Research Forum Abstracts

Methods: Core data and complications were prospectively collected from January
1, 2004 to June 30, 2007 on all patients who received procedural sedation with
propofol by our nine emergency physicians. The nurses collected data regarding the
procedure and any complications on a form placed in the chart. Propofol was titrated
IV by the physician until the desired level of sedation was obtained, usually level III
or level IV. Patients were given propofol in a titrated dose at the discretion of the
emergency physician. The drug was given without regard to time of last oral intake.
Vital signs and pulse oximetry were recorded during the procedure and until recovery.
Hypotension (SBP 90 mmHg or age appropriate decrease in children), hypoxemia
(pulse oximetry 90%), respiratory depression requiring assisted ventilation or
intubation, aspiration, airway obstruction, or anesthesia consultation were considered
complications.
Results: Over the study period, 308 patients underwent 314 procedures. The
patients received propofol for orthopedic manipulation (246/314), lumbar puncture
(10/314), incision and drainage of abscess (22/314), laceration repair (8/314), chest
tube insertion (7/314), and other indications (21/314). Average total dose of propofol
was 111 mg (range 10 to 600 mg). The overall procedural success rate was 95.5%.
Transient hypotension occurred in one patient (0.3%). The hypotension responded
quickly to fluid bolus and did not recur. Transient hypoxia developed in five patients
(1.6%). In four of these cases, the hypoxia resolved with simple airway repositioning.
One patient required assisted ventilation by bag-valve-mask for more than five
minutes. No patient required intubation, aspirated, or needed admission due to the
sedation. In 93% of patients, a single physician performed the procedure and
sedation. In the remaining patients, an orthopedist or emergency physician performed
the procedure. Of the five patients who experienced transient hypoxia, four had single
physician and one had two physician presence. No patient required intubation or
anesthesia consultation and no patient aspirated. The complication rate was similar
among the nine emergency physicians.
Conclusion: This is the first study with a large number of patients to address the
safety of propofol use in a rural community hospital. The results show that propofol
is safe and effective for sedation during procedures carried out by rural emergency
physicians. The results further show that the ASA recommendation for two physician
presence for procedural sedation is unfounded. The rapid onset of action and short
half-life allow for safe, early discharge. The patients in this study were awake and alert
in an average of 12 minutes and those of sufficient age reported total amnesia and
very high patient satisfaction. Of specific note, the emergency physicians administered
propofol without regard to time of last oral intake with zero incidence of aspiration.

392

The Accuracy of Emergency Physician Prediction

of and Resuscitation of Dehydration in the
Pediatric Patient

Gupta S, Ryan JG, Suarez AE, Perl RB, Benasher D, Rusczyk G/New York
Hospital Queens, Flushing, NY

Study Objective: To evaluate the accuracy of physician prediction of the severity

of pediatric dehydration in terms of percentage of total body weight. To evaluate the
efficacy of fluid resuscitation of pediatric patients with gastroenteritis and dehydration
by emergency physicians.
Methods: The study is prospective and observational. The setting is a 25K annual
visit urban emergency department which is part of an established 3 year emergency
medicine residency. Inclusion criteria involve patients between the ages of 3-72
months who were treated for dehydration due to vomiting, diarrhea, or anorexia.
These patients had a sma-7 blood sample drawn for testing, were weighed, and
received oral and/or intravenous re-hydration. A convenience sample of patients was
followed up for a convalescent weight in the hospital affiliated outpatient pediatric
clinic or returned to the ED for a convalescent weight. The patients were followed up
5-7 days after cessation of symptoms. A convenience sample of 47 patients established
over a 9-month period was utilized for study purposes. A data sheet was completed at
initial contact by the health care provider, which recorded history, physical exam,
clinical estimates of dehydration, the laboratory data, and the amount of oral or
intravenous fluid administered. In patients 2 years old, 0-5% dehydration was
stratified as mild, 5-10% moderate, 10% severe. In patients 2 years old, 0-3%
dehydration was stratified as mild, 3-6% as moderate, 6% as severe. The body fluid
deficit and percentage of dehydration was calculated with the difference between the
convalescent and sick weights. Utilizing Chi-squared analysis, the clinical estimates of
patient dehydration vs. the true percentage of dehydration was compared. Utilizing
the paired T-test, the amount of resuscitative fluid vs. the body fluid deficit was
compared. Both analyses were further stratified according to patient age rage, above

Volume , . : September

or below 2 years old. For the conversion of mg to mL of water, 1 mg water1mL

water.
Results: The median follow-up time for convalescent weights was 12 days post
initial ED visit. The mean fluid deficit in all patients was 0.505 L and the mean
amount of fluid administered in the ED was 0.324 L, with calculated difference of
means t 4.093 with 46 degrees of freedom (P 0.001) [95% CI 0.269 to
0.0918]. The patients 2 years old, the mean fluid deficit was 0.452 L and the
mean amount of fluid administered was 0.302 L, t 2.672 with 29 degrees of
freedom (P 0.012) [95% CI 0.0354 to 0.266]. The patients 2 years old, the
mean fluid deficit was 0.598 L, and the mean amount of fluid administered was
0.364 L, t 3.291 with 16 degrees of freedom (P 0.005) [95% CI 0.0830 to
0.383]. The analysis of the clinical estimation of dehydration vs. the actual percentage
of dehydration was not significant for the entire group (P 0.079), for patients 2
years old (P 0.270), or for patients 2 years old (P 0.119).
Conclusion: Emergency physicians may not accurately predict the degree of
dehydration of pediatric patients on clinical grounds and often under resuscitate with
fluids during the acute interventional phase of dehydration treatment in the
emergency department.

393

The Correlation of the Percentage of

Dehydration to the Serum Bicarbonate and
Anion Gap of the Pediatric Patient

Gupta S, Ryan JG, Suarez AE, Perl RB, Benasher D, Rusczyk G/New York
Hospital Queens, Flushing, NY

Background: The decrease in serum bicarbonate level and the presence of a high
anion gap metabolic acidosis have been demonstrated to be identifiers of dehydration
in pediatric patients with acute gastroenteritis or anorexia due to febrile illness.
Despite this association between dehydration and acidosis in children, little data is
available that demonstrates the association between bicarbonate level, anion gap, and
percentage of dehydration in children.
Study Objective: To evaluate the relationship of the serum bicarbonate, the anion
gap, and the percentage of dehydration in pediatric patients with vomiting, diarrhea,
or anorexia due to febrile illness.
Methods: The study is prospective and observational. The setting is a 25K annual
visit urban emergency department which is part of an established 3 year emergency
medicine residency. Inclusion criteria involve patients between the ages of 3-72 months
who were treated for dehydration due to vomiting, diarrhea, or anorexia. These patients
had a sma-7 blood sample drawn for testing, were weighed, and received oral and/or
intravenous re-hydration. A convenience sample of patients was followed up for a
convalescent weight in the hospital affiliated outpatient pediatric clinic or returned to the
ED for a convalescent weight. The patients were followed up 5-7 days after cessation of
symptoms. A convenience sample of 47 patients established over a 9-month period was
utilized for study purposes. A data sheet was completed at initial contact by the health care
provider, which recorded history, physical exam findings, clinical estimates of
dehydration, and the laboratory data of included subjects. Convalescent weights were
filled at a later time. The percentage of dehydration was calculated with the difference
between the convalescent and sick weights. Utilizing the Pearson Product Moment
Correlation, the monotonic relationships of the percentage of dehydration to the
bicarbonate level and anion gap were evaluated.
Results: The Pearson Product Moment Correlation of the percentage of
dehydration to the bicarbonate is R-0.478, p.001. The Pearson Product Moment
Correlation of the percentage of dehydration to the anion gap is R0.295, p0.044.
The Pearson Product Moment Correlation of the bicarbonate to the anion gap is R
0.762, p0.001.
Conclusion: The percentage of dehydration in the pediatric patient correlates
with a decrease in the bicarbonate level or an increase in the anion gap. These finding
of the bicarbonate level to the anion gap also suggest the presence of unmeasured
anions in the blood of dehydrated pediatric patients.

394

The Accuracy of Pediatric Weight in the

Emergency Department: Do Caregiver Weight
Estimates Measure Up?

Patel A, Zikos V, Rzechula K, McQuillen K/Advocate Christ Medical Center, Oak

Lawn, IL

Study Objectives: It is not always feasible to weigh a seriously ill or injured child
in an emergency situation where lifesaving measures are often calculated according to

Annals of Emergency Medicine S123