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Pediatric Pearls - Pediatric Fever – Step by Step

Ilene Claudius, MD and Solomon Behar, MD
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09:58
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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01:54

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EM:RAP 2016 December Written Summary 910 KB - PDF

A new algorithm for evaluating febrile infants.

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Jason S. -

Sol/Ilene,

Given the extremely poor sensitivity and specificity (low 70s) of procalcitonin to detect a bacterial illness, how do you feel about this algorithm using it as a branch point?

It would seem to me that this would make Step by Step invalid as a protocol and no more useful anything else. My additional concern, is that this may further the reliance on procalcitonin without proof that it is reliable or predictive of any significant bacterial illness.

Jason Stone

ilene c. -

I'm excited to have found the one person who may actually have access to a procalcitonin test for use in the ED! Good point, which doesn't bother me much at all because we STILL don't have the test. But, I will say the following- one of the biggest studies of procalcitonin specifically in febrile infants <3 months showed a sensitivity of 90% at a threshold of 0.3 ng/mL. This study (Milcent. JAMA Peds in 1/2016) had a lower cutoff and a very specifically defined population. Is 90% acceptable? No. Is it better than CRP or WBC? Yes. Overall, the sensitivity of step-by-step was 92%. Also, not OK, but (in the one study we reviewed) superior to a lot of other clinical algorithms commonly used in practice. In step-by-step, procalcitonin is also a small part of a multistep decision tool looking for a rare disease. The fact is, I'm not sure the holy grail of tests to figure out which unassessable small infant has an SBI with near perfect sensitivity will be developed during my career. And I would never base the decision to send a high-risk, ill-appearing neonate home on a normal PC. But I think it is one piece of data that might help pick out the needle in a haystack, and this is one reasonable decision tool to consider for people who find algorithms helpful.

Ian L., Dr -

The most reliable method of establishing a UTI in infants is supra pubic aspiration under ultrasound or catherisation but it is invasive and distress causing doctors specially in primary to fear it and avoid it .
So research into far less distressful ways of catheterisation or better supra public aspiration are vital for increasing efficacy
The other way more humane is clean catch . But often elusive and has pot luck.
Like to know if "you can get away" with urine dip stick and bag specimens and the efficacy of this method in real world .
Sterile urine bag collectors or gene diagnostics to determine the true pathogenic strains this is also a future hope .

ilene c. -

Great question. Haven't done an SP in years on a baby, but usually do cath, and often get a quick bladder ultrasound before to make sure it's not a dry cath. BUT, you are right- parents and kids don't like it. A sterile bag specimin is fine, if it's negative. But if it is positive, the vast majority are going to be false positives, so it is recommended to do a cath at that point. Unfortunately, many of these kids are sick, febrile, and a little dry, so (even with cup after cup of apple juice) it often it takes hours to get the bag sample, then to have to cath them anyway seems to make it worse. Even if a kid is not potty-trained, I will often give them a cup and see if they can collect the urine- some little kids pee when they are cleaned off and others can urinate if you sit them on the toilet, even if they are not technically "potty-trained." If you place cold-saline soaked gauze over the SP area with gentle pressure, you can get about 1/3 of them to pee (http://onlinelibrary.wiley.com/doi/10.1111/jpc.13245_3/full). And there is a paper by Fernandez looking at suspending a small infant vertically and doing alternating SP taps and lumbar massage in which ~90% urinated (http://www.adhb.govt.nz/newborn/Guidelines/Infection/UrineCollectByBladderStimulation.htm)
There is a larger study underway as well (https://clinicaltrials.gov/ct2/show/NCT02381834). Fingers crossed

Lars E., M.D. -

I would appreciate some input from Dr.s Claudius and Behar... One of my largest barriers to thorough workup of febrile infants is that it is significantly stressful for everyone involved. Holding down a screaming, sweaty patient to draw blood/start an IV, cath for urine, and perform an LP is hard on the patient, the parents, and ED providers. I haven't had much success with sucrose. I have considered the use of ketamine sedation for these patients. The rationale is that once the patient is dissociated, it ought to be easier (and quieter) to cath for urine, do the LP, and start an IV with much less discomfort for everyone involved. Unfortunately, the last I tried to look into this, I couldn't find any literature support for this practice. Do you know of anyone who is doing this? What is your opinion as to the safety/feasibility of "sedation for workup"?

ilene c. -

I think you echo the sentiments of many with your concerns. As a general comment (not to you, but based on the literature overall) about 50% of the procedures done in young children are unnecessary, and a recurring theme in the pain and sedation literature is to minimize the procedures. In a well appearing kids (particularly immunized if >2m), I typically get an LP if <2m, blood cx if <3m, and risk stratify for urine under 2 years as a general rule. Some tips on getting urine are in the last comment. It was a difficult departure for me to do this, as when I was training, we LP'd and blood cultured everyone under 6 months. This is my long winded explanation of why I generally don't use ketamine. The newer guidelines have extended the use down to 3 months, but nearly everything I do except urine is in children under 3 months. If the child were older (like an ill appearing or high risk kid), I think that is a reasonable idea. Personally, I use fentanyl because we have an intranasal protocol to deliver 2 mcg/kg IN and it works in about 7 minutes. I think it takes the edge off from an analgesic perspective in the older children and makes them a little bit high! There is also some literature on nitrous in older infants and children (particularly children with developmental and behavioral issues) for IV starts and work-ups. You are correct that there is none for ketamine (at least I haven't seen it either), and I think it would be hard to do, since it is the rare kid that gets the full work-up in the age range OK for ketamine. I haven't helped much, but the last thing I might add is that, for the child who is not likely to be admitted, but is getting a blood culture, sometimes it is easier to butterfly that try to get and secure and IV in a sweaty, moving child. And the rates of false positive blood cultures are significantly lower with this method

ilene c. -

The other thing I forgot to say about the sucrose is that I will instill 1mL of sucrose into the buccal area before the procedure. But, during the LP, I'll make the parent in charge of continuously dipping a pacifier into sucrose solution and holding in the kids mouth. I talk to them a bit about about the literature on the topic so that they see it as an important task that demands their attention. It gives them a job that distracts them from what I am doing and keeps the kid much quieter because someone is keeping a pacifier in the mouth

Lars E., M.D. -

Thanks for the "pro tips". I'm going to try that nasal fentanyl suggestion. On the patient, of course.

Frank N. -

This is not specific to Peds, but Peds provides an excellent example.... Please set me straight, why is obtaining cultures prior to giving abx for suspected infection (neonatal fever) so important? Why can't we treat with the antibiotics at first reasonable opportunity if we aren't able to obtain cultures. If the bacteria is susceptible, then we don't get growth, but the patient will get better, and I think we have done our job. If the abx don't work then the culture will grow out the offending bug and a sensitivity will follow.

Many times hours go by... nurses can't get blood, parents won't concept to urine cath, computers can't order a HSV PCR, mom wants dad there before she consents to tap ect. before I can finally get the tap and give abx.

My logic (although frequently flawed) tells me one thing, common practice and guidelines dictate another. Aren't cultures that don't grow but the patient gets better a clinician centered outcome that patients don't care about? It seems like there is all up side and no downside to this approach.

ilene c. -

That is an excellent point, and ultimately, using the same logic in infants we use in adults is the best way to practice, in my opinion. While I have occasionally given IM antibiotics because I couldn't get an IV, usually it is the CSF that is the issue. The formal recs are to get CSF as soon as feasible, preferably (but not mandatory) before antibiotics. Usually, enough WBCs are hanging around to give a sense that it is meningitis for about 24 hours after antibiotics are started. I think there are 2 distinct situations. One is that we really cannot get it (either the consent or the tap), in which case, for sure start the antibiotics. The other is an ED basically chooses to defer the procedure until transfer to the floor or to another hospital (and I've seen this at my own shop as well). In this case, I'd say that the initial treating physician should at least give it a try. You are correct in that if the patient gets better, they get better. But if the cultures are negative and the baby better, they are usually discharged at 48 hours. If a true infection is identified, the duration of therapy is much longer- as long as 21 days for neonatal HSV meningitis! So, even though our job is first and foremost to treat the patient, even in absentia of all the info we would like, our getting this data point as quickly as is feasible makes a big difference for the kid on the back end.

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