Publications by authors named "Vikram Sabhaney"

10 Publications

  • Page 1 of 1

Prevalence of Bacterial Meningitis Among Febrile Infants Aged 29-60 Days With Positive Urinalysis Results: A Systematic Review and Meta-analysis.

JAMA Netw Open 2021 May 3;4(5):e214544. Epub 2021 May 3.

Division of Pediatric Emergency Medicine, Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.

Importance: Fever in the first months of life remains one of the most common pediatric problems. Urinary tract infections are the most frequent serious bacterial infections in this population. All published guidelines and quality initiatives for febrile young infants recommend lumbar puncture (LP) and cerebrospinal fluid (CSF) testing on the basis of a positive urinalysis result to exclude bacterial meningitis as a cause. For well infants older than 28 days with an abnormal urinalysis result, LP remains controversial.

Objective: To assess the prevalence of bacterial meningitis among febrile infants 29 to 60 days of age with a positive urinalysis result to evaluate whether LP is routinely required.

Data Sources: MEDLINE and Embase were searched for articles published from January 1, 2000, to July 25, 2018, with deliberate limitation to recent studies. Before analysis, the search was repeated (October 6, 2019) to ensure that new studies were included.

Study Selection: Studies that reported on healthy, full-term, well-appearing febrile infants 29 to 60 days of age for whom patient-level data could be ascertained for urinalysis results and meningitis status were included.

Data Extraction And Synthesis: Data were extracted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and used the Newcastle-Ottawa Scale to assess bias. Pooled prevalences and odds ratios (ORs) were estimated using random-effect models.

Main Outcomes And Measures: The primary outcome was the prevalence of culture-proven bacterial meningitis among infants with positive urinalysis results. The secondary outcome was the prevalence of bacterial meningitis, defined by CSF testing or suggestive history at clinical follow-up.

Results: The parent search yielded 3227 records; 48 studies were included (17 distinct data sets of 25 374 infants). The prevalence of culture-proven meningitis was 0.44% (95% CI, 0.25%-0.78%) among 2703 infants with positive urinalysis results compared with 0.50% (95% CI, 0.33%-0.76%) among 10 032 infants with negative urinalysis results (OR, 0.74; 95% CI, 0.39-1.38). The prevalence of bacterial meningitis was 0.25% (95% CI, 0.14%-0.45%) among 4737 infants with meningitis status ascertained by CSF testing or clinical follow-up and 0.28% (95% CI, 0.21%-0.36%) among 20 637 infants with positive and negative urinalysis results (OR, 0.89; 95% CI, 0.48-1.68).

Conclusions And Relevance: In this systematic review and meta-analysis, the prevalence of bacterial meningitis in well-appearing febrile infants 29 to 60 days of age with positive urinalysis results ranged from 0.25% to 0.44% and was not higher than that in infants with negative urinalysis results. These results suggest that for these infants, the decision to use LP should not be guided by urinalysis results alone.
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May 2021

Adaptive randomised controlled non-inferiority multicentre trial (the Ketodex Trial) on intranasal dexmedetomidine plus ketamine for procedural sedation in children: study protocol.

BMJ Open 2020 12 10;10(12):e041319. Epub 2020 Dec 10.

Women and Children's Health Research Institute (WCHRI), University of Alberta, Edmonton, Alberta, Canada.

Introduction: Up to 40% of orthopaedic injuries in children require a closed reduction, almost always necessitating procedural sedation. Intravenous ketamine is the most commonly used sedative agent. However, intravenous insertion is painful and can be technically difficult in children. We hypothesise that a combination of intranasal dexmedetomidine plus intranasal ketamine (Ketodex) will be non-inferior to intravenous ketamine for effective sedation in children undergoing a closed reduction.

Methods And Analysis: This is a six-centre, four-arm, adaptive, randomised, blinded, controlled, non-inferiority trial. We will include children 4-17 years with a simple upper limb fracture or dislocation that requires sedation for a closed reduction. Participants will be randomised to receive either intranasal Ketodex (one of three dexmedetomidine and ketamine combinations) or intravenous ketamine. The primary outcome is adequate sedation as measured using the Paediatric Sedation State Scale. Secondary outcomes include length of stay, time to wakening and adverse effects. The results of both per protocol and intention-to-treat analyses will be reported for the primary outcome. All inferential analyses will be undertaken using a response-adaptive Bayesian design. Logistic regression will be used to model the dose-response relationship for the combinations of intranasal Ketodex. Using the Average Length Criterion for Bayesian sample size estimation, a survey-informed non-inferiority margin of 17.8% and priors from historical data, a sample size of 410 participants will be required. Simulations estimate a type II error rate of 0.08 and a type I error rate of 0.047.

Ethics And Dissemination: Ethics approval was obtained from Clinical Trials Ontario for London Health Sciences Centre and McMaster Research Ethics Board. Other sites have yet to receive approval from their institutions. Informed consent will be obtained from guardians of all participants in addition to assent from participants. Study data will be submitted for publication regardless of results.

Trial Registration Number: NCT0419525.
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December 2020

Improving the diagnostic accuracy of appendicitis using a multidisciplinary pathway.

J Pediatr Surg 2020 May 31;55(5):889-892. Epub 2020 Jan 31.

Department of Surgery, University of British Columbia, Vancouver, Canada. Electronic address:

Background/purpose: Improvement opportunities exist in the accuracy and timeliness of the diagnosis of childhood appendicitis. The purpose of our study was to conduct a post-implementation audit of a diagnostic pathway for children with suspected appendicitis presenting to our pediatric emergency department.

Methods: We adopted a diagnostic pathway that utilized a validated risk of appendicitis stratification tool (Alvarado Score) with protocolized use of abdominal ultrasound for moderate risk patients. We conducted a 10% convenience sample audit of pathway patients treated over the subsequent 18-month period. Outcome measures included false negative and positive rates, sensitivity, specificity, and overall pathway accuracy.

Results: One hundred thirty-four pathway patients, of which 22 (16.4%) had appendicitis confirmed pathologically, were evaluated. The risk group distribution of patients was: low risk (29%), moderate risk (60%), and high risk (11%). The negative appendectomy rate was 4.4% (reduced from 14% pre-pathway), and the false negative (missed appendicitis) rate was 3.0%. No patients received CT scans. Pathway sensitivity was 81.8%% (95% CI 59.7% to 94.8%), specificity-92.9%% (95% CI 86.4%-96.9%), and overall accuracy-91.0% (95% CI 84.9%-95.3%).

Conclusion: Implementation of a diagnostic pathway achieved a high level of accuracy and reduced our institutional negative appendectomy rate by 67%. The audit identified additional pathway improvement opportunities.

Levels Of Evidence: Level IV.
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May 2020

Intranasal Dexmedetomidine for Procedural Distress in Children: A Systematic Review.

Pediatrics 2020 01;145(1)

Department of Pediatrics and Alberta Research Centre for Health Evidence.

Context: Intranasal dexmedetomidine (IND) is an emerging agent for procedural distress in children.

Objective: To explore the effectiveness of IND for procedural distress in children.

Data Sources: We performed electronic searches of Medline (1946-2019), Embase (1980-2019), Google Scholar (2019), Cumulative Index to Nursing and Allied Health Literature (1981-2019), and Cochrane Central Register.

Study Selection: We included randomized trials of IND for procedures in children.

Data Extraction: Methodologic quality of evidence was evaluated by using the Cochrane Collaboration's risk of bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system, respectively. The primary outcome was the proportion of participants with adequate sedation.

Results: Among 19 trials ( = 2137), IND was superior to oral chloral hydrate (3 trials), oral midazolam (1 trial), intranasal midazolam (1 trial), and oral dexmedetomidine (1 trial). IND was equivalent to oral chloral hydrate (2 trials), intranasal midazolam (2 trials), and intranasal ketamine (3 trials). IND was inferior to oral ketamine and a combination of IND plus oral ketamine (1 trial). Higher doses of IND were superior to lower doses (4 trials). Adverse effects were reported in 67 of 727 (9.2%) participants in the IND versus 98 of 591 (16.6%) in the comparator group. There were no reports of adverse events requiring resuscitative measures.

Limitations: The adequacy of sedation was subjective, which possibly led to biased outcome reporting.

Conclusions: Given the methodologic limitations of included trials, IND is likely more effective at sedating children compared to oral chloral hydrate and oral midazolam. However, this must be weighed against the potential for adverse cardiovascular effects.
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January 2020

Bone fractures in children: is there an association with obesity?

J Pediatr 2014 Aug 13;165(2):313-318.e1. Epub 2014 May 13.

Department of Pediatrics, BC Children's Hospital, Vancouver, British Columbia, Canada.

Objective: To determine the relationship between body mass index (BMI) and odds of extremity bone fractures in children.

Study Design: This was a prospective cross-sectional study conducted at 2 tertiary care pediatric emergency departments. A convenience sample of children 2-17 years of age with a nonpenetrating extremity injury was enrolled. Demographics, activity level, mechanism of injury, participant BMI, and presence of a fracture were recorded. The main outcome was the odds of an extremity bone fracture based on BMI category; logistic regression was used to estimate the odds of fracture by BMI category.

Results: We enrolled 2213 children, of whom 1078 (48.7%) sustained a fracture and 316 (14.3%) were classified as obese. The mean (SD) age was 9.5 (4.2) years, and percentage of male children was 56.8%. Compared with children with a normal BMI, the adjusted odds of fracture among obese, overweight, and underweight children were 0.75 (0.58, 0.97), 1.15 (0.89, 1.48), and 1.44 (1.00, 2.07) respectively.

Conclusions: Obese children had a minor but statistically significant decreased odds of fracture relative to children with a normal BMI, but no association was observed in overweight children. However, underweight children were found to be at an increased odds of fracture. This study suggests that overweight and obese children do not have increased odds of extremity fracture.
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August 2014

Commentaries on 'procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections' with a response from the review authors.

Evid Based Child Health 2013 Jul;8(4):1372-4

Division of Emergency Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.

These are commentaries on a Cochrane review, published in this issue of EBCH, first published as: Schuetz P, Müller B, Christ-Crain M, Stolz D, Tamm M, Bouadma L, Luyt CE, Wolff M, Chastre J, Tubach F, Kristoffersen KB, Burkhardt O, Welte T, Schroeder S, Nobre V, Wei L, Bhatnagar N, Bucher HC, Briel M. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007498. DOI: 10.1002/14651858.CD007498.pub2.
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July 2013

Child health update. Management of dog bites in children.

Can Fam Physician 2012 Oct;58(10):1094-6, e548-50

BC Children's Hospital, Department of Pediatrics, Room K4-226, Ambulatory Care Bldg, 4480 Oak St, Vancouver, BC V6H 3V4.

Question: A 4-year-old girl was playing with her neighbour's dog. The dog became excited and bit the girl on the forearm, leaving a puncture wound. As a result of the injury, she has presented to my office. Should she be treated with antibiotics? If so, which antibiotic should be used and for how long?

Answer: Initiation of prophylactic antibiotics is indicated if the dog bite has undergone primary closure; if there is a moderate or severe bite wound; for puncture wounds (especially if penetration of bone, tendon sheath, or joint), facial bites, bites to the hands or feet, or genital area bites; or wounds sustained by victims who are immunocompromised or asplenic. The first-line choice of antibiotic is amoxicillin-clavulanate. Appropriate tetanus and rabies prophylaxis as indicated should also be a part of caring for a patient who has sustained a dog bite, as well as local debridement and thorough cleaning of the wound.
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October 2012

Assessment of ondansetron-associated hypokalemia in pediatric oncology patients.

ISRN Oncol 2012 19;2012:798239. Epub 2012 Sep 19.

Division of Pediatric Nephrology, University of Alberta, 11405-87 Avenue, Edmonton, AB, Canada T6G 1C9.

Objectives. Ondansetron is a 5-hydroxytryptamine (5-HT(3), serotonin) receptor antagonist used as antiemetic prophylaxis preceding chemotherapy administration. Hypokalemia is a rare complication of ondansetron, which may be underreported due to confounding emesis and chemotherapy-induced tubulopathy. We performed a prospective cohort study to determine if ondansetron caused significant hypokalemia independently as a result of renal potassium wasting. Methods. Twelve patients were recruited, with ten completing the study. Blood and urine samples were collected before and after ondansetron administration in patients admitted for intravenous (IV) hydration and chemotherapy. Dietary histories and IV records were analyzed to calculate sodium and potassium balances. Results. We observed an expected drop in urine osmolality, an increase in urine sodium, but no statistically significant change in sodium or potassium balance before and after ondansetron. Conclusion. Ondansetron does not cause significant potassium wasting in appropriately hydrated and nutritionally replete patients. Careful monitoring of serum potassium is recommended in patients with chronic nutritional or volume status deficiencies receiving this medication.
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October 2012

The role of physician assistants in a pediatric emergency department: a center review and survey.

Pediatr Emerg Care 2012 Aug;28(8):783-8

Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.

Objectives: The objectives of this study were to outline the clinical conditions presenting to a Canadian pediatric emergency department (ED), survey the opinions of physician assistants (PAs) and emergency pediatricians to determine which conditions they consider could be managed by PAs, and to estimate the proportion of the total pediatric ED volume that PAs could potentially manage.

Methods: We reviewed the 2007 British Columbia Children's Hospital database of ED visits to identify clinical presentation and chief complaint of all patients seen. International Classification of Diseases, 10th Revision codes were used to categorize the presenting complaint of each ED visit. Following categorization, the results were discussed by a focus group composed of pediatric emergency medicine-trained physicians and PAs, to review the list of chief complaints. We then surveyed via e-mailed questionnaire a group of emergency pediatricians (n = 17) and PAs (n = 5) to seek their opinion on the categories of clinical presentation appropriate for PA management.

Results: Of 38,722 visits, 9.2% were triaged as "resuscitation" or "emergent." We sorted the remaining 35,077 ED visits into 57 clinical categories. More than 85% of respondents selected 30 clinical categories for PA management with physician supervision, representing 74% of the total ED volume. Of these, 3 were also deemed appropriate for PA management without direct physician supervision. There were statistically significant differences in mean length of stay, waiting time, and admission rates between the clinical conditions selected for PA involvement. However, the difference in waiting time was not clinically meaningful.

Conclusions: A large proportion of pediatric ED visits are designated as semiurgent or nonurgent. Clinicians (ED physicians and PAs) thought that the majority of these ED visits could be managed by PAs.
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August 2012

A systematic review: The role and impact of the physician assistant in the emergency department.

Emerg Med Australas 2011 Feb 20;23(1):7-15. Epub 2011 Jan 20.

Department of Pediatrics School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.

This systematic review describes the role and impact of physician assistants (PAs) in the ED. It includes reports of surveys, retrospective and prospective studies as well as guidelines and reviews. Seven hundred and twelve studies were identified of which only 66 were included, and many of these studies were limited by methodological quality. Generally the use of PAs in the ED is modest with 13-18% of US EDs having PAs although academic medical centres report PA use in 65-68% of EDs. The evidence indicates that PAs are reliable in assessing certain medical complaints and performing procedures, and are well accepted by ED staff and patients alike. There is limited evidence as to whether PAs improve ED flow or are cost-effective. Future studies on work processes, cost-effectiveness, unfamiliar patients' willingness to be treated by non-physician providers, and ED physicians' acceptability of PAs are needed to inform and guide the integration of PAs into EDs.
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February 2011