Jakelin Caal Maquin. That is the name of the 7 year old girl who died in the custody of US officials soon after arriving at our border. More details about her death may follow, but, as of now, we know that she reportedly died from dehydration after a long journey from Guatemala. Apparently she was in US custody for 90 minutes before receiving any medical attention. Finger pointing will now ensue and the death of this little girl may serve as a political football for advocates on different sides of the issues.
ACEP in San Diego was an enriching experience. We had an opportunity to learn new techniques, see old friends and reinforce critical concepts that are essential to our practice. We opened the ACEP PEM section meeting with a dynamic presentation from Dr. Christopher Amato, who provided guidance on being an effective speaker. November’s microsite highlights education, and the editor’s thought it a timely opportunity to showcase a portion of Dr. Amato’s presentation. Enjoy!
Jessica Wall, MD, MPH
In medical school and residency we are taught to be vigilant for mental status changes and cerebral edema in our pediatric patients with diabetic ketoacidosis (DKA). It is medical dogma that we must rehydrate them gently and slowly to prevent such a devastating complication, but the little evidence that we have for this teaching is observational and/or decades old. Recently, “Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis” was published in The New England Journal of Medicine, with which Nate Kuppermann and the PECARN DKA FLUID Study Group have taken a major first step in changing how we think about fluid administration in DKA.
The structure of their study is elegant in that they completed a large, randomized study in which there was a 2-by-2 factorial design, allowing for the assessment of both fluid type (0.9% sodium chloride or 0.45% sodium chloride) and rate of administration (10% of body weight replaced in a 36 hour regimen or 5% body weight replaced in a 48 hour regimen). This design allowed for an assessment of both sodium chloride concentration and fast replacement with a higher volume versus slow replacement with a lower volume.
And drum roll please… there was no significant difference in proportion of patients with a drop in Glasgow Coma Score or neurocognitive assessment after recovery between all four treatment groups. Interestingly, there was a trend to a higher incidence of clinically apparent brain injury in the slow hydration groups, but this was not statistically significant. Now there were a few differences between non-neurologic adverse events, mainly higher rates of hyperchloremic acidosis in the 0.9% sodium chloride group and/or rapid administration group, and higher rates of hypocalcemia and hypophosphatemia in the 0.9% sodium chloride groups. However, the take home point from this study is that isotonic versus hypotonic intravenous hydration and slow versus fast hydration does not affect the incidence of neurologic compromise in diabetic ketoacidosis. We can hydrate these patients when they are in extremis without having that nagging thought in the back of our minds that we are increasing the risk of cerebral edema.
It is time to rethink our protocols and open discussion with our endocrinology and critical care colleagues about fluids in DKA.
Kuppermann N, Ghetti S, Schunk JE, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med. 2018;378(24):2275-2287. doi:10.1056/NEJMoa1716816.
I can vividly remember my first day as a REAL doctor. I started on the pediatric pulmonology service, and recall spending what felt like an hour, deliberating whether I could order Tylenol for my patient. Would it interact with the Pulmozyme treatment? Fortunately, I had very patient senior resident who calmed my nerves and was empathetic to my intern anxiety. July is an exciting, terrifying, rewarding and sometimes frustrating month, as we celebrate a new “medical year.” Whether or not you subscribe to the controversial premise of the July effect, there is no doubt that during this time you can leave a pivotal educational footprint in the life and career of a young doctor.
As we lead these learners on this educational journey, one of the most poignant lessons we can teach them is how to think critically. This includes recognizing and managing cognitive biases. Pattern recognition, which primarily occurs unconsciously, and analytical thinking which is deliberate and conscious, are the principle means by which we make medical decisions. Cognitive biases are errors in reasoning that affect primarily the pattern recognition pathway. Debiasing strategies focus on transitioning from pattern recognition to a more analytic approach.1 By utilizing these debiasing strategies, we can reduce clinical errors committed by our learners and ourselves.
The first step in this process is to define and recognize the different type of cognitive errors that most commonly occur in medicine.
Anchoring: The patient’s chief complaint is sore throat, and they report an exposure to a family member with “strep.” This preliminary information seems quite convincing for a Group A beta-hemolytic streptococcal infection. However, upon further history gathering, the patient reveals symptoms of periodic heartburn, frequent belching and the sensation of food “getting stuck.” Your learner, however, despite this additional information, is convinced that the patient should be treated immediately with antibiotics for the infectious process. This is an example of anchoring, during which one prematurely locks on to a diagnosis based on important preliminary information and fails to adjust this impression when additional information becomes available.
Information Bias: Innovative medical technology has afforded us the use of advanced radiologic imaging techniques and near instantaneous laboratory testing results. The utilization of such is not always efficient, affordable or practical. The tendency to believe that the more data one can collect to support a diagnosis the better, is called information bias.
Blind Spot Bias: As a seasoned, skilled physician, you have developed well defined illness scripts. You can recognize when a learner is going astray and are able to gently guide him or her back on track. Perhaps you do not recognize your own tendency towards gender bias or stereotyping. This is an example of blind spot bias: the ability to recognize the weakness or cognitive errors in others, and a tendency to overlook our own.
Over 100 different types of cognitive biases have been described in the literature. We are all vulnerable to these types of errors and being aware of them is a meaningful start to mitigating their effects. Wilson and Brekke 2 suggest an algorithmic approach to managing bias:
- Become aware of the bias
- Ensure that you and your learner are motivated to correct the bias
- Recognize the magnitude of the bias
- Apply an appropriate debiasing strategy
The authors suggest that successful completion of these steps lead to optimal decision making, however failure to complete these tasks leads to distortion of clinical reasoning. Dr. Croskerry 3,4 describes the following debiasing strategies.
Procedural sedation is often required in the pediatric emergency department for a variety of chief complaints, including abscess incision and drainage, fracture reduction, laceration repair and burn management. While there have been numerous advances in the field of procedural sedation as well as updates to practice guidelines, there are often no guidelines for indications for sedation or medications for particular patient types.
Miller et al describes patient care variability in the setting of procedural sedation in the pediatric emergency department. The objective of this study was to describe sedation trends over time as well as to quantify the variation in procedural sedation in terms of rate of use, patient characteristics, indications and choice of agents. A retrospective, cross-sectional study was performed. Data were obtained using the Pediatric Health Information System (PHIS) database. This database contains emergency department, inpatient, ambulatory surgery and observation encounter-level data from 45 tertiary care hospitals in the Unites States. Inclusion criteria consisted of children who presented to a participating emergency department between January 1, 2009 and December 31, 2014 and were younger than 19 years of age. The authors identified patients who would potentially receive procedural sedation based on the following diagnostic categories: fractures, lacerations, abscesses, dislocations, and other (burns, amputations, etc.). Patients with chronic comorbid conditions, patients who received paralytics (these were likely used for intubation) and patients receiving sedation medications in the operating room were excluded. Administration of the following medications were considered to constitute procedural sedation: propofol, ketamine, ketamine and propofol, midazolam and fentanyl, dexmedetomidine, etomidate, chloral hydrate, pentobarbital, methohexital, meperidine, promethazine, and chlorpromazine. Single agent use of an opiate or benzodiazepine was not considered procedural sedation.
Results showed that 1,265,386 patients met inclusion criteria. Of this number, 99,951 (7.9%) received procedural sedation medications. The rate of procedural sedation was 7.4% in ages 0-4, 9.3% in ages 5-11 years, and 6.3% in ages 12-18 years. Fractures made up 54.5% of all procedural sedations, followed by laceration repairs, abscess drainage, and dislocations. In the most recent year of the study, ketamine was used most commonly (73.7%), followed by midazolam and fentanyl (15.9%), ketamine with propofol (7.3%) and propofol (2.7%). The combination of midazolam and fentanyl increased over time (OR 1.39), while other sedation medications decreased in use over time including ketamine (OR 0.81), pentobarbital (OR 0.73), etomidate (OR 0.78), chloral hydrate (OR 0.37) and methohexital (0.58). The median sedation rate in 2009 was 6.9% (range 0.03%-15.1%), while in 2014 the median sedation rate was 8% (range 0.21%-32%). After removing outlier hospitals, which constituted the uppermost 25th percentile and lowermost 25th percentiles, there remains ~3-fold difference in overall sedation rate across children’s hospital emergency departments.
There are several limitations to this study. First, data was gathered from a database of tertiary care hospitals and may not be generalizable to all emergency departments. Second, diagnostic codes were used to identify the study population, which is reliant on provider billing for the appropriateness of the condition/diagnosis. Lastly, the authors acknowledge the possibility of some spectrum bias. For example, patients without public insurance may have been more likely to present with conditions that did not require sedation.
It is interesting that such practice variation exists among children’s hospitals in the United States. To date, there is no single study assessing the practice patterns of non-pediatric hospitals regarding procedural sedation in children.