European Resuscitation Council Guidelines for Resuscitation.

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical supervision; careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications; appropriate fasting for elective procedures and a balance between depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure; a focused airway examination for large tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction; a clear understanding of the pharmacokinetic and pharmacodynamic effects of the medications used for sedation, as well as an appreciation for drug interactions; appropriate training and skills in airway management to allow rescue of the patient; age- and size-appropriate equipment for airway management and venous access; appropriate medications and reversal agents; sufficient numbers of people to carry out the procedure and monitor the patient; appropriate physiologic monitoring during and after the procedure; a properly equipped and staffed recovery area; recovery to presedation level of consciousness before discharge from medical supervision; and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

https://pediatrics.aappublications.org/content/pediatrics/118/6/2587.full.pdf

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures.

Blood culture contamination represents an ongoing source of frustration for clinicians and microbiologists alike. Ambiguous culture results often lead to diagnostic uncertainty in clinical management and are associated with increased health care costs due to unnecessary treatment and testing. A variety of strategies have been investigated and employed to decrease contamination rates. In addition, numerous approaches to increase our ability to distinguish between clinically significant bacteremia and contamination have been explored. In recent years, there has been an increase in the application of computer-based tools to support infection control activities as well as provide clinical decision support related to the management of infectious diseases. Finally, new approaches for estimating bacteremia risk which have the potential to decrease unnecessary blood culture utilization have been developed and evaluated. In this review, we provide an overview of blood culture contamination and describe the potential utility of a variety of approaches to improve both detection and prevention. While it is clear that progress is being made, fundamental challenges remain.

Updated Review of Blood Culture Contamination

Objectives:The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock Provide the 2014 update of the 2007 American College of Critical Care Medicine “Clinical Guidelines for Hemodynamic Support of Neonates and Child

/pdf/american-college-of-critical-care-medicine-clinical-practice-34y5jgypur.pdf

American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock.

https://www.giejournal.org/article/S0016-5107(10)02317-5/pdf

Management of ingested foreign bodies and food impactions

Context. Children frequently ingest coins. When lodged in the esophagus, the coin may cause complications and must either be removed or observed to pass spontaneously. Objectives. (1) To compare relatively immediate en- doscopic removal to a period of observation followed by removal when necessary and (2) to evaluate the relation- ship between select clinical features and spontaneous passage. Design/Setting. Randomized, prospective study of children 24 hours earlier. Children were randomized to either endoscopic removal (surgery) or admission for ob- servation, with repeat radiographs 16 hours after the initial image. Outcome Measures. Proportion of patients requiring endoscopic removal, length of hospital stay, and the number of complications observed. Results. Among 168 children who presented with esophageal coins lodged in the esophagus, 81 were eligi- ble. Of those eligible, 60 enrolled, 20 refused consent, and 1 was not approached. In the observation group, 23 of 30 (77%) children required endoscopy compared with 21 of 30 (70%) in the surgical group. Total hospital length of stay was longer in the randomized-to-observation group compared with the randomized-to-surgery group (mean: 19.4 (SD: 8.0) hours vs 10.7 (SD: 7.1) hours, respectively). There were no complications in either group. Spontaneous passage occurred at similar rates in both groups (23% vs 30%). Spontaneous passage was more likely in older patients (66 vs 46 months) and male patients (odds ratio: 3.7; 95% confidence interval: 0.98- 13.99) and more likely to occur when the coin was in the distal one third of the esophagus (56% vs 27% (95% confidence interval: 1.07-5.57)). Conclusions. Because 25% to 30% of esophageal coins in children will pass spontaneously without complica- tions, treatment of these patients may reasonably include a period of observation, in the range of 8 to 16 hours, particularly among older children and those with distally located coins. Pediatrics 2005;116:614-619; emergency de- partment use, foreign body, gastrointestinal system.

/pdf/a-randomized-clinical-trial-of-the-management-of-esophageal-40ltkg019i.pdf

A randomized clinical trial of the management of esophageal coins in children.

Bispectral index monitoring quantifies depth of sedation during emergency department procedural sedation and analgesia in children.

To elucidate the role gap junctions play in the bystander effect, we examined the cytotoxic effect of herpes simplex virus thymidine kinase (HSVtk) modified tumor cells on gap junction communication-deficient tumor cells and their connexin transfectants. Communication competent Walker 256 tumor cells engineered to express the HSVtk gene (Walker-tk+) when cocultured with N2A mouse neuroblastoma and PC12 rat pheochromocytoma cells with absent endogenous junctional conductance showed no bystander cytotoxicity. Transfection of N2A cells with the rat connexin37 gene (5Q) and PC12 cells with the human connexin43 gene rendered them susceptible to bystander cell death. Additionally, communication-deficient N2A cells transfected with the HSVtk gene failed to exert a bystander effect, whereas N2A transfectants coexpressing the connexin37 and HSVtk genes (5Qtk+ cells) exerted bystander cytotoxicity on gap junction communication-competent 5Q but not on communication-deficient N2A cells in vitro. In vivo experiments also showed tumor growth inhibition of communication-competent 5Q but not communication-incompetent N2A cells by 5Qtk+ cells. In conclusion, these results indicate that in several cellular environments the bystander effect is dependent on connexin expression and gap junctional communication between HSVtk-positive and HSVtk-negative cells.

The bystander effect exerted by tumor cells expressing the herpes simplex virus thymidine kinase (HSVtk) gene is dependent on connexin expression and cell communication via gap junctions

Objectives:We hypothesized that transillumination would increase peripheral intravenous (IV) insertion success rates in pediatric emergency department patients. Primary outcome was success in first attempt, and secondary outcome was success within 2 attempts.Methods:We evaluated IV insertion by pedi

Veinlite transillumination in the pediatric emergency department: a therapeutic interventional trial.

Purpose of review Coins are the most commonly ingested foreign body encountered in the pediatric population. Coins that are in the esophagus and are causing symptoms (cough, stridor, respiratory distress, drooling or pain) are managed with immediate removal via various methods. Asymptomatic coins have been a perplexing problem to the clinician for decades, with some advocating for immediate removal while others are proponents of "watchful waiting". Recent findings This article will provide a review of the current literature on management options for symptomatic and asymptomatic esophageal coins. The article will discuss clinical decision-making strategies for the diagnosis of the unwitnessed ingestion, as well as diagnostic studies, such as plain radiographs, as well as novel modalities, such as metal detectors. Discussion of the anatomic issues related to esophageal foreign bodies will be addressed. Treatment options for asymptomatic patients will be reviewed utilizing data from retrospective studies as well as a prospective randomized trial. Summary In the symptomatic patient with an esophageal coin, immediate removal via endoscopy is recommended. For the asymptomatic patient with an esophageal coin, current data support expectant management for a period of 12-24 h with the hope of spontaneous passage and avoidance of general anesthesia and surgical procedure.

Mark L. Waltzman

Papers

A randomized clinical trial of the management of esophageal coins in children.

Bispectral index monitoring quantifies depth of sedation during emergency department procedural sedation and analgesia in children.

The bystander effect exerted by tumor cells expressing the herpes simplex virus thymidine kinase (HSVtk) gene is dependent on connexin expression and cell communication via gap junctions

Veinlite transillumination in the pediatric emergency department: a therapeutic interventional trial.

Management of esophageal coins.