Determining which patients are at highest risk of acute chest syndrome (ACS) is challenging for pediatric emergency department (PED) providers, resulting in more chest x-rays (CXR), increased radiation exposure, and higher healthcare costs. The objective of this study was to identify significant clinical predictors of ACS to better guide care. In this retrospective review, we included patients diagnosed with sickle cell disease (SCD), aged 2-12 years, who presented to the PED between 2016-2018. We compared patients who were febrile vs. afebrile on presentation, and those diagnosed with ACS vs. those who were not. A total of 424 patients met inclusion criteria, 25% presenting with fever. For febrile patients, 69% received a CXR on presentation vs. 42% of afebrile subjects (p=<0.0001). Overall, 10% of patients were diagnosed with ACS: 13% of febrile presentations vs. 9% of afebrile presentations. Patients diagnosed with ACS were significantly more likely to present with chest pain (p=0.003), tachypnea (p=0.001), hypoxia (p<0.0001), and a history of asthma (p=0.0085). Upon multivariable modeling the only significant predictors were chest pain (OR 3.3, CI 1.5-7.4) and hypoxia (OR 8.4, CI 4-17.9). Current guidelines recommend empiric treatment and a CXR for SCD patients presenting with fever, hypoxia, tachypnea, tachycardia or abnormal respiratory exam. Our data demonstrate that hypoxia and chest pain are significant predictors of ACS. Additionally, data indicated that CXRs were likely performed in excess in febrile patients. Further research is needed, but chest pain and hypoxia may focus the use of CXR on the appropriate patients.

Background: Once diagnosis of malignancy is made in pediatric patients, it can be important to initiate therapy to prevent delay in benefits derived from treatment. These patients require provision of central vascular access to begin treatment. The aim of this study was to compare vascular access provision by a designated PVAT with surgical placement of central venous access in pediatric oncology patients. Methods: This was an IRB-approved retrospective medical record review of subjects diagnosed with an oncologic malignancy with inclusion criteria: ages 0-21 years of age, treatment for pediatric malignancy at the University of Maryland Children’s Hospital between 1/1/2017-12/31/2019. Results: We identified 69 patients who met the inclusion criteria with 39% (n=27) having undergone line placement by PVAT. The mean time from consult to line placement was 10 hours (SD = 9) in the PVAT group vs 76 hours (SD = 56) in the surgery group (p < 0.0001). There was a statistically significant difference in length of procedure, with PVAT placement requiring less time (27 +/- 12 minutes) vs surgical placement (48 +/- 19 minutes), p=0.0005. Conclusion: At our institution, having a PVAT in house has allowed for more efficient line placements, decreased length of time to provision of access and transition to placement of surgical lines when more stable. This allows for not only patients to receive care faster, but also to have lines placed in shorter times while optimizing patient safety.