Department of Emergency Medicine, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th Street, Box 179, Room M-130, New York, NY 10065, United States of America.
Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Box 62, Chicago, IL 60611, United States of America.
Am J Emerg Med. 2022 Oct;60:121-127. doi: 10.1016/j.ajem.2022.07.058. Epub 2022 Aug 3.
Hypothermic infants are at risk for serious bacterial and herpes simplex virus infections, but there are no evidence-based guidelines for managing these patients. We sought to characterize variations and trends in care for these infants in the emergency department (ED).
We conducted a retrospective cross-sectional study of infants under 90 days old presenting to 32 pediatric EDs from 2009 through 2019 with an International Classification of Diseases diagnosis code for hypothermia. We characterized variation in diagnostic testing, antimicrobial treatment, and disposition of children in three age groups (≤30 days, 31-60 days, and 61-90 days old) and analyzed care trends.
Of 7828 ED encounters meeting inclusion criteria, most (81%) were ≤ 30 days of age. Infants in the 0-30 days old age group, compared to 61-90 days old age group, had a higher proportion of blood (75% vs. 68%), urine (72% vs. 64%), and cerebrospinal fluid (CSF; 35% vs. 22%) cultures obtained (p < 0.01) and greater antimicrobial use (81% vs. 68%; p < 0.01) in the ED. From 2009 to 2019, C-reactive protein (CRP), and procalcitonin usage steadily increased, from 25% to 40% and 0% to 30% respectively, while antibiotic use (83% to 77%), CSF testing (53% to 44%), and chest radiography (47% to 34%) decreased. Considerable interhospital variation was noted in testing and treatment, including CSF testing (14-70%), inflammatory markers (CRP and procalcitonin; 8-88%), and antibiotics (56-92%).
Substantial hospital-level variation exists for managing hypothermic infants in the ED. Long-term trends are notable for changing practice over time, particularly with increased use of inflammatory markers. Prospective studies are needed to risk stratify and optimize care for this population.
低体温婴儿存在严重细菌和单纯疱疹病毒感染的风险，但目前尚无循证医学指南来管理这些患者。我们旨在描述急诊科（ED）中这些患者的护理差异和变化趋势。
我们对 2009 年至 2019 年期间，32 家儿科 ED 中因低体温接受 ICD 诊断编码的 90 天以下婴儿进行了回顾性横断面研究。我们对三个年龄段（≤30 天、31-60 天和 61-90 天）的诊断检测、抗菌治疗和患儿处置方面的差异进行了描述，并分析了护理变化趋势。
在符合纳入标准的 7828 例 ED 就诊中，大多数（81%）年龄≤30 天。与 61-90 天组相比，0-30 天组婴儿的血液（75%比 68%）、尿液（72%比 64%）和脑脊液（CSF；35%比 22%）培养阳性率更高（p＜0.01），且 ED 中抗菌药物使用率更高（81%比 68%；p＜0.01）。从 2009 年至 2019 年，C 反应蛋白（CRP）和降钙素原的使用率稳步上升，分别从 25%增加到 40%和从 0%增加到 30%，而抗生素使用率（83%降至 77%）、CSF 检测（53%降至 44%）和胸部 X 线摄影（47%降至 34%）下降。在检测和治疗方面，各医院之间存在显著差异，包括 CSF 检测（14-70%）、炎症标志物（CRP 和降钙素原；8-88%）和抗生素（56-92%）。
ED 中管理低体温婴儿的医院间存在大量差异。随着时间的推移，实践发生了显著变化，特别是炎症标志物的使用增加，值得关注。需要前瞻性研究对该人群进行风险分层和优化护理。
