Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.
Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
Emerg Med J. 2019 Mar;36(3):148-153. doi: 10.1136/emermed-2018-208000. Epub 2019 Feb 6.
Serious bacterial infections in young infants with bronchiolitis are rare. Febrile infants <1 month old with bronchiolitis often receive a lumbar puncture (LP), despite limited data for this practice and lack of clinical practice guidelines for this population. The primary objective was to investigate practice patterns in performance of LPs in the ED management of febrile infants aged ≤30 days with bronchiolitis.
A cross-sectional survey of two national paediatric emergency research networks (PediatricEmergency Research Canada (PERC) and the PediatricEmergency Research UK/Ireland (PERUKI)) was conducted January to November 2017 using a modified Dillman technique. The survey was preceded by a clinical vignette describing a well appearing, 21-day-old infant with low-grade fever, respiratory findings typical of bronchiolitis and no perinatal serious bacterial infection (SBI) risk features.
The response rate from PERC was 169/250 (68%) and 172/201 (86%) from PERUKI. Nine physicians in training were excluded, leaving 332 eligible participants. Although most physicians believe that neonates with bronchiolitis rarely have meningitis (PERC 141/161 (87.6%); PERUKI 154/171 (90%)) and feel comfortable diagnosing bronchiolitis in this group (PERC 136/161 (84.5%); PERUKI 143/171 (83.6%)), there was significant variation in the proportion who would be likely/very likely to perform an LP (PERC 100/161 (62.1%); PERUKI 15/171 (8.8%)) (p<0.0001). Practice in Canada, <10 years in practice and lack of comfort with diagnosing bronchiolitis represent multivariable predictors of LP; OR 23.7 (95% CI 11.7 to 47.9), 2.3 (95% CI 1.2 to 4.2) and 2.5 (95% CI 1.1 to 5.0), respectively. Rapid knowledge of respiratory syncytial virus positivity would decrease LP probability from 35.4% to 20.2%.
Estimated probability of performing LPs and other interventions in otherwise healthy febrile neonates with bronchiolitis is highly variable between emergency physicians in Canada and the UK/Ireland. Network, <10 years in ED practice and comfort level with diagnosing bronchiolitis in newborns constitute independent predictors of the likelihood of LP performance.
婴幼儿毛细支气管炎很少会并发严重细菌感染。尽管对于这种做法的数据有限，且针对这一人群缺乏临床实践指南，但发热且不满 1 个月的毛细支气管炎婴儿往往会接受腰椎穿刺（LP）。本研究的主要目的是研究在 ED 管理中，对于发热且≤30 天的毛细支气管炎婴儿，行 LP 的实践模式。
采用经改良的 Dillman 技术，于 2017 年 1 月至 11 月，对加拿大儿科急诊研究网络（PediatricEmergency Research Canada，PERC）和英国/爱尔兰儿科急诊研究网络（PediatricEmergency Research UK/Ireland，PERUKI）进行了一项横断面调查。在进行调查之前，先提供了一个临床病例描述：一个表现良好的 21 天大的婴儿，有低热，呼吸发现符合毛细支气管炎，且无围产期严重细菌感染（SBI）的危险因素。
PERC 的应答率为 169/250（68%），PERUKI 的应答率为 172/201（86%）。排除 9 名实习医生，共纳入 332 名合格参与者。尽管大多数医生认为患有毛细支气管炎的新生儿很少患有脑膜炎（PERC 141/161（87.6%）；PERUKI 154/171（90%）），并且对在该人群中诊断毛细支气管炎有信心（PERC 136/161（84.5%）；PERUKI 143/171（83.6%）），但在是否可能/很可能会进行 LP 方面存在显著差异（PERC 100/161（62.1%）；PERUKI 15/171（8.8%））（p<0.0001）。在加拿大，实践年限<10 年和对诊断毛细支气管炎缺乏信心是 LP 的多变量预测因素；OR 分别为 23.7（95%CI 11.7 至 47.9）、2.3（95%CI 1.2 至 4.2）和 2.5（95%CI 1.1 至 5.0）。快速了解呼吸道合胞病毒阳性率可将 LP 概率从 35.4%降至 20.2%。
加拿大和英国/爱尔兰的急诊医生在对患有毛细支气管炎的健康发热新生儿行 LP 及其他干预的概率方面存在很大差异。网络、ED 实践年限<10 年和对新生儿毛细支气管炎的诊断信心是 LP 实施可能性的独立预测因素。
