Search

Meningiomas represent the most common benign histological tumor of the central nervous system. Usually, meningiomas are intracranial, showing a typical dural tail sign on brain MRI with Gadolinium, but occasionally they can infiltrate the skull or be sited extracranially. We present a systematic review of the literature on extracranial meningiomas of the head and neck, along with an emblematic case of primary extracranial meningioma (PEM), which provides further insights into PEM management. A literature search according to the PRISMA statement was conducted from 1979 to June 2021 using PubMed, Web of Science, Google Scholar, and Scopus databases, searching for relevant Mesh terms (primary extracranial meningioma) AND (head OR neck). Data for all patients were recorded when available, including age, sex, localization, histological grading, treatment, possible recurrence, and outcome. A total of 83 published studies were identified through PubMed, Google Scholar, and Scopus databases, together with additional references list searches from 1979 to date. A total of 49 papers were excluded, and 34 manuscripts were considered for this systematic review, including 213 patients. We also reported a case of a 45-year-old male with an extracranial neck psammomatous meningioma with sizes of 4 cm × 3 cm × 2 cm. Furthermore, whole-body 68Ga-DOTATOC PET/CT was performed, excluding tumor spread to other areas. Surgical resection of the tumor was accomplished, as well as skin flap reconstruction, obtaining radical removal and satisfying wound healing. PEMs could suggest an infiltrative and aggressive behavior, which has never found a histopathological correlation with a malignancy (low Ki-67, 68Ga-DOTATOC PET/CT should be considered in the patient’s global assessment. Surgical removal is a resolutive treatment, and the examination of frozen sections can confirm the benignity of the lesion, reducing the extension of the removal of healthy tissue surrounding the tumor.

Introduction Surgery is the primary treatment for Cushing's disease(CD). In cases with no biochemical remission after surgical resection or when recurrence occurs after a period of remission stereotactic radiosurgery (SRS) is used as alternative/adjuvant treatment. The aim of this study is to demonstrate the effectiveness of SRS and FSRS(Fractionated stereotactic radiosurgery) for the treatment of CD in a long term follow up. Methods This is a retrospective study in which 41 patient (36 females and 5 males) who underwent surgery for CD from 2009 to 2019 were included. Out of 41 cases, 34 cases had microadenomas while 7 had macroadenomas. These patients had recurrence or persistence of hypercortisolism post-operatively. After multidisciplinary evaluation, these patients were treated by CyberKnife (SRS & FSRS). Results Remission rate in our study was 60.97% with a median follow up period of 79.03 months. The median time to biochemical remission was 14 months. Tumour growth control was achieved in 95.12%. Hypopituitarism of different axes was seen in 34.14% patients. Secondary hypothyroidism was the most common pituitary insufficiency (34%) followed by secondary hypogonadism in 17%. Conclusion CyberKnife radiosurgery and hypofractionated radiosurgery can be used as an adjuvant treatment in patient with active disease and no biochemical remission after one or multiple surgical resections. Risk of radiation induced hypopituitarism and other complication is relatively low 34.14% and tumour growth control is significantly higher.

Purpose Computed tomography (CT) has been shown to change management in children on extracorporeal membrane oxygenation (ECMO). Although techniques have been described to transport these critically ill patients to the CT suite in the radiology department, transport out of the intensive care setting is not without risk, and using portable CT is a practical alternative. However, obtaining a CT pulmonary angiogram (CTPA) in a patient on veno-arterial (VA) ECMO presents unique challenges due to bypass of the cardiopulmonary system, which may lead to suboptimal opacification of the pulmonary arteries. Methods We describe a method to obtain a diagnostic CTPA study in an infant on VA ECMO in the intensive care unit using portable CT. Our solution involved temporary withholding ECMO and using the venous cannula to deliver a compact contrast bolus to the right atrium to adequately opacify the pulmonary arteries. Special attention was given to the delivery of the contrast bolus, which was given by hand injection, to ensure it coincided with image acquisition and minimized the time ECMO was withheld. Results We were able to successfully obtain a diagnostic CTPA study in an infant on VA ECMO in the intensive care unit using portable CT. Conclusion: This case demonstrates that in select instances CTPA in infants on VA ECMO can be achieved using a portable CT system.

We report a case of refractory post-operative cerebrospinal fluid leak from a posterior fossa operative site secondary to superior vena cava construction. The patient developed the leak after a posterior fossa craniotomy and resection of a cerebellar lung metastasis. The leak persisted despite conservative measures and lumbar drain insertion. Suspicion of superior vena cava obstruction was raised following clinical examination. She was managed with stenting of the superior vena cava, with cessation of leak.

OBJECTIVE: To examine levels of plasma osteopontin (OPN), a recently described neuroinflammatory biomarker, in children with abusive head trauma (AHT) compared with children with other types of traumatic brain injury (TBI). STUDY DESIGN: The study cohort comprised children aged

OBJECTIVEEvidence shows mixed efficacy of applying guidelines for the treatment of traumatic brain injury (TBI) in children. A multidisciplinary team at a children’s health system standardized intensive care unit–based TBI care using guidelines and best practices. The authors sought to investigate the impact of guideline implementation on outcomes.METHODSA multidisciplinary group developed a TBI care protocol based on published TBI treatment guidelines and consensus, which was implemented in March 2011. The authors retrospectively compared preimplementation outcomes (May 2009 to March 2011) and postimplementation outcomes (April 2011 to March 2014) among patients < 18 years of age admitted with severe TBI (Glasgow Coma Scale score ≤ 8) and potential survivability who underwent intracranial pressure (ICP) monitoring. Measures included mortality, hospital length of stay (LOS), ventilator LOS, critical ICP elevation time (percentage or total time that ICP was > 40 mm Hg), and survivor functionality at discharge (measured by the WeeFIM score). Data were analyzed using Student t-tests.RESULTSA total of 71 and 121 patients were included pre- and postimplementation, respectively. Mortality (32% vs 19%; p < 0.001) and length of critical ICP elevation (> 20 mm Hg; 26.3% vs 15%; p = 0.001) decreased after protocol implementation. WeeFIM discharge scores were not statistically different (57.6 vs 58.9; p = 0.9). Hospital LOS (median 19.6 days; p = 0.68) and ventilator LOS (median 10 days; p = 0.24) were unchanged.CONCLUSIONSA multidisciplinary effort to develop, disseminate, and implement an evidence-based TBI treatment protocol at a children’s hospital was associated with improved outcomes, including survival and reduced time of ICP elevation. This type of ICP-based protocol can serve as a guide for other institutions looking to reduce practice disparity in the treatment of severe TBI.

Objective As a result of a workshop to identify common causes of unplanned extubation, Children's Healthcare of Atlanta developed a scoring tool (Risk Assessment Score) to stratify patients into groups of low, moderate, high, and extreme risk. This tool could be used to institute appropriate monitoring or interventions for patients with high risks of unplanned extubation to enhance safety. The objective of this study is to test the hypothesis that the Risk Assessment Score will correlate with the occurrence rate of unplanned extubation in pediatric patients. Design Retrospective review of 2,811 patients at five ICUs conducted between December 2012 and July 2014. Setting Five ICUs at two freestanding pediatric hospitals within a large children's healthcare system in the United States. Patients All intubated pediatric patients. Interventions Data of intubations and Risk Assessment Score were collected. Extubation outcomes and severity levels were compared across demographic groups and with the maximum Risk Assessment Score of each intubation. Measurements and main results Out of 4,566 intubations, 244 were unplanned extubations (5.3%). The occurrence rates of unplanned extubations in those less than 1, 1-6, and more than 6 years old were 6.7%, 3.6%, and 2.7%, respectively, corresponding to a rate of 0.59, 0.53, and 0.58 unplanned extubation every 100 ventilator days. The occurrence rates were 13.6% for patients weighing less than 1 kg (0.59 unplanned extubation per 100 ventilation days) and 3.8% for patients weighing greater than or equal to 1 kg (0.58 unplanned extubation per 100 ventilation days). For intubations with maximum risk score falling in risk categories of low, moderate, high, and extreme, the occurrence rates were 4.7%, 7.7%, 12.0%, and 8.3%, respectively, which corresponded to rates of 0.54, 0.62, 0.95, and 0.92 unplanned extubation per 100 ventilator days. Conclusions Higher Risk Assessment Scores are associated with occurrence rates of unplanned extubation.

Objective: We report a 63 years old female who presented with confusion, urinary retention and gait disturbances.Method: CT head shows communicating hydrocephalus. Spinal MRI demonstrated an L5- S1...

To compare outcome between young [65 yrs] and old [65 yrs] patients of Parkinson's disease who underwent bilateral STN DBS a non-randomized retrospective study was done. 20 young (Young group) and 20 elderly (Old group) patients with matched baseline UPDRS were selected and followed up for 2 years after deep brain stimulation (DBS) surgery. The total and motor UPDRS, before, one year and two years after surgery was compared. PDQ39 a quality of life questionnaire and MMSE were also recorded. Zarit care burden interview (ZCBI) was used to analyse caregiver burden. Analysis of data was done using Mann-Whitney Test as the data was ordinal. The difference was not statistically significant at 1st and 2nd year of follow up in total and motor UPDRS. A significant reduction in Levodopa equivalent daily dose was seen in young and old group from preoperative period to 1stthen 2nd year of follow up. The difference was not statistically significant (P = 0.946) at 1st (P = 0.946) and at 2nd year (P = 0.989). Both the groups showed improvement in their PDQ39. The difference was not statistically significant at 1st (P = 0.636) and at 2nd year of follow up (P = 0.417). Caregiver burden (ZCBI) improved in both the groups and the difference was not statistically significant at 1st (P = 0.105) and at 2nd year of follow up (P = 0.078).In this study STN DBS didn't lead to any cognitive decline (MMSE) whatever is the age of patient during follow up. Bilateral STN DBS for Parkinson's disease is equally effective in young and elderly patients.

Intrathecal baclofen infusion trial is a sophisticated tool for selecting patients for permanent intra thecal baclofen infusion therapy We report our clinical experience of fifteen patients with refractory spasticity who underwent a continuous ITB trial using a temporary intraspinal indwelling catheter prior to permanent pump implantation. Patients underwent placement of a temporary intrathecal catheter that was connected to an external pump. Multisource feedback was obtained from the various healthcare professionals involved (Staff Nurse, Specialist nurse, physiotherapist, Doctor, family members, patient) regarding progress of test over 48–72 h. Average Modified Ashworth score after the trial was less than 2. Some degree of dose related minor adverse events (AEs) occurred in 8 patients, with the most common being nausea, constipation, urinary retention and hypotension. 10 patients received pump implant. 5 patients did not receive a pump because of AEs or because the goals were not met. 1 patient had pump removed after 4 years because of infection.

A 74 year old male presented with 1 month history of weakness in right upper limb and motor aphasia for 15 days. Magnetic resonance imaging (MRI) of the brain showed three discrete ring enhancing lesions. An image guided awake craniotomy and biopsy of a lesion was performed. The histopathological examination revealed it to be a grade III Oligodendroglioma. This was a rare case of multicentric high grade oligodendroglioma has never been reported in literature. We report such a case with relevant review of literature.

Background: Because nearly 23,000 more neurosurgeons are needed globally to address 5 million essential neurosurgical cases that go untreated each year, there is an increasing interest in task-shifting and task-sharing (TS/S), delegating neurosurgical tasks to nonspecialists, particularly in low- and middle-income countries (LMICs). This global survey aimed to provide a cross-sectional understanding of the prevalence and structure of current neurosurgical TS/S practices in LMICs. Methods: The survey was distributed to a convenience sample of individuals providing neurosurgical care in LMICs with a Web-based survey link via electronic mailing lists of continental societies and various neurosurgical groups, conference announcements, e-mailing lists, and social media platforms. Country-level data were analyzed by descriptive statistics. Results: The survey yielded 127 responses from 47 LMICs; 20 countries (42.6%) reported ongoing TS/S. Most TS/S procedures involved emergency interventions, the top 3 being burr holes, craniotomy for hematoma evacuation, and external ventricular drain. Most (65.0%) believed that their Ministry of Health does not endorse TS/S (24.0% unsure), and only 11% believed that TS/S training was structured. There were few opportunities for TS/S providers to continue medical education (11.6%) or maintenance of certification (9.4%, or receive remuneration (4.2%). Conclusions: TS/S is ongoing in many LMICs without substantial structure or oversight, which is concerning for patient safety. These data invite future clinical outcomes studies to assess effectiveness and discussions on policy recommendations such as standardized curricula, certification protocols, specialist oversight, and referral networks to increase the level of TS/S care and to continue to increase the specialist workforce. Key words: Capacity, Global health, Global neurosurgery, LMIC, Task-sharing, Task-shifting, Workforce

Objective: cEEG is an emerging technology for which there are no clear guidelines for patient selection or length of monitoring. The purpose of this study was to identify subgroups of pediatric patients with high incidence of seizures. Study Design: We conducted a retrospective study on 517 children monitored by cEEG in the intensive care unit (ICU) of a children's hospital. The children were stratified using an age threshold selection method. Using regression modeling, we analyzed significant risk factors for increased seizure risk in younger and older children. Using two alternative correction procedures, we also considered a relevant comparison group to mitigate selection bias and to provide a perspective for our findings. Results: We discovered an approximate risk threshold of 14 months: below this threshold, the seizure risk increases dramatically. The older children had an overall seizure rate of 18%, and previous seizures were the only significant risk factor. In contrast, the younger children had an overall seizure rate of 45%, and the seizures were significantly associated with hypoxic-ischemic encephalopathy (HIE; p = 0.007), intracranial hemorrhage (ICH; p = 0.005), and central nervous system (CNS) infection (p = 0.02). Children with HIE, ICH, or CNS infection accounted for 61% of all seizure patients diagnosed through cEEG under 14 months. Conclusions: An extremely high incidence of seizures prevails among critically ill children under 14 months, particularly those with HIE, ICH, or CNS infection.

Spinal Atypical Teratoid/Rhabdoid Tumour (AT/RT) is a highly malignant tumour, and its prognosis is dismal especially for very young patients. In this article, we present the case of a teenage boy with AT/RT in the cervical spine and its multimodality management. A review of the literature on ATRT of the spine is also presented.

A physician schedule that maximizes continuity (i.e., reduces instances of patients being treated by multiple physicians) could improve the efficiency of handoffs—the transfer of patients from the care of one physician to another. We present a modeling and solution approach for assigning physicians to service and call shifts in the pediatric intensive care unit (PICU) at Children’s Healthcare of Atlanta at Egleston (Children’s). We developed the handoff continuity score (HCS) for measuring the continuity of a schedule. We combined the HCS with a mixed-integer programming model (MIP) with the objective of maximizing the HCS, while minimizing violations of physician preferences. For a 51-week horizon and a physician pool of 16 physicians, no feasible solution to this MIP is found within 48 hours using CPLEX 12.4. However, an iterative heuristic incorporating modified versions of the MIP produces a schedule (3.42 percent optimality gap) for the scheduling instance faced by Children’s for this period. Our solution approach facilitates resource optimization, and automated scheduling requires less time than manually constructing such a schedule. We generated six-month schedules that were implemented in the PICU at Children’s in 2011, 2012, and 2013. Such automated schedule construction allows for creation of schedules that maximize continuity.

Spinal ependymoma commonly presents as an intramedullary tumor. We present a rare case of multicentric intradural extramedullary spinal ependymoma. A 59 years old female presented to us with spastic quadriparesis for 10 months. Magnetic resonance imaging of the spinal cord showed discretely located enhancing tumor masses from at C1-C2, C6-C7, and D4 to L3 level. Subtotal resection of the symptomatic tumor at C6-C7 and D7-D9 was done. The patient underwent radiotherapy with 50.4 Gy. At follow-up of 11 months, patient is doing well. The relevant literature is reviewed.

Poor workflow associated with physician rounding can produce inefficiencies that decrease time for essential activities, delay clinical decisions, and reduce staff and patient satisfaction. Workflow and provider resources were not optimized when a pediatric intensive care unit increased by 22,000 square feet (to 33,000) and by nine beds (to 30). Lean methods (focusing on essential processes) and scenario analysis were used to develop and implement a patient-centric standardized rounding process, which we hypothesize would lead to improved rounding efficiency, decrease required physician resources, improve satisfaction, and enhance throughput.Human factors techniques and statistical tools were used to collect and analyze observational data for 11 rounding events before and 12 rounding events after process redesign. Actions included: 1) recording rounding events, times, and patient interactions and classifying them as essential, nonessential, or nonvalue added; 2) comparing rounding duration and time per patient to determine the impact on efficiency; 3) analyzing discharge orders for timeliness; 4) conducting staff surveys to assess improvements in communication and care coordination; and 5) analyzing customer satisfaction data to evaluate impact on patient experience.Thirty-bed pediatric intensive care unit in a children's hospital with academic affiliation.Eight attending pediatric intensivists and their physician rounding teams.Eight attending physician-led teams were observed for 11 rounding events before and 12 rounding events after implementation of a standardized lean rounding process focusing on essential processes.Total rounding time decreased significantly (157 ± 35 mins before vs. 121 ± 20 mins after), through a reduction in time spent on nonessential (53 ± 30 vs. 9 ± 6 mins) activities. The previous process required three attending physicians for an average of 157 mins (7.55 attending physician man-hours), while the new process required two attending physicians for an average of 121 mins (4.03 attending physician man-hours). Cumulative distribution of completed patient rounds by hour of day showed an improvement from 40% to 80% of patients rounded by 9:30 AM. Discharge data showed pediatric intensive care unit patients were discharged an average of 58.05 mins sooner (p.05). Staff surveys showed a significant increase in satisfaction with the new process (including increased efficiency, improved physician identification, and clearer understanding of process). Customer satisfaction scores showed improvement after implementing the new process.Implementation of a lean-focused, patient-centric rounding structure stressing essential processes was associated with increased timeliness and efficiency of rounds, improved staff and customer satisfaction, improved throughput, and reduced attending physician man-hours.

OBJECTIVE: To investigate the characteristics of tricycle-related injuries in children presenting to US emergency departments (EDs). METHODS: Data regarding tricycle injuries in children younger than 18 years of age were obtained from the National Electronic Injury Surveillance System for calendar years 2012 and 2013. Data included body regions injured, ED disposition, and demographics. RESULTS: There were an estimated 9340 tricycle-related injuries treated in US EDs from 2012 to 2013. The average age was 3 years. Children 2 years of age had the highest frequency of injuries. Boys accounted for 63.6% of all injuries. Children 1 to 2 years of age represented 51.9% of all injuries. Lacerations were the most common type of injury. Internal organ damage was the most common type of injury in 3- and 5-year-olds. Contusions were the most common type of injury in 1- and 7-year-olds. The head was the most commonly injured region of the body and the most common region to endure internal damage. The elbows were the most commonly fractured body part. The upper extremity was more frequently fractured than the lower extremity. Approximately 2.4% of all injured children were admitted to the hospital. CONCLUSIONS: The upper extremity of children, particularly the elbow, was more frequently fractured than the lower extremity. The head was the most common body part to endure internal damage. By elucidating the characteristics of tricycle-related injuries, preventive measures can be implemented to decrease the incidence of tricycle-related injuries and ED visits.

Objectives: To determine the impact of extracorporeal life support (ECLS) on mortality in pediatric patients with acute hypoxemic respiratory failure (AHRF) at our institution; and to calculate the hospital charges associated with the use of ECLS. Design: Retrospective review of medical records and hospital charges. Setting: Pediatric intensive care unit (ICU) of a university-affiliated children's hospital. Patients: Twenty patients admitted to the pediatric ICU between 1991 and 1995 for AHRF who received ECLS as a part of their hospital course. Interventions: Predicted mortality was calculated using the Pediatric Respiratory Failure score and was compared with survival at the time of hospital discharge. Hospital charges were used as a proxy for resource utilization. Cost-per-life-year-saved calculations were performed based on a normal life expectancy for survivors. Measurements and Main Results: Twenty patients were identified. The median age was 4.83 yrs. The median duration of ECLS was 9 days, with 19.5 days in the pediatric ICU and 23.5 days for the entire hospital length of stay. The observed mortality rate for these patients was 20%. Median predicted mortality rate based on the Pediatric Respiratory Failure score calculation was 83%. The hospital charges incurred by these patients was a median of $199,096. Based on a normal life expectancy for survivors, this results in a cost of $4,190/life-year. Conclusions: ECLS for the pediatric patient with AHRF is done at a considerable cost. However, ECLS affects survival favorably, and compares favorably when considering cost/life-year calculations. The data presented in this study may serve as a benchmark for comparison with newer therapies (i.e., liquid ventilation, nitric oxide). These data also provide a framework for cost-based analyses at other ECLS institutions.

Purpose Our goal was to examine intensivists' perception of comfort, staff satisfaction, teaching, and efficiency with family-centered rounds (FCR). Materials and methods Surveys were sent to intensivists at Emory University. Responses of physicians that participate in FCR were compared with those who do not. Survey questions were developed using a 5-point Likert scale with 1 representing a negative response and 5 being positive. Results Of 46 surveys sent, there were 31 responses (response rate, 67%). Seventeen responses were from adult intensivists and 14 from pediatric. Sixteen respondees (52%) participate in FCR, whereas 15 respondents (48%) do not. There is a significant difference in physician comfort with the practice with an average score of 4.4 + 1.0 for those who participate and 2.7 + 1.7 for those who do not ( P = .002). There is also a significant difference in the perception of the impact of FCR on staff. Those who participate feel that it has a significantly greater positive impact on staff's involvement during rounds with an average score of 3.6 + 1.2 vs an average score of 2.3 + 1.2 for those who do not practice FCR ( P = .003). Those who participate in FCR have significantly more positive perception on its impact on patient outcomes with an average score of 3.8 + 1.1 compared with an average score of 2.9 + 1.3 for those who do not participate in FCR ( P = .05). There are no significant differences in perceptions on teaching and efficiency among participants and nonparticipants in FCR. Conclusions Participation in FCR is associated with an increase in perceived physician comfort, positive impact on staff involvement, and positive impact on patient outcome. Concerns over teaching and efficiency remain.

Intraventricular meningiomas are rare in the pediatric population. These tumors are often large in size and aggressive in behavior when they occur in children. The management of these tumors is a surgical challenge.

Pediatric acute liver failure is often accompanied by hepatic encephalopathy, cerebral edema, and raised intracranial pressure. Elevated intracranial pressure can be managed more effectively with intracranial monitoring, but acute-liver-failure-associated coagulopathy is often considered a contraindication for invasive monitoring due to risk for intracranial bleeding. We reviewed our experience with use of early intracranial pressure monitoring in acute liver failure in children listed for liver transplantation.Retrospective review of all intubated pediatric acute liver failure patients with grade III and grade IV encephalopathy requiring intracranial pressure monitoring and evaluated for potential liver transplant who were identified from an institutional liver transplant patient database from 1999 to 2009.None.A total of 14 patients were identified who met the inclusion criteria. Their ages ranged from 7 months to 20 yrs. Diagnoses of acute liver failure were infectious (three), drug-induced (seven), autoimmune hepatitis (two), and indeterminate (two). Grade III and IV encephalopathy was seen in ten (71%) and four (29%) patients, respectively. Computed tomography scans before intracranial pressure monitor placement showed cerebral edema in five (35.7%) patients. Before intracranial pressure monitor placement, fresh frozen plasma, vitamin K, and activated recombinant factor VIIa were given to all 14 patients, with significant improvement in coagulopathy (p.04). The initial intracranial pressure ranged from 5 to 50 cm H2O; the intracranial pressure was significantly higher in patients with cerebral edema by computed tomography (p.05). Eleven of 14 (78%) patients received hypertonic saline, and three (22%) received mannitol for elevated intracranial pressure. Eight of 14 (56%) monitored patients were managed to liver transplant, with 100% surviving neurologically intact. Four of 14 (28%) patients had spontaneous recovery without liver transplant. Two of 14 (14%) patients died due to multiple organ failure before transplant. One patient had a small 9-mm intracranial hemorrhage but survived after receiving a liver transplant. No patient developed intracranial infection.In our series of patients, intracranial pressure monitoring had a low complication rate and was associated with a high survival rate despite severe hepatic encephalopathy and cerebral edema in the setting of pediatric acute liver failure. In our experience, monitoring of intracranial pressure allowed interventions to treat increased intracranial pressure and provided additional information regarding central nervous system injury before liver transplant. Further study is warranted to confirm if monitoring allows more directed intracranial pressure therapy and improves survival in pediatric acute liver failure.

A physician group in a pediatric intensive care unit faced challenges when moving to a larger unit. Challenges included increased time for rounds, nonbillable attending physician hours, poor communication with pediatric intensive care unit staff, and meeting resident physician duty hours and teaching requirements. The purpose of this analysis was to identify waste and opportunities for improvement to improve physician efficiency.Human factor (observational data collection) techniques were used to capture60 hrs of rounding data. Twelve attending physicians and their rounding teams were shadowed to capture rounds on 130 pediatric intensive care unit patients. Rounding events, times, and patient interactions were recorded. Lean methods and scenario analysis were used to analyze the data and identify opportunities for improvement. Rounding events were categorized to determine value-added and nonvalue-added activities. Value-added activities were subclassified as essential or nonessential to morning rounds.Thirty-bed pediatric intensive care unit in a children's hospital with academic affiliation. PATIENTS OR SUBJECTS: Eight attending pediatric intensivists and their physician rounding teams.Eight attending physician-led rounding teams were observed for 12 rounding events and a total of 130 patient contacts.Large variation existed in the rounding process. Nonessential activities was highly correlated with physician preference and created a wide range in rounding time per patient. Essential activities showed the least variation and represents a "lean process." Scenario analysis was used to determine the impact of removing waste and reallocating the nonessential activities outside of rounds. Results of the analysis indicated that rounds could be reduced by 42% and that plan of care completion would be timelier (decreased from a mean of 157 to 82 mins).In a large physician group, essential activities showed the least variation. Practice variation focused on minimizing nonessential activities could have dramatic impacts on standardizing practice. Further study is indicated to determine whether standardizing rounds to focus on essential activities can lead to more effective processes that require fewer resources while improving outcomes for all stakeholders.

EMLA (eutectic mixture of local anesthetics) is a eutectic mixture of lidocaine and prilocaine used to provide topical anesthesia for various procedures. When used properly, EMLA can provide anesthesia to a depth of 5 mm in intact skin, allowing for better pain control during superficial procedures (eg, venipuncture and lumbar puncture).1 Its use has grown widely over the past few years. The adverse effects most commonly related to the use of EMLA are mild local reactions such as edema, erythema, and transient pallor. More-severe reactions, however, have been reported, including methemoglobinemia and seizures.1–6 Only 2 prior reports have described the association between the use of EMLA and the development of seizures.2 This case stands out from prior reports in that a proper amount of EMLA was used but applied to a large area of diseased skin. A healthy 3-year-old white female with a history of eczema was referred to an allergist because of seasonal and environmental allergy symptoms. She was scheduled for allergy skin testing. Her parents were given a prescription for a 5-g tube of EMLA to be applied to the patient’s back, which then was to be covered with plastic wrap, before arriving at the allergist’s office on the day of skin testing. On the morning of the scheduled visit, the parents … Address correspondence to James F. Parker, MD, Children’s Healthcare of Atlanta, 1645 Tullie Cir, Atlanta, GA 30329. E-mail: jparke4{at}emory.edu