Occluded Vascular Catheter

Occluded Vascular CatheterChildren with chronic medical problems may require a variety of specialized tools, but what do you do when those tools become the problem. We have previously reviewed issues with Baclofen Pumps as well as Vagal Nerve Stimulators.  We have also discussed more commonly encountered equipment like VP Shunts, but one that deserves specific attention is the Central Vascular Line.  What can be done to fix the Occluded Vascular Catheter?

 

Vascular Access In Children

  • Emergent access in children is a challenge!
    • See Access Denied!
    • See Interosseous Needle (for Neonates and Video)
    • Attaining central venous access in children is more difficult to than in adults – small target vs bigger target
      • Obviously, this is a gross generalization based solely on my personal experience…
      • But, it is still “true.”
    • IO should be favored over Central Venous Access (CVC) or Triple Lumen Catheter (TLC) in true emergent states.
      • Actually, I’d also argue that IOs should be used before CVC or TLC in adults who need immediate access as well!
  • Some children require long-term central venous access.
    • Some examples frequently encountered in the ED:
      • Patients who require frequent medication administrations (ex, Chemotherapy, Antibiotic regimens)
      • Patients who require nutritional support
      • Patients who require blood product administration
      • Patients who require hyper-osmolar medications
    • These central vascular catheters can be:
      • Tunnelled (ex, Broviac, Hickman, Groshong)  or implanted
      • Inserted Peripherally (ex, PICC)
      • Single Lumen or Multi-lumen

 

Occluded Vascular Catheter

  • An occluded vascular catheter may be:
    • Totally occluded – cannot infuse or aspirate
    • Partial occluded – can infuse, but cannot aspirate
  • Unfortunately, maintaining long-term catheters is also a challenge.
    • 14-36% of patients with CVCs will have a complication within 2 years of placement. [Baskin, 2009]
    • CVCs can be complicated by:
      • Mechanical failure / issues
        • Kinked tube
        • Dislodged or displaced catheter
        • Lumen orifice occluded by abutting vessel wall
      • Infection 
        • Localized infection / cellulitis
        • Nidus of systemic infection
      • Thrombosis
        • CVCs are the most frequent cause of thrombosis in children
        • May prevent function of line.
        • May lead to Deep Vein Thrombosis or Pulmonary Embolism

 

Occluded Vascular Catheter Management

  • Start Simple!
    • Look for external compression (ex, clamps, sutures)
    • Adjust position
      • Lift arm
      • Shrug shoulder forward
    • Have patient cough or Valsalva [Giordano, 2015; Kerner, 2006]
    • Look for signs of infection or DVT [Kerner, 2006]
  • Don’t underestimate the potential for mechanical failure!
    • In addition to external compression, there may be internal kinking or migration.
    • Chest radiograph is first option for imaging. [Giordano, 2015]
    • The CXR can be done with contrast infused through line if it is partially occluded.
  • Don’t overlook potential for associated Venous Thrombosis
    • Consider the potential for a CVC-associated venous thrombus that is external to the catheter.
    • Ultrasound can be useful to help with this investigation and may also visualize thrombus at the apex of the catheter.
    • If U/S is inconclusive, or pre-test probability is high in the setting of a possible false negative U/S, may need to use CT or MRI. [Giordano, 2015]
  • Dissolve the Occlusion!
    • Occluded vascular catheters can be due to:
      • Chemical occlusions
        • Precipitants from infused drugs and minerals
        • Residue from infused lipids
      • Thrombus formation
    • If occluded vascular catheter due to Chemical Occlusion, then: [Giordano, 2015]
      • Use NaOH 0.1 N for Basic Substances (ex, Phenytoin)
        • Allow up to 150% of the volume of the CVC capacity to sit in situ for up to 6 hours
      • Use HCL 0.1 N for Acidic Substances (ex, Vancomycin) or Calcium Phosphate Crystals
        • Allow 100% of the volume of the CVC capacity to sit in situ for up to 1 hour
      • Use Ethilic Alcohol 70% for Lipids
        • Use up to 3 mL (maximum of 0.55ml/kg)
        • Can only be used for silicone CVCs, not Polyurethane CVCs.
    • If occluded vascular catheter due to thrombus formation, then: [Giordano, 2015]
      • Instill a quantity sufficient to fill the CVC capacity of either:
        • Alteplase (t-PA) 1 mg/ml, left in situ for 15 – 60 min
          • t-PA has been shown to be both safe and effective in restoration of function on CVC in kids. [Anderson, 2013; Blaney, 2006]
          • t-PA has also been effective as an infusion as well as a dwell. [Ragsdale, 2014]
        • Urokinase 5,000 IU/ml, left in situ for 15-60 min
      • One published protocol [Kerner, 2006] recommends:
        • After 30 min, attempt to aspirate 3 ml; if able to do so, flush; if unable, wait additional 90 min then repeat.
        • If not able to aspirate after 120 min, then re-dose t-PA.
      • If persistent thrombotic occlusion may need to consider systemic infusion of thrombolytic, but need to ensure no other CVC-associated thrombosis as therapy for that is different.

 

Moral of the Morsel

  • The use of indwelling central lines can be life-saving / changing for many children.
  • These lines do have associated risks and complications that may cause the patients to present to your ED.
  • These lines should be viewed as highly valuable, and all attempts to salvage appropriate CVCs should be made.
  • Keep it simple and don’t overlook simple mechanical issues.
  • Know your hospitals resources… many already have protocols for evaluation and management of occluded vascular catheters.

 

References

Giordano P1, Saracco P2, Grassi M1, Luciani M3, Banov L4, Carraro F5, Crocoli A6, Cesaro S7, Zanazzo GA8, Molinari AC4; Italian Association of Pediatric Hematology and Oncology (AIEOP). Recommendations for the use of long-term central venous catheter (CVC) in children with hemato-oncological disorders: management of CVC-related occlusion and CVC-related thrombosis. On behalf of the coagulation defects working group and the supportive therapy working group of the Italian Association of Pediatric Hematology and Oncology (AIEOP). Ann Hematol. 2015 Nov;94(11):1765-76. PMID: 26300457. [PubMed] [Read by QxMD]

Ragsdale CE1, Oliver MR, Thompson AJ, Evans MC. Alteplase infusion versus dwell for clearance of partially occluded central venous catheters in critically ill pediatric patients. Pediatr Crit Care Med. 2014 Jul;15(6):e253-60. PMID: 24751787. [PubMed] [Read by QxMD]

Pai VB1, Plogsted S. Efficacy and safety of using L-cysteine as a catheter-clearing agent for nonthrombotic occlusions of central venous catheters in children. Nutr Clin Pract. 2014 Oct;29(5):636-8. PMID: 25118177. [PubMed] [Read by QxMD]

Anderson DM1, Pesaturo KA, Casavant J, Ramsey EZ. Alteplase for the treatment of catheter occlusion in pediatric patients. Ann Pharmacother. 2013 Mar;47(3):405-9. PMID: 23463740. [PubMed] [Read by QxMD]

Baskin JL1, Pui CH, Reiss U, Wilimas JA, Metzger ML, Ribeiro RC, Howard SC. Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. Lancet. 2009 Jul 11;374(9684):159-69. PMID: 19595350. [PubMed] [Read by QxMD]

Kerner JA Jr1, Garcia-Careaga MG, Fisher AA, Poole RL. Treatment of catheter occlusion in pediatric patients. JPEN J Parenter Enteral Nutr. 2006 Jan-Feb;30(1 Suppl):S73-81. PMID: 16387916. [PubMed] [Read by QxMD]

Blaney M1, Shen V, Kerner JA, Jacobs BR, Gray S, Armfield J, Semba CP; CAPS Investigators. Alteplase for the treatment of central venous catheter occlusion in children: results of a prospective, open-label, single-arm study (The Cathflo Activase Pediatric Study). J Vasc Interv Radiol. 2006 Nov;17(11 Pt 1):1745-51. PMID: 17142704. [PubMed] [Read by QxMD]

Werlin SL1, Lausten T, Jessen S, Toy L, Norton A, Dallman L, Bender J, Sabilan L, Rutkowski D. Treatment of central venous catheter occlusions with ethanol and hydrochloric acid. JPEN J Parenter Enteral Nutr. 1995 Sep-Oct;19(5):416-8. PMID: 8577023. [PubMed] [Read by QxMD]

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Pneumatosis Intestinalis

Tram TrackingAir may be considered the sine qua non of life (without it there is nothing); however, we prefer to have it in specific areas, like our lungs.  Finding air where it isn’t supposed to be can often portend serious medical conditions and complications.  Previously, we have discussed abnormal collections of air (ex, pneumothorax, pneumomediastinum).  Now, let us look at another potentially alarming situation- Pneumatosis Intestinalis:

 

Pneumatosis Intestinalis – Basics

  • Pneumatosis intestinalis refers to gas within the bowel wall.
  • Can be visualized on:
    • Plain radiographs
    • Fluoroscopy (ex, air-contrast enemas)
    • CT scans
    • Ultrasound
    • MRI
  • It is NOT a diagnosis.
    • It is a radiographic or physical finding.
    • The cause of the pneumatosis intestinalis is the diagnosis.
  • Pneumatosis intestinalis is relatively rare in children.
    • When encountered, it is typically in the premature infant or neonate.
    • Does occur in older children, who are more likely to have a benign course. [Kurbegov, 2001]
  • Divided into two groups:
    • Primary (Idiopathic)
      • Often benign or incidental findings.
      • Usually with no associated symptoms (don’t just look at the image, look at the patient!)
      • Radiographically, has very small bubbles of air in the lamina propria.
    • Secondary
      • More common version (~85%)
      • Associated with larger collections of gas – often in linear or curvilinear fashion parallel to the bowel wall.
      • Appear like “tram tracks” without railroad ties.
      • Potentially ominous sign.

 

Pneumatosis Intestinalis – Diagnoses

Once pneumatosis intestinalis is noticed on imaging studies, consider what the cause may be.  Below is an abridged list, but a good place to start:

  • Process leading to Immunocompromised State
    • Chemotherapies and Steroid Therapies
    • Solid Organ Transplant [Abdel-Aziz, 2013]
    • Bone Marrow / Stem Cell Transplant [Shulman, 2012; Korhonen, 2012]
    • Leukemia / Lymphoma
    • AIDS
  • Other Associated Conditions
    • Rheumatologic Condition [Chang, 2014]
    • Collagen Vascular Condition
    • Congenital Heart Disease (CHD)
    • Pulmonary Disease (ex, Asthma, Cystic Fibrosis)
    • Gastroenteritis in immunocompromised patients
      • Cases associated with Norovirus known [Kim, 2011]
      • Cases associated with Rotavirus, CMV, adenovirus, and C. Diff
    • Iatrogenic (ex, placement of G-tube)

Pneumatosis Intestinalis – Management

  • Obviously, ABCDEs — manage the patient not the X-ray.
  • Management should be geared toward underlying etiology.
  • Many cases can be managed conservatively with: [Kim, 2011; Kurbegov, 2001]
    • Bowel rest
    • IV antibiotics
    • Serial examinations
    • Supportive therapies for the underlying etiology (ex, treatment for Graft vs Host Disease) [Korhonen, 2012]
    • Since steroids are often implicated as possible influencing agent, they should be decreased or discontinued. [Fleenor, 2002]
  • Surgery rarely needed.
    • Reasonable to consult surgical team, but most can be treated conservatively without surgery. [Shulman, 2012; Li, 2012; Korhonen, 2012Kurbegov, 2001]
    • Cases with free intra-abdominal air do not necessarily benefit from surgery either. [Korhonen, 2012]
    • Patients with portal venous gas, evidence of mechanical obstruction, or “high risk” underlying medical condition (CHD or transplant) were more likely to require surgery in one study. [Kurbegov, 2001]

 

Moral of the Morsel

  • Pneumatosis intestinalis is not just for neonates!
  • Fortunately, when it occurs in non-neonates, it is often more benign and can be managed conservatively.
  • Even though it may be managed conservatively, we should be vigilant and guard against complacency.

 

References

Kalkwarf KJ1, Betzold RD, Hung SY, Rinewalt AN, Robertson RD. Management of Pneumatosis Intestinalis in a Pediatric Burn Patient. J Burn Care Res. 2016 Mar-Apr;37(2):e193-5. PMID: 25377864. [PubMed] [Read by QxMD]

Chang CY1, Marzan KA2. Benign pneumatosis intestinalis in a pediatric patient with multiple risk factors including granulomatosis with polyangiitis: a case report and review of the literature. Semin Arthritis Rheum. 2015 Feb;44(4):423-7. PMID: 25455684. [PubMed] [Read by QxMD]

Ye X1, Van JN1, Munoz FM2,3,4, Revell PA2,4,5, Kozinetz CA6, Krance RA2,4, Atmar RL1,3, Estes MK3, Koo HL1,4. Noroviruses as a Cause of Diarrhea in Immunocompromised Pediatric Hematopoietic Stem Cell and Solid Organ Transplant Recipients. Am J Transplant. 2015 Jul;15(7):1874-81. PMID: 25788003. [PubMed] [Read by QxMD]

Abdel-Aziz O1, Elaffandi AH, El Shazly M, Hosny A, El-Karaksy H. Pneumatosis intestinalis following pediatric live-related liver transplant: a case report and successful conservative approach. Pediatr Transplant. 2014 Feb;18(1):E18-21. PMID: 24283569. [PubMed] [Read by QxMD]

Shulman SC1, Chiang F, Haight AE, Steelman CK, Chiang KY, Gow K, Shehata BM. Pneumatosis intestinalis in pediatric hematopoietic stem cell transplantation patients: an uncommon complication. Fetal Pediatr Pathol. 2012 Oct;31(5):309-14. PMID: 22432915. [PubMed] [Read by QxMD]

Korhonen K1, Lovvorn HN 3rd, Koyama T, Koehler E, Calder C, Manes B, Evans M, Bruce K, Ho RH, Domm J, Frangoul H. Incidence, risk factors, and outcome of pneumatosis intestinalis in pediatric stem cell transplant recipients. Pediatr Blood Cancer. 2012 Apr;58(4):616-20. PMID: 21721114. [PubMed] [Read by QxMD]

Kim MJ1, Kim YJ, Lee JH, Lee JS, Kim JH, Cheon DS, Jeong HS, Koo HH, Sung KW, Yoo KH, Choe YH. Norovirus: a possible cause of pneumatosis intestinalis. J Pediatr Gastroenterol Nutr. 2011 Mar;52(3):314-8. PMID: 21150655. [PubMed] [Read by QxMD]

Fleenor JT1, Hoffman TM, Bush DM, Paridon SM, Clark BJ 3rd, Spray TL, Bridges ND. Pneumatosis intestinalis after pediatric thoracic organ transplantation. Pediatrics. 2002 May;109(5):E78-8. PMID: 11986484. [PubMed] [Read by QxMD]

Kurbegov AC1, Sondheimer JM. Pneumatosis intestinalis in non-neonatal pediatric patients. Pediatrics. 2001 Aug;108(2):402-6. PMID: 11483806. [PubMed] [Read by QxMD]

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Vagal Nerve Stimulator

Pacemaker for the BrainManaging seizures in pediatric patients is a common occurrence in the Emergency Department. We have discussed seizure related issues in the past: Seizure Mimics, Neonatal Seizures, Simple Febrile Seizures, and Complex Febrile Seizures.  Some seizures require us to remember unique pediatric conditions (ex, Pyridoxine Dependent Seizures) and some others require us to know unique therapies (ex, Ketogenic Diet).  As with any therapy, there are pros and cons to understand.  Let us look at the pros and cons related to Vagal Nerve Stimulators (VNS):

 

Vagal Nerve Stimulator: What is that?

  • pulse generator (similar to a cardiac pacemaker) is implanted in the chest.
  • It’s electric lead is attached to the vagus nerve in the neck (no brain surgery is needed).
  • The VNS generator is programmed to stimulate the vagus nerve in regular intervals (ex, for 30 seconds every 5 minutes). [See Epilepsy Foundation)
  • The frequency, amplitude, and duration of the stimulation pulses can also be adjusted.
  • Placing a magnet over the VNS can also lead to extra stimulation.
    • Patients who have focal seizures or auras may abort seizures themselves.
    • Family members (or other providers) may also utilize the VNS via the magnet.
  • Intermittent stimulation of the cervical vagus nerve via VNS has been shown to be effective and safe. [Serdaroglu, 2016; Terra, 2014; Connor, 2012]
  • The mechanism of action of vagal stimulation is still not fully understood.

 

Vagal Nerve Stimulator: Is it helpful?

  • 10-30% of children with seizure disorders will continue to have significant seizures despite optimal medical or surgical (resection) options.
  • The VNS is used for difficult to control seizure disorders, so its “success” is marked in relative terms.
  • Long-term studies have shown that patients can have reduction seizure burden. [Serdaroglu, 2016; Terra, 2014]
    • 62.5% of cases had 50% reduction in seizure frequency.
    • The percentage of those who had reduction of seizures increased each year.
    • There is also reduction in traumas and other seizure-related morbidities.
    • VNS can also reduce number of days of inpatient care.

 

Vagal Nerve Stimulator: The Complications

  • Generally, the VNS is well tolerated and has minimal side-effects. [Serdaroglu, 2016]
  • The setting of the VNS stimulation frequency, amplitude and duration can influence side-effects.
  • Side-effects are: [Serdaroglu, 2016; Smyth, 2003]
    • Hoarseness
    • Cough
    • Sore Throat
    • Anorexia
    • Tingling sensation in throat
    • Drooling
    • Outbursts of laughter
    • Dysphagia
    • Shoulder abduction
    • Torticolis and neck spasms
    • Urinary retention
  • Complications do occur: [Smyth, 2003]
    • Superficial infections
    • Deep space infections (~3.5%)
    • Stridor and Sleep Apnea
      • Contraction of supraglottic structures and vocal folds [Kelts, 2014]
    • Ipsilateral vocal cord paralysis
    • Cardiac arrhythmia [Cantarin-Extremera, 2015]
      • Generally the left vagus nerve is selected to stimulate as it innervates the SA node while the right vagus nerve innervates the AV node.
      • Cases still exist of arrhythmias with using the left vagus nerve.
    • Lead fracture
      • May occur due to patient manipulation of the device.
      • Twiddler Syndrome
        • Classically occurs in adults who repeatedly manipulate their cardiac pacemaker/defibrillator.
        • Similar behavior can lead to VNS lead fracture in children. [Trout, 2013]
    • Facial muscle paresis

 

References

Serdaroglu A1, Arhan E2, Kurt G3, Erdem A4, Hirfanoglu T3, Aydin K1, Bilir E5. Long term effect of vagus nerve stimulation in pediatric intractable epilepsy: an extended follow-up. Childs Nerv Syst. 2016 Apr;32(4):641-6. PMID: 26767841. [PubMed] [Read by QxMD]

Cantarín-Extremera V1, Ruíz-Falcó-Rojas ML2, Tamaríz-Martel-Moreno A3, García-Fernández M4, Duat-Rodriguez A5, Rivero-Martín B6. Late-onset periodic bradycardia during vagus nerve stimulation in a pediatric patient. A new case and review of the literature. Eur J Paediatr Neurol. 2016 Jul;20(4):678-83. PMID: 27056279. [PubMed] [Read by QxMD]

Kelts G1, O’Connor PD2, Hussey RW3, Maturo S4. An electrical cause of stridor: pediatric vagal nerve stimulators. Int J Pediatr Otorhinolaryngol. 2015 Feb;79(2):251-3. PMID: 25500186. [PubMed] [Read by QxMD]

Terra VC1, Furlanetti LL2, Nunes AA3, Thomé U4, Nisyiama MA4, Sakamoto AC4, Machado HR4. Vagus nerve stimulation in pediatric patients: Is it really worthwhile? Epilepsy Behav. 2014 Feb;31:329-33. PMID: 24210463. [PubMed] [Read by QxMD]

Trout AT1, Larson DB, Mangano FT, Gonsalves CH. Twiddler syndrome with a twist: a cause of vagal nerve stimulator lead fracture. Pediatr Radiol. 2013 Dec;43(12):1647-51. PMID: 23832019. [PubMed] [Read by QxMD]

Connor DE Jr1, Nixon M, Nanda A, Guthikonda B. Vagal nerve stimulation for the treatment of medically refractory epilepsy: a review of the current literature. Neurosurg Focus. 2012 Mar;32(3):E12. PMID: 22380853. [PubMed] [Read by QxMD]

Smyth MD1, Tubbs RS, Bebin EM, Grabb PA, Blount JP. Complications of chronic vagus nerve stimulation for epilepsy in children. J Neurosurg. 2003 Sep;99(3):500-3. PMID: 12959437. [PubMed] [Read by QxMD]

The post Vagal Nerve Stimulator appeared first on Pediatric EM Morsels.

Vagal Nerve Stimulator

Pacemaker for the BrainManaging seizures in pediatric patients is a common occurrence in the Emergency Department. We have discussed seizure related issues in the past: Seizure Mimics, Neonatal Seizures, Simple Febrile Seizures, and Complex Febrile Seizures.  Some seizures require us to remember unique pediatric conditions (ex, Pyridoxine Dependent Seizures) and some others require us to know unique therapies (ex, Ketogenic Diet).  As with any therapy, there are pros and cons to understand.  Let us look at the pros and cons related to Vagal Nerve Stimulators (VNS):

 

Vagal Nerve Stimulator: What is that?

  • pulse generator (similar to a cardiac pacemaker) is implanted in the chest.
  • It’s electric lead is attached to the vagus nerve in the neck (no brain surgery is needed).
  • The VNS generator is programmed to stimulate the vagus nerve in regular intervals (ex, for 30 seconds every 5 minutes). [See Epilepsy Foundation)
  • The frequency, amplitude, and duration of the stimulation pulses can also be adjusted.
  • Placing a magnet over the VNS can also lead to extra stimulation.
    • Patients who have focal seizures or auras may abort seizures themselves.
    • Family members (or other providers) may also utilize the VNS via the magnet.
  • Intermittent stimulation of the cervical vagus nerve via VNS has been shown to be effective and safe. [Serdaroglu, 2016; Terra, 2014; Connor, 2012]
  • The mechanism of action of vagal stimulation is still not fully understood.

 

Vagal Nerve Stimulator: Is it helpful?

  • 10-30% of children with seizure disorders will continue to have significant seizures despite optimal medical or surgical (resection) options.
  • The VNS is used for difficult to control seizure disorders, so its “success” is marked in relative terms.
  • Long-term studies have shown that patients can have reduction seizure burden. [Serdaroglu, 2016; Terra, 2014]
    • 62.5% of cases had 50% reduction in seizure frequency.
    • The percentage of those who had reduction of seizures increased each year.
    • There is also reduction in traumas and other seizure-related morbidities.
    • VNS can also reduce number of days of inpatient care.

 

Vagal Nerve Stimulator: The Complications

  • Generally, the VNS is well tolerated and has minimal side-effects. [Serdaroglu, 2016]
  • The setting of the VNS stimulation frequency, amplitude and duration can influence side-effects.
  • Side-effects are: [Serdaroglu, 2016; Smyth, 2003]
    • Hoarseness
    • Cough
    • Sore Throat
    • Anorexia
    • Tingling sensation in throat
    • Drooling
    • Outbursts of laughter
    • Dysphagia
    • Shoulder abduction
    • Torticolis and neck spasms
    • Urinary retention
  • Complications do occur: [Smyth, 2003]
    • Superficial infections
    • Deep space infections (~3.5%)
    • Stridor and Sleep Apnea
      • Contraction of supraglottic structures and vocal folds [Kelts, 2014]
    • Ipsilateral vocal cord paralysis
    • Cardiac arrhythmia [Cantarin-Extremera, 2015]
      • Generally the left vagus nerve is selected to stimulate as it innervates the SA node while the right vagus nerve innervates the AV node.
      • Cases still exist of arrhythmias with using the left vagus nerve.
    • Lead fracture
      • May occur due to patient manipulation of the device.
      • Twiddler Syndrome
        • Classically occurs in adults who repeatedly manipulate their cardiac pacemaker/defibrillator.
        • Similar behavior can lead to VNS lead fracture in children. [Trout, 2013]
    • Facial muscle paresis

 

References

Serdaroglu A1, Arhan E2, Kurt G3, Erdem A4, Hirfanoglu T3, Aydin K1, Bilir E5. Long term effect of vagus nerve stimulation in pediatric intractable epilepsy: an extended follow-up. Childs Nerv Syst. 2016 Apr;32(4):641-6. PMID: 26767841. [PubMed] [Read by QxMD]

Cantarín-Extremera V1, Ruíz-Falcó-Rojas ML2, Tamaríz-Martel-Moreno A3, García-Fernández M4, Duat-Rodriguez A5, Rivero-Martín B6. Late-onset periodic bradycardia during vagus nerve stimulation in a pediatric patient. A new case and review of the literature. Eur J Paediatr Neurol. 2016 Jul;20(4):678-83. PMID: 27056279. [PubMed] [Read by QxMD]

Kelts G1, O’Connor PD2, Hussey RW3, Maturo S4. An electrical cause of stridor: pediatric vagal nerve stimulators. Int J Pediatr Otorhinolaryngol. 2015 Feb;79(2):251-3. PMID: 25500186. [PubMed] [Read by QxMD]

Terra VC1, Furlanetti LL2, Nunes AA3, Thomé U4, Nisyiama MA4, Sakamoto AC4, Machado HR4. Vagus nerve stimulation in pediatric patients: Is it really worthwhile? Epilepsy Behav. 2014 Feb;31:329-33. PMID: 24210463. [PubMed] [Read by QxMD]

Trout AT1, Larson DB, Mangano FT, Gonsalves CH. Twiddler syndrome with a twist: a cause of vagal nerve stimulator lead fracture. Pediatr Radiol. 2013 Dec;43(12):1647-51. PMID: 23832019. [PubMed] [Read by QxMD]

Connor DE Jr1, Nixon M, Nanda A, Guthikonda B. Vagal nerve stimulation for the treatment of medically refractory epilepsy: a review of the current literature. Neurosurg Focus. 2012 Mar;32(3):E12. PMID: 22380853. [PubMed] [Read by QxMD]

Smyth MD1, Tubbs RS, Bebin EM, Grabb PA, Blount JP. Complications of chronic vagus nerve stimulation for epilepsy in children. J Neurosurg. 2003 Sep;99(3):500-3. PMID: 12959437. [PubMed] [Read by QxMD]

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BRUE

Brief Resolved Unexplained EventsWe have previously explored some issues with one of my “favorite” topics: Apparent Life Threatening Events (See ALTE and Never Trust a Neonate).  Recently, it has been recommended that the term “Apparent Life Threatening Event / ALTE” be removed from our medical lexicons.  Since we like to always stay in style and remain “hip and with it” (said in the voice of Dr. Evil), let’s review what the cool kids will be referring to in the future: Brief Resolved Unexplained Event / BRUE.

 

BRUE: What’s in a name?

  • We have known that the definition of an ALTE is imprecise at best.
    • This leads to challenges in studying the entity as a whole.
    • This also leads to many challenges with its evaluation and management.
    • “Life Threatening” also seems to generate confusion when the family is then told “everything is ok.”
  • Brief Resolved Unexplained Events” is the term now recommended to be used.
    • It aims to be more precise (at least it has age limits).
    • It highlights the reassuring qualities of the “typical” episode: Brief and Resolved.
    • The clinical practice guideline also defines “Lower Risk” patients.

 

BRUE: What is it?

  • BRUE describes an event that:
    • Occurs in a child younger than 1 year of age,
    • Lasts less than 1 minute (typically 20-30 seconds),
    • Has one or more of the following:
      • Central Cyanosis or Pallor 
        • Discoloration of face, gums and/or trunk.
        • Not acrocyanosis or only peri-oral cyanosis
        • Not rubor / redness
      • Absent, Decreased, or Irregular breathing
      • Marked change in tone (hypertonia or hypotonia)
      • Altered level of responsiveness
    • Resolves and patient returns to baseline, and
    • Has a reassuring history, physical exam, and vital signs during ED evaluation.
  • BRUE is used only when another condition cannot be discerned as the etiology of the event.
    • BRUE is still a constellation of symptoms that, in the end, may be attributed to a more specific diagnosis, but if you can be more specific at the outset, then do not label as BRUE.
      • For example, if a child has bronchiolitis and had an apneic event, that is not a BRUE… it is apnea associated with bronchiolitis.
      • Additionally, if the child a choking event, this is not a BRUE either. Maybe it is a T-E fistula…
    • A good goal is to attempt to use the H+P to determine a more precise Ddx rather than BRUE.

 

BRUE: Low Risk?

  • There are characteristics of patients at Lower Risk for having a serious underlying condition.
  • Lower Risk criteria:
    • Older than 60 days
    • Gestational Age 32 weeks or greater and a Postconceptional Age of 45 weeks or greater.
    • First BRUE (no previous BRUE ever and not occurring in clusters)
    • Not requiring CPR by a trained medical provider
    • NO concerning historic features 
      • See Guideline’s Table 2 for long list of features to consider [Tieder, 2016]
      • Some features not to overlook:
        • History concerning for potential Abuse.
        • Family history of sudden death in first degree relatives.
        • Social and Environmental issues
          • House mold problems (yes… mold is listed as a concerning feature)
          • Previous Child Protective Services or Law Enforcement involvement
          • Current level of concern/anxiety of family
    • NO concerning physical examination findings
      • Obviously, these children need a thorough physical exam… use your super sleuth skills.
      • Don’t overlook skin and genital exam.
  • If the patient does not meet Lower Risk criteria, then she/he is High Risk by default!

 

BRUE: What to do?

  • This is similar to what we would have done for ALTE.
  • There is a nice diagram in the Guideline’s… [Tieder, 2016]
  • But I’m simple so…
  • Medical Stabilization! 
    • Don’t forget, little neonates can be tricky and deceptive. Check capillary refill!
    • Check a glucose early! (I say this mostly so I don’t forget!)
  • History and Physical
    • The foundation upon which we build all medical decisions
    • Abnormal vital signs? H+P consistent with a specific diagnosis? – NOT a BRUE.
    • H+P meets BRUE criteria? No other explanation? – It’s a BRUE! (yeah)
      • Even if BRUE, consider the broad Ddx that exists
      • Try to narrow down the most likely culprits to help guide evaluation and work-up.
        • Cardiac vs Pulmonary
        • Neuro vs GI
        • Zebras vs Horses
  • Risk Stratify BRUE
    • This is simple… does the patient fit Lower Risk criteria?
      • Yes! = Lower Risk
      • No! = High Risk
    • Realize that Lower Risk does not equate to “No Risk.”
  • Disposition
    • High Risk
      • Hospitalize.
      • Base initial evaluation upon your assessment of most likely culprits on DDx.
        • Neonate doing weird things? –> LP and start antibiotics
        • “Funny” story that changes? –> Head CT and evaluate for NAT
      • We know that indiscriminate, broad work-ups are not useful.
    • Lower Risk
      • Avoid:
        • Indiscriminate labs and imaging studies – not helpful in this group either.
        • Empirically prescription of GI meds (ex, acid suppression medications) -unless you are diagnosing the episode was GER… in which case it is not a BRUE.
        • Admission solely for CardioPulmonary monitoring.
      • Do:
        • It is reasonable to obtain 12 Lead ECG.
        • Some advocate for pertussis testing.
        • Monitor the child in the ED and perform serial exams [Tieder, 2016]
          • 1-4 hours seems “reasonable” – no solid evidence
          • Establish stability of vital signs and exam.
          • May witness another event that assists in the diagnosis.
        • Educate family
          • Discuss BRUE.
          • Discuss CPR training for families.
          • Engage in shared decision making.
        • If, and only if, the stars align and the child can be discharged safely and the family is comfortable, ensure ability to be re-evaluated within the next 12-24 hours.

 

BRUE: What’s new?

Admittedly, this is my humble opinion (feel free to gently disagree with me… my feelings are fragile).

  • Essentially, I do not see this change in terminology as a huge alteration in my current practice.
    • I like the term BRUE as it accentuates the Brief and Resolved nature, but fear that that may also diminish provider’s vigilance.
    • “BRUE” should not equate to no concern, even though it does offer a pathway to actually discharge some.
    • Remember, being vigilant most often only requires a thorough H+P.
  • First and foremost: NEVER TRUST A NEONATE!
    • Similar to what we worried about with ALTE, BRUE in a neonate is concerning for badness!
    • Neonates are, by definition, High Risk kids in BRUE criteria.
  • Use your super sleuth skills for the history and exam – Is this a BRUE or something else that is Brewing (get it?).
  • Don’t order a million tests. Direct initial evaluation toward what your super sleuth skills have determined to be the most likely etiology of the event.
  • What’s new is the fact that there is now a guideline that supports the potential discharge of a LOWER RISK patient who has had a BRUE.
    • This does not mean all lower risk kids get to go home.
    • Part of the lower risk characteristics is the family’s perspective of the event.  It may be counterproductive to argue with a family that their CPR was not necessary and the kid is safe at home. (Yes, CPR provided by untrained personnel (ex, family) would still qualify as being Lower Risk potentially).
    • Often, the story and exam evolves… many times before your eyes… use observation in the ED in cases where you are unsure.

 

FOR ANOTHER PERSPECTIVE, See Dr. May’s post on St. Emlyns.

 

References

Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B, Katz ES, Krilov LR, Merritt JL 2nd, Norlin C, Percelay J, Sapién RE, Shiffman RN, Smith MB; SUBCOMMITTEE ON APPARENT LIFE THREATENING EVENTS. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics. 2016 May;137(5). PMID: 27244835. [PubMed] [Read by QxMD]

Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B, Katz ES, Krilov LR, Merritt JL 2nd, Norlin C, Percelay J, Sapién RE, Shiffman RN, Smith MB; SUBCOMMITTEE ON APPARENT LIFE THREATENING EVENTS. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary. Pediatrics. 2016 May;137(5). PMID: 27244836. [PubMed] [Read by QxMD]

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