Hi team,
Welcome to the first edition of our St. Agnes clinical question digest. Below are summaries of the evidenced-based clinical pearls that came up this (albeit short) week, relating to patients on Heldrich/5400.
Have a good weekend,
Ben
1. Is CT head necessary in acute mastoiditis in a child?
Certainly not to make the diagnosis, which is a clinical one. If there is concern for complications of mastoiditis, get one. These could include neuro symptoms that could indicate intracranial pathology (tinnitus, facial nerve palsy, altered mental status, nystagmus, vertigo) or signs of abscess formation (neck mass). In a retrospective study of 50 kids with acute mastoiditis, 2 had CTs at admission and 4 during their hospitalization. The two admission CTs were done because one patient was in a stupor (and was found to have a sigmoid sinus thrombus) and one had a history of a cholesteatoma. The four done inpatient were performed for continued fever; none of these four CTs affected management decisions.
2. What is the sensitivity of ultrasound in detecting nephrolithiasis?
In most studies, it ranges from 60-76%. Unlike CT, ultrasound can detect radiolucent (e.g. uric acid) stones and structural signs of obstruction. However, it is more likely to miss stones less than 5mm in diameter, papillary or calyceal stones, or ureteral stones. In one case series of 50 patients with confirmed nephrolithiasis at Children's Boston, u/s failed to identify 8 stones and missed bilateral disease in 6 patients, resulting in a 76% sensitivity (and 100% specificity).
3. Are NSAIDs contraindicated in pyelonephritis?
No. The primary mechanism by which NSAIDs cause kidney damage is by prostaglandin inhibition. In euvolemic states, prostaglandins have a negligible effect on renal perfusion. The incidence of NSAID-induced kidney injury rises in patients who are dehydrated or who for other reasons have ramped-up RAAS systems (and therefore are more likely to be relying on prostaglandins for renal perfusion). If you're managing the fluid status of your pyelonephritis patients well, and they don't have preexisting renal disease, this shouldn't be the case.
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