Pain management practices surrounding lumbar punctures in children: A survey of Canadian emergency physicians.

OBJECTIVES: Lumbar punctures (LPs) are painful for children, and analgesia is recommended by academic societies. However, less than one-third of pediatric emergency physicians (EPs) adhere to recommendations. We assessed the willingness to provide analgesia among pediatric and general EPs and explored patient and provider-specific barriers. METHODS: We surveyed physicians in the Pediatric Emergency Research Canada (PERC) or Canadian Association of Emergency Physicians (CAEP) databases from May 1 to August 1, 2016, regarding hypothetical scenarios for a 3-week-old infant, a 3-year-old child, and a 16-year-old child requiring an LP. The primary outcome was the willingness to provide analgesia. Secondary outcomes included the type of analgesia, reasons for withholding analgesia, and their perceived competence performing LPs. RESULTS: For a 3-week old infant, 123/144 (85.4%) pediatric EPs and 231/262 (88.2%) general EPs reported a willingness to provide analgesia. In contrast, the willingness to provide analgesia was almost universal for a 16-year-old (144/144 [100%] of pediatric EPs and 261/262 [99.6%] of general EPs) and a 3-year-old (142/144 [98.6%] of pediatric EPs and 256/262 [97.7%] of general EPs). For an infant, the most common barrier cited by pediatric EPs was the perception that it produced additional discomfort (13/21, 61.9%). The same reason was cited by general EPs (12/31, 38.7%), along with unfamiliarity surrounding analgesic options (13/31, 41.9%). CONCLUSION: Compared to a preschool child and adolescent, the willingness to provide analgesia for an LP in a young infant is suboptimal among pediatric and general EPs. Misconceptions and the lack of awareness of analgesic options should be targets for practice-changing strategies

Corrigendum: Pain management practices surrounding lumbar punctures in children: A survey of Canadian emergency physicians (Canadian Journal of Emergency Medicine (2018) DOI: 10.1017/cem.2018.382)

In the original publication of this article, Pediatric Emergency Research Canada (PERC) was not listed as an author. The authors regret this error. The original version has been updated

Quality Indicators for the Assessment and Management of Pain in the Emergency Department: A Systematic Review

BACKGROUND: Evidence indicates that pain is undertreated in the emergency department (ED). The first step in improving the pain experience for ED patients is to accurately and systematically assess the actual care being provided. Identifying gaps in the assessment and treatment of pain and improving patient outcomes requires relevant, evidence-based performance measures.OBJECTIVE: To systematically review the literature and identify quality indicators specific to the assessment and management of pain in the ED.METHODS: Four major bibliographical databases were searched from January 1980 to December 2010, and relevant journals and conference proceedings were manually searched. Original research that described the development or collection of data on one or more quality indicators relevant to the assessment or management of pain in the ED was included.RESULTS: The search identified 18,078 citations. Twenty-three articles were included: 15 observational (cohort) studies; three before-after studies; three audits; one quality indicator development study; and one survey. Methodological quality was moderate, with weaknesses in the reporting of study design and methodology. Twenty unique indicators were identified, with the majority (16 of 20) measuring care processes. Overall, 91% (21 of 23) of the studies reported indicators for the assessment or management of presenting pain, as opposed to procedural pain. Three of the studies included children; however, none of the indicators were developed specifically for a pediatric population.CONCLUSION: Gaps in the existing literature include a lack of measures reflecting procedural pain, patient outcomes and the pediatric population. Future efforts should focus on developing indicators specific to these key areas.Peer Reviewe

Adverse Events Related to Emergency Department Care: A Systematic Review

<div><p>Objective</p><p>To systematically review the literature regarding the prevalence, preventability, severity and types of adverse events (AE) in the Emergency Department (ED).</p><p>Methods</p><p>We systematically searched major bibliographic databases, relevant journals and conference proceedings, and completed reference reviews of primary articles. Observational studies (cohort and case-control), quasi-experimental (e.g. before/after) studies and randomized controlled trials, were considered for inclusion if they examined a broad demographic group reflecting a significant proportion of ED patients and described the proportion of AE. Studies conducted outside of the ED setting, those examining only a subpopulation of patients (e.g. a specific entrance complaint or receiving a specific intervention), or examining only adverse drug events, were excluded. Two independent reviewers assessed study eligibility, completed data extraction, and assessed study quality with the Newcastle Ottawa Scale.</p><p>Results</p><p>Our search identified 11,624 citations. Ten articles, representing eight observational studies, were included. Methodological quality was low to moderate with weaknesses in study group comparability, follow-up, and outcome ascertainment and reporting. There was substantial variation in the proportion of patients with AE related to ED care, ranging from 0.16% (n = 9308) to 6.0% (n = 399). Similarly, the reported preventability of AE ranged from 36% (n = 250) to 71% (n = 24). The most common types of events were related to management (3 studies), diagnosis (2 studies) and medication (2 studies).</p><p>Conclusions</p><p>The variability in findings and lack of high quality studies on AE in the high risk ED setting highlights the need for research in this area. Further studies with rigorous, standardized outcome assessment and reporting are required.</p></div

Summary of Quality Assessments.

1<p>Maximum of 4 stars for: representativeness of the exposed cohort; selection of the non-exposed cohort; ascertainment of exposure; and demonstration that outcome of interest was not present at start of study.</p>2<p>Maximum of 2 stars for: comparability of cohorts on the basis of the design or analysis.</p>3<p>Maximum of 3 stars for: assessment of outcome; was follow-up long enough for outcome to occur; and adequacy of follow-up of cohorts.</p><p>NR not reported.</p

Summary of Studies.

*<p>Refers to proportion of patients with AE related to ED care, unless otherwise specified.</p

PRISMA Diagram.

<p>PRISMA Diagram.</p

Antibiotic Prescribing Practices for Urinary Tract Infection in a Pediatric Emergency Department: Is This a Problem Worth Cefix-ing?

Background: Pediatric urinary tract infection (UTI) is associated with diagnostic and therapeutic challenges. Objective: To determine the least-broad-spectrum oral antibiotic that would cover 80% of pathogens from lower (afebrile) and upper (febrile) UTIs in a Canadian pediatric emergency department (ED). Methods: This retrospective case series involved children discharged from the ED between September 2020 and February 2021 with a diagnosis of UTI and collection of a sample for urinalysis that had growth on culture. Results: Of 188 patients who met the inclusion criteria, 184 (97.9%) were discharged on antibiotics. Culture results indicated a UTI in 170 cases (92.4% of those discharged on antibiotics). The 95 urinary isolates from lower UTIs were susceptible to cephalexin (n = 81, 85.3%), cefixime (n = 78, 82.1%), nitrofurantoin (n = 76, 80.0%), trimethoprim sulfamethoxazole (TMP–SMX) (n = 64, 67.4%), and amoxicillin (n = 55, 57.9%). The 75 urinary isolates from upper UTIs were susceptible to cefixime (n = 71, 94.7%), TMP–SMX (n = 57, 76.0%), and amoxicillin (n = 48, 64.0%). The mean prescribed duration of antibiotic therapy was 8.3 days for patients with a lower UTI and 9.1 days for those with an upper UTI (mean difference 0.80 days, 95% confidence interval 0.05–1.54). Conclusions: Empiric treatment with cephalexin or nitrofurantoin would have been successful for almost all lower UTIs. More complete reporting of cephalexin minimal inhibitory concentrations might have allowed use of this drug for most upper UTIs. Although there was a trend toward shorter duration of therapy for lower versus upper UTI, lower UTIs were always treated for longer than recommended by current guidelines. RÉSUMÉ Contexte : L’infection des voies urinaires (IVU) pédiatrique présente des défis diagnostiques et thérapeutiques. Objectif : Déterminer l’antibiotique oral à large spectre le moins élevé qui couvrirait 80 % des pathogènes des IVU inférieures (sans fièvre) et des IVU supérieures (avec fièvre) dans un service d’urgences pédiatriques canadien. Méthodes : Cette série de cas rétrospective impliquait des enfants sortis du service des urgences entre septembre 2020 et février 2021 avec un diagnostic d’IVU et la collecte d’un échantillon pour une analyse d’urine avec croissance dans la culture d’urine. Résultats : Parmi les 188 patients répondant aux critères d’inclusion, 184 (97,9 %) ont reçu des antibiotiques au moment du congé. Les résultats de la culture ont indiqué une IVU dans 170 cas (92,4 % des patients ayant reçu des antibiotiques au moment du congé). Les 95 isolats urinaires des IVU inférieures étaient sensibles à la céphalexine (n = 81, 85,3 %), au céfixime (n = 78, 82,1 %), à la nitrofurantoïne (n = 76, 80,0 %), au triméthoprime-sulfaméthoxazole (TMP-SMX) (n = 64, 67,4 %) et à l’amoxicilline (n = 55, 57,9 %). Les 75 isolats urinaires des IVU supérieures étaient sensibles au céfixime (n = 71, 94,7 %), au TMP-SMX (n = 57, 76,0 %) et à l’amoxicilline (n = 48, 64,0 %). La durée moyenne de prescription d’antibiotiques était de 8,3 jours pour les patients atteints d’une IVU inférieure et de 9,1 jours pour ceux atteints d’une IVU supérieure (différence moyenne 0,80 jours, IC à 95 % 0,05-1,54). Conclusions : Un traitement empirique avec la céphalexine ou la nitrofurantoïne aurait été efficace pour la grande majorité des infections urinaires inférieures. Un rapport plus complet des concentrations minimales inhibitrices de la céphalexine aurait peut-être permis d’utiliser ce médicament pour la plupart des infections urinaires supérieures. Bien qu’il y ait eu une tendance vers une durée de traitement plus courte pour les infections urinaires inférieures par rapport aux infections urinaires supérieures, les infections urinaires inférieures étaient toujours traitées plus longtemps que ce qui est recommandé par les lignes directrices actuelles

A systematic review of adverse drug events associated with administration of common asthma medications in children

<div><p>Objective</p><p>To systematically review the literature and determine frequencies of adverse drug events (ADE) associated with pediatric asthma medications.</p><p>Methods</p><p>Following PRISMA guidelines, we systematically searched six bibliographic databases between January 1991 and January 2017. Study eligibility, data extraction and quality assessment were independently completed and verified by two reviewers. We included randomized control trials (RCT), case-control, cohort, or quasi-experimental studies where the primary objective was identifying ADE in children 1 month– 18 years old exposed to commercial asthma medications. The primary outcome was ADE frequency.</p><p>Findings</p><p>Our search identified 14,540 citations. 46 studies were included: 24 RCT, 15 cohort, 4 RCT pooled analyses, 1 case-control, 1 open-label trial and 1 quasi-experimental study. Studies examined the following drug classes: inhaled corticosteroids (ICS) (n = 24), short-acting beta-agonists (n = 10), long-acting beta-agonists (LABA) (n = 3), ICS + LABA (n = 3), Leukotriene Receptor Antagonists (n = 3) and others (n = 3). 29 studies occurred in North America, and 29 were industry funded. We report a detailed index of 406 ADE descriptions and frequencies organized by drug class. The majority of data focuses on ICS, with 174 ADE affecting 13 organ systems including adrenal and growth suppression. We observed serious ADE, although they were rare, with frequency ranging between 0.9–6% per drug. There were no confirmed deaths, except for 13 potential deaths in a LABA study including combined adult and pediatric participants. We identified substantial methodological concerns, particularly with identifying ADE and determining severity. No studies utilized available standardized causality, severity or preventability assessments.</p><p>Conclusion</p><p>The majority of studies focus on ICS, with adrenal and growth suppression described. Serious ADE are relatively uncommon, with no confirmed pediatric deaths. We identify substantial methodological concerns, highlighting need for standardization with future research examining pediatric asthma medication safety.</p></div

Is caregiver refusal of analgesics a barrier to pediatric emergency pain management? A cross-sectional study in two Canadian centres.

Clinician\u27s Capsule What is known about the topic? Children\u27s pain in the emergency department (ED) continues to be under-recognized and sub-optimally managed.What did this study ask?We sought to evaluate the frequency of caregiver/child acceptance of analgesia offered in the ED.What did this study find?Of the 743 children who presented to the ED with a painful condition, 408 (54.9%) were offered analgesia. If offered in the ED, analgesia was accepted by 91% (373/408) of the caregivers/children.Why does this study matter to clinicians?This study suggests that caregiver/child refusal of analgesia is a not a major barrier to optimal pain management and highlights the importance of ED personnel in encouraging adequate analgesia