atelectasis, or barotraumas, because of the small diameter and short length of the trachea. Therefore, the exact placement of tube tip in the middle third of trachea is very important; however, normal reference ranges of the length from incisors to middle third of the trachea for Korean children is not prepared yet. Methods A retrospective study was conducted on 48 children, who underwent endotracheal intubation in the emergency department of Asan Medical Center, between February 1997 and October 2007. After correcting the depth in actual tip positions by the difference between the actual intubation depths and calculated or measured depths by various methods, such as PALS guidelines, APLS formula, formula method, Broselow tape, and new formula, a comparison between these various methods was done. Results Most commonly, the tube position was too deep including position in the right main bronchus (71%). Among the children who underwent right main bronchus intubation, more than half were children less than 2 years of age (58%). The highest rate of appropriate tube position was observed when corrected using the PALS guideline (69%), and the lowest rate was observed in formula method (26%). Conclusion Meticulous intubation technique requires not to intubate too deep especially in young children less than 2 years of age. Physicians responsible for acute care of children should be knowledgeable of the PALS guideline for the appropriate depth of tracheal tube. However, it is also important to note the possibility of deep intubation while adhering to this guideline (approximately 40%). The development of methods or devices based on the distance from incisors to mid-portion of the trachea for Korean children is necessary. Key Words: Child; Intubation; Airway Management; Emergencies
Purpose: Acute bronchiolitis (AB)-related return visits incur overuse of emergency medicine resources, crowding of emergency departments (EDs), and deterioration of rapport with the guardians. The authors aimed to analyze factors associated with the return visits to the ED.Methods: This study was conducted based on the medical records of 447 children aged 24 months or younger with AB who visited the ED from January 2019 through December 2020. A return visit was defined as an AB-related visit to the ED within 7 days of index visit. According to the return visit, we compared the clinical features. Multivariable logistic regression was conducted to identify independent factors for the return visit.Results: Of the 323 children with AB, 77 (23.8%) made return visits. The returning children showed a younger median age (6 [interquartile range, 2-10] vs. 8 months [3-14]; P < 0.001), a lower mean oxyhemoglobin saturation (92.9 ± 4.3% vs. 97.1 ± 1.8%; P < 0.001), and higher frequencies of congenital heart diseases (22.1% vs. 10.6%; P = 0.009) and bronchopulmonary dysplasia (11.7% vs. 5.7%; P = 0.013), and respiratory syncytial virus infection (57.1% vs. 37.0%; P = 0.002). No other variables, such as the hospitalization rate, differed as per return visits. The factors associated with return visits were respiratory syncytial virus infection (adjusted odds ratio, 9.41; 95% confidence interval, 2.13-41.57), lower oxygen saturation (2.00; 1.64-2.43), and age younger than 3 months (1.25; 1.07-1.24).Conclusion: AB-related return visits may be associated with age younger than 3 months, lower oxygen saturation, and respiratory syncytial virus infection.
The aim of this study was to evaluate whether point-of-care ultrasound (POCUS) for intussusception screening streamlines the workflow of clinically nonspecific intussusception (CNI), an intussusception presenting with only 1 manifestation of the classic triad, and/or vomiting.We reviewed 274 consecutive children with intussusception, aged 6 years or younger, who visited a tertiary care hospital emergency department between May 2012 and April 2016. This period was dichotomized by May 2014 (the "PRE" and "POST" groups), starting point of implementation of the POCUS protocol for intussusception screening. All children with CNI who had positive results on or forwent POCUS underwent radiologist-performed ultrasound (US). We measured and compared emergency department length of stay (EDLOS), the sum of door-to-reduction and observation times, and the frequency of POCUS and positive US results between the 2 groups.Of 160 children with CNI, 93 visited the emergency department since May 2014. The POST group showed a shorter median EDLOS (856 vs 630 minutes, P < 0.001), door-to-reduction time (137 vs 111 minutes, P = 0.002), and observation time (700 vs 532 minutes, P < 0.001). The POST group had a higher frequency of POCUS (12% vs 60%, P < 0.001) with positive US results (33% vs 59%, P < 0.001). The PRE group had a higher frequency of severe bowel edema (16% vs 1%, P < 0.001). No significant differences were found in the severity, recurrence, admission, and surgery. One child had a false-negative result on POCUS.Point-of-care ultrasound could streamline the workflow of CNI via decrease in EDLOS and unnecessary referrals for US.
The role of the Ferric Uptake Regulator (FUR) in the acid resistance of Helicobacter pylori (H. pylori) has been thought to be independent of urease. However, we demonstrated in this study that Fur influences urease activity.A fur knockout mutant of H. pylori was constructed by replacing the Fur gene with a kanamycin resistant marker gene. The wild-type H. pylori and fur mutant were compared for survival. The integrity of the inner membrane of the bacteria was evaluated by confocal microscopy using membrane-permeant and -impermeant fluorescent DNA probes. Urease activity of intact H. pylori was measured between pH 3 and 8. Real time PCR of both strains was performed for urease genes including ureI, ureE, ureF, ureG, and ureH.The fur deletion affected the survival of H. pylori at pH 4. The urease activity curve of the intact fur mutant showed the same shape as the wild-type but was 3-fold lower than the wild-type at a pH of less than 5. Real time PCR revealed that the expression of all genes was consistently down-regulated in the fur mutant.The results of this study showed that fur appears to be involved in acid resistant H. pylori urease activity.
Front Cover: Biodegradable PLGA-patterned substrates with immobilization of ECM proteins via a DOPA coating significantly promote contact guidance and neuronal differentiation of hNSCs. The addition of neurotrophic factor (NGF) further enhances neurogenesis of hNSCs, indicating a synergistic effect of biophysical and biochemical cues on hNSC differentiation. (Cover designed by J. Kim and K. Yang) Further details can be found in the article by K. Yang, E. Park, J. S. Lee, I.-S. Kim, K. Hong, K. I. Park, S.-W. Cho, H. S. Yang on page 1348.
Pediatric sedation in the emergency department (ED) is widely performed in Korea; thus exploring the trends of its use is necessary. This study aimed to investigate the characteristics of patients and sedatives use in the ED and verify their changes over recent years.A nationwide population-based retrospective study was conducted including pediatric patients aged ≤ 15 years who received sedative medication in the ED and were discharged during 2007-2018, using the Korean Health Insurance Review and Assessment Service database. Patient characteristics (age, sex, level of ED, and diagnosis) and type of sedative used were analyzed.Sedation was performed in total 468,221 visits during 2007-2018 (399,320 visits, at least 3.8% of overall ED visits during 2009-2018). Among these, 71.0% were children aged 1-3 years and 93.5% were sedated to support diagnosis of injury. An increase in total sedation was observed in patients aged 4-6 years during the study period (from 13.8% to 21.8%). A gradual decrease in the use of chloral hydrate (CH) compared with an increase in ketamine use was observed (CH, from 70.6% to 28.6%; ketamine, from 23.8% to 60.7%). Therefore, ketamine was the most used sedative since 2014. The most frequently used sedatives over the study period differed according to age groups (CH in <1 year and 1-3 years; ketamine in 4-6 years and 7-10 years; and midazolam in 11-15 years).The characteristics of patients related to sedatives use in the ED have changed over time. These changes should be considered in the development of future Korean guidelines regarding pediatric sedation in the ED.
Purpose To investigate whether performance of point-of-care ultrasound (POCUS) can reduce emergency department length of stay (EDLOS) for children with nonspecific manifestations of intussusception (NMI), defined as 2 or less manifestations of the classic triad of intussusception, and/or vomiting. Methods We reviewed medical records of 141 consecutive children with intussusception aged 6 years or younger who visited the emergency department of Asan Medical Center in Seoul, Korea from May 2014 through April 2016 and underwent diagnostic radiology ultrasound and pneumatic reduction. The children were grouped according to whether they underwent POCUS or not (POCUS and no POCUS groups, respectively). POCUS was performed to children with NMI by an attending emergency physician who had completed a POCUS training course endorsed by the Korean Society of Pediatric Emergency Medicine. We measured EDLOS, which consisted of door-to-reduction and observation times. These time intervals were compared between the 2 groups. Results Of 112 eligible children, 65 (58%) underwent POCUS. The median EDLOS was shorter in the POCUS group than in the no POCUS group (566 minutes, interquartile range [IQR] 497 to 765 vs. 745 minutes, IQR 551 to 981; P = 0.003). The median door-to-reduction and observation times were also shorter in the POCUS group (105 vs. 138 minutes, P < 0.001 and 440 vs. 628 minutes, P = 0.008, respectively). These differences were possibly due to the performance of POCUS and the trend toward early discharge after pneumatic reduction. We found 1 child with false negative result on POCUS, but there may have been more. Conclusion Performance of POCUS may reduce EDLOS in children with NMI. Key Words: Child; Emergency Service, Hospital; Intussusception; Length of Stay; Point-of-Care Systems; Ultrasonography
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