What is the right dose of epinephrine?

OBJECTIVE: To review the findings and discuss implications of studies on high-dose epinephrine (0.1 mg/kg) during cardiopulmonary resuscitation in children. DESIGN: A critical appraisal of "A Comparison of High-Dose and Standard-Dose Epinephrine in Children with Cardiac Arrest" by Perondi et al. (N Engl J Med 2004; 350:1722-1730), with literature review. FINDINGS: Retrospective studies investigating the use of high-dose epinephrine during pediatric cardiopulmonary resuscitation demonstrate conflicting results with respect to return of spontaneous circulation and survival. The randomized controlled trial by Perondi et al. demonstrates decreased survival with the use of high-dose epinephrine and no difference in return of spontaneous circulation when compared with the standard dose. CONCLUSIONS: There is no benefit from the use of high-dose epinephrine in pediatric cardiopulmonary resuscitation. There is potential harm from such dosing. The cumulative evidence against the use of high-dose epinephrine during pediatric cardiopulmonary resuscitation is strong.     

Ruling out the need for antibiotics: are we sending the right message?

OBJECTIVES: To examine the relationships among physician-parent communication practices, physicians' perceptions of parental expectations for antibiotic treatment, and inappropriate antibiotic prescribing for viral upper respiratory tract infections. DESIGN: Cross-sectional study of pediatric encounters motivated by cold symptoms between October 1, 2000, and June 30, 2001. Each encounter was videotaped. Physicians completed a postvisit survey that measured whether they perceived the parent as expecting antibiotics. Coded communication variables were merged with survey variables. Multivariate analyses identified key predictors of parent-physician communication practices, physician perceptions of parents' expectations for antibiotics, and inappropriate antibiotic prescribing for viral conditions. SETTING: Twenty-seven pediatric practices in Los Angeles, Calif. PARTICIPANTS: Thirty-eight pediatricians and 522 consecutively approached parents of children with cold symptoms. MAIN OUTCOME MEASURES: Physicians' perceptions of parental expectations for antibiotics, inappropriate antibiotic prescribing, and parental questioning of nonantibiotic treatments. RESULTS: Physicians were 20.2% more likely to perceive parents as expecting antibiotics when they questioned the physician's treatment plan (P = .004; 95% confidence interval, 6.3%-34.0%). When physicians perceived parents as expecting antibiotics, they were 31.7% more likely to inappropriately prescribe them (P<.001; 95% confidence interval, 16.0%-47.3%). Parents were 24.0% more likely to question the treatment plan when the physician ruled out the need for antibiotics (P = .004; 95% confidence interval, 7.7%-40.3%). CONCLUSIONS: Parental questioning of the treatment plan increases physicians' perceptions that antibiotics are expected and thus increases inappropriate antibiotic prescribing. Treatment plans that focus on what can be done to make a child feel better, rather than on what is not needed, ie, antibiotics, may decrease inappropriate antibiotic prescribing.     

Ceftriaxone use in the emergency department: are we doing it right?

OBJECTIVE: To evaluate the patterns of ceftriaxone use in an urban pediatric emergency department (PED) and to determine if overuse exists based on published guidelines for management of febrile infants. METHODS: We conducted a retrospective study of 229 young febrile patients who received ceftriaxone between January 1 and March 31, 1995, in a large urban PED in a teaching hospital in Atlanta. Patients younger than 3 months, patients with chronic illnesses (eg, sickle cell anemia, HIV), and those who received ceftriaxone for sexually transmitted diseases were excluded. RESULTS: During the study period, ceftriaxone was administered 289 times to 229 patients (53% male) aged 3 months to 18 years. Sixty patients (26%) received ceftriaxone two or more times for the same illness. Data were stratified based on age, source of fever, temperature, leukocyte count, diagnosis of pneumonia, and visit order (initial or follow-up). At the time of their initial visit, 180 of 229 patients had an identifiable focus of infection (76 had pneumonia), but no source could be identified in the remaining 49. Based on temperature, leukocyte count, and the presence or absence of a focus, ceftriaxone use, as compared with practice guidelines, was justified in 40 of 229 (17.5%) patients, questionable in 43 of 229 (18.8%), and not justified in 146 of 229 (63.7%). For the 60 patients who received ceftriaxone more than once, its use was justified in only 13%. Results of blood cultures were positive in 3 of 229 (1.3%) patients. Ceftriaxone was justified according to published guidelines in two of these three patients, whereas one patient with pneumonia and pneumococcal bacteremia could have been treated with oral antibiotics. Overall, for the entire study population (289 encounters at initial and subsequent visit combined), ceftriaxone use was justified in 48 patients (16.6%), questionable in 49 patients (17%), and not justified in 192 patients (66.4%). CONCLUSIONS: Based on published guidelines, ceftriaxone use in the PED was not justified in the majority of cases.     

Problems associated with intravenous fluid administration in children: do we have the right solutions?

Edema, both in its cellular and tissue form, is a frequent complication in critically ill patients. In health, a balance is struck between intracellular and extracellular osmotic forces and interstitial and intravascular oncotic forces, which in turn governs fluid distribution between the intracellular, extracellular and interstitial fluid compartments. The use of hypo- and hypernotic electrolyte solutions has major effects on brain cells, which can be detrimental or beneficial. The controversy over the use of colloids versus crystalloid solutions in critically ill patients remains unresolved.     

Mechanism responsible for D‐transposition of the great arteries: Is this part of the spectrum of right isomerism?

D‐transposition of the great arteries (TGA) is one of the most common conotruncal heart defects at birth and is characterized by a discordant ventriculoarterial connection with a concordant atrioventricular connection. The morphological etiology of TGA is an inverted or arrested rotation of the heart outflow tract (OFT, conotruncus), by which the aorta is transposed in the right ventral direction to the pulmonary trunk. The rotational defect of the OFT is thought to be attributed to hypoplasia of the subpulmonic conus, which originates from the left anterior heart field (AHF) residing in the mesodermal core of the first and second pharyngeal arches. AHF, especially on the left, at the early looped heart stage (corresponding to Carnegie stage 10–11 in the human embryo) is one of the regions responsible for the impediment that causes TGA morphology. In human or experimentally produced right isomerism, malposition of the great arteries including D‐TGA is frequently associated. Mutations in genes involving left–right (L–R) asymmetry, such as NODAL, ACTRIIB and downstream target FOXH1, have been found in patients with right isomerism as well as in isolated TGA. The downstream pathways of Nodal‐Foxh1 play a critical role not only in L–R determination in the lateral plate mesoderm but also in myocardial specification and differentiation in the AHF, suggesting that TGA is a phenotype in heterotaxia as well as the primary developmental defect of the AHF.