Objectives: Prospectively identifying children with significant dehydration from gastroenteritis is difficult in acute care settings. Previous work by our group has shown that bedside ultrasound (US) measurement of the inferior vena cava (IVC) and the aorta (Ao) diameter ratio is correlated with intravascular volume. This study was designed to validate the use of this method in the prospective identification of children with dehydration by investigating whether the IVC ⁄ Ao ratio correlated with dehydration in children with acute gastroenteritis. Another objective was to investigate the interrater reliability of the IVC ⁄ Ao measurements.Methods: A prospective observational study was carried out in a pediatric emergency department (PED) between November 2007 and June 2009. Children with acute gastroenteritis were enrolled as subjects. A pair of investigators obtained transverse images of the IVC and Ao using bedside US. The ratio of IVC and Ao diameters (IVC ⁄ Ao) was calculated. Subjects were asked to return after resolution of symptoms. The difference between the convalescent weight and ill weight was used to calculate the degree of dehydration. Greater than or equal to 5% difference was judged to be significant. Linear regression was performed with dehydration as the dependent variable and the IVC ⁄ Ao as the independent variable. Pearson's correlation coefficient was calculated to assess the degree of agreement between observers.Results: A total of 112 subjects were enrolled. Seventy-one subjects (63%) completed follow-up. Twentyeight subjects (39%) had significant dehydration. The linear regression model resulted in an R 2 value of 0.21 (p < 0.001) and a slope (B) of 0.11 (95% confidence interval [CI] = 0.08 to 0.14). An IVC ⁄ Ao cutoff of 0.8 produced a sensitivity of 86% and a specificity of 56% for the diagnosis of significant dehydration. Forty-eight paired measurements of IVC ⁄ Ao ratios were made. The Pearson correlation coefficient was 0.76. Conclusions:In this pilot study the ratio of IVC to Ao diameters, as measured by bedside US, was a marginally accurate measurement of acute weight loss in children with dehydration from gastroenteritis. The technique demonstrated good interrater reliability.

Objective To investigate the performance characteristics of bedside emergency department ultrasound by non-radiologist, physician sonographers in the diagnosis of ileo-colic intussusception in children. Methods This was a prospective, observational study conducted in a pediatric emergency department of an urban tertiary care children’s hospital. Pediatric emergency medicine (PEM) physicians with no previous experience in bowel ultrasound underwent a focused one-hour training session conducted by a pediatric radiologist. The session included a didactic component on sonographic appearances of ileo-colic intussusception, review of positive and negative images for intussusceptions, and a hands-on component using a live child model. Upon completion of the training a prospective convenience sample study was performed. Children were enrolled if they were to undergo a diagnostic radiology (DR) ultrasound for suspected intussusception. Bedside ultrasound (BUS) by trained PEM physicians were performed and interpreted as either positive or negative for ileo-colic intussusception. Ultrasound studies were then performed by DR and their results were used as the reference standard. Test characteristics (sensitivity, specificity, positive and negative predictive values) and likelihood ratios were calculated. Results Six PEM physicians completed the training and performed the bedside studies. Eighty two patients were enrolled. The median age was 25 months (range 3 months – 127 months). Thirteen patients (16%) were diagnosed with ileo-colic intussusception by DR. BUS had a sensitivity of 85% (95% confidence interval [CI] 54% to 97%), specificity of 97% (95% CI 89% to 99%), positive predictive value of 85% (95% CI 54% to 97%) and negative predictive value of 97% (95% CI 89% to 99%). A positive BUS had a likelihood ratio of 29 (95% CI 7.3 to 114) and a negative BUS had a likelihood ratio of 0.16 (95% CI 0.04 to 0.57). Conclusions With limited and focused training, PEM physicians can accurately diagnose ileo-colic intussusception in children using BUS.

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Objective Data suggest that capnography is a more sensitive measure of ventilation than standard modalities and detects respiratory depression before hypoxemia occurs. We sought to determine if adding capnography to standard monitoring during sedation of children increased the frequency of interventions for hypoventilation, and whether these interventions would decrease the frequency of oxygen desaturations. Methods We enrolled 154 children receiving procedural sedation in a pediatric emergency department. All subjects received standard monitoring and capnography, but were randomized to whether staff could view the capnography monitor (intervention) or were blinded to it (controls). Primary outcome were the rate of interventions provided by staff for hypoventilation and the rate of oxygen desaturation <95%. Results Seventy-seven children were randomized to each group. Forty-five percent had at least one episode of hypoventilation. The rate of hypoventilation per minute was significantly higher among controls (7.1% vs. 1.0%, p=.008). There were significantly fewer interventions in the intervention group than in the control group (OR 0.25; 95% CI 0.13, 0.50). Interventions were more likely to occur contemporaneously with hypoventilation in the intervention group (2.26, 95% CI 1.34, 3.81). Interventions not in time with hypoventilation were associated with higher odds of oxygen desaturation <95% (OR 5.31; 95% CI 2.76, 10.22). Conclusion Hypoventilation is common during sedation of pediatric emergency department patients. This can be difficult to detect by current monitoring methods other than capnography. Providers with access to capnography provided fewer but more timely interventions for hypoventilation. This led to fewer episodes of hypoventilation and of oxygen desaturation.

Objective Technologies are not always successfully implemented into practise. We elicited experiences of acute care providers with the introduction of technology and identified barriers and facilitators in the implementation process. Methods A qualitative study using one-on-one interviews among a purposeful sample of 19 physicians and nurses within ten emergency departments and intensive care units was performed. Grounded theory, iterative data analysis and the constant comparative method were used to inductively generate ideas and build theories. Results Five major categories emerged: decision-making factors, the impact on practise, technology's perceived value, facilitators and barriers to implementation. Barriers included negative experiences, age, infrequent use, and access difficulties. A positive outlook, sufficient training, support staff, and user friendliness were facilitators. Conclusions This study describes strategies implicated in the successful implementation of newly adopted technology in acute care settings. Improved implementation methods and evaluation of implementation processes are necessary for successful adoption of new technology.