Intravenous Site Research Articles

Neonatal Miliaria Pustulosa—A Case Series

ABSTRACTBackground/ObjectivesMiliaria pustulosa is a noninfectious, transient skin eruption of pustules overlying erythematous plaques secondary to obstruction of eccrine glands. There are very few case reports in the literature detailing miliaria pustulosa in neonates. When presenting in neonates, its similarity to life‐threatening infections may cause diagnostic confusion. By differentiating this condition from similar presentations, unnecessary treatments and tests in this population may be avoided.MethodsRetrospective review of the medical records of nine neonates presenting with a pustular eruption diagnosed as miliaria pustulosa. Patients were seen at a children's hospital in Chicago, IL, USA; cases were selected by investigator recall.ResultsIn this case series, miliaria pustulosa presents in nine neonates as clusters of eruptive pustules with resolution or significant improvement noted after an average of 2.6 days (range 1–5 days). The average age was 4.6 days (range 1–10 days old) and the average gestational age was 34.7 weeks (range 26.3–40.1 weeks). All patients had pustular outbreaks in areas occluded by swaddling, clothes, or adhesive. Seven patients had geometric lesions that were underlying sites of intravenous (IV) site adhesive or electrocardiogram (EKG) leads.ConclusionsThe consistent morphological features of this pustular eruption at sites of skin occlusion and the transient course in the setting of an otherwise well‐appearing infant are strongly suggestive of the diagnosis of miliaria pustulosa. It is important for clinicians to be familiar with this benign presentation and to differentiate it from other neonatal pustular eruptions to minimize invasive tests and treatments in this vulnerable population.

Consumer experience and outcomes of insertion, removal, and management practices of short and midline peripheral intravenous catheters in acute health care: a mixed methods systematic review protocol.

This review will synthesize and integrate current research on the practices relating to the insertion, removal, and management of short and midline peripheral intravenous catheters on consumer experiences and outcomes in acute health care. The aim is to provide consolidated evidence to support policy decision-makers and health care workers in overcoming peripheral intravenous catheter device management challenges. Implementing the evidence provided by this review could increase positive consumer outcomes and reduce the gap between research evidence and clinical practice. Peripheral intravenous catheterization is a process in which a device is inserted into a patient's peripheral vein to administer medication, blood products, and therapeutic fluids. Recent studies have demonstrated the positive and negative impacts of peripheral intravenous catheter site placement, pain relief for insertion, complications, consumer engagement, and routine versus clinically indicated removal of these devices on consumers and the health care system. Managing these impacts in relation to research-practice gaps and conflicting evidence remains challenging. Moreover, consumer experiences and outcomes concerning these challenges are unclear. This review will consider quantitative, qualitative, and mixed methods studies on consumer experiences and outcomes in acute health care. The quantitative component will consider outcomes of patients' pain, satisfaction, anxiety, distress, preferences, fear, and comfort. The qualitative component will consider consumer experiences, including perceptions, preferences, perspectives, attitudes, expectations, and satisfaction. This study will follow JBI's convergent segregated approach for mixed method systematic reviews. A search of 11 databases will be conducted for peer-reviewed published articles, theses, and dissertations. There will be no age, date, or language limitations. PROSPERO CRD42023410214.

Characteristics that increase the risk for pain on propofol injection

BackgroundPropofol for anesthesia has become increasingly popular for endoscopic procedures. However, pain on propofol injection (POPI) remains an issue with administration. The primary endpoint of this study was to identify patient characteristics and factors, such as IV site and gauge, that could predict the occurrence of POPI.MethodsThis was a prospective chart review study of 291 patients undergoing endoscopic procedures. The patient’s demographics, intravenous (IV) site, and gauge were extrapolated. POPI was scored 0–3: 0 for no pain, 1 for minimal discomfort or awareness of sensation, 2 for discomfort but manageable/tolerable, and 3 for severe discomfort with writhing.Results291 patient charts were reviewed. One patient was excluded for a lower extremity IV site. 225 (77.6%) had no pain, 48 (16.6%) grade 1 pain, 16 (5.5%) grade 2 pain, and 1 (0.3%) grade 3 pain. 137, 13, and 140 patients respectively had antecubital (AC), forearm, and hand IVs. Zero patients with an AC IV experienced a score greater than 1. Compared to AC, forearm IVs with pain of 2–3 had a univariate odds ratio (OR) of 11.3 (0.66,1.92; p-value < 0.001), and hand IVs had a univariate OR of 18.8 (2.46,143.3; p-value < 0.001) with a multivariable OR 15.2 (1.93,118.9; p-value 0.004). Patients with anxiety/depression and pain had a univariate OR 2.31 (1.09, 7.27; p-value 0.031) with a multivariable OR 2.85 (1.06, 7.74; p-value 0.039). SSRI/SNRI use had a univariate OR 1.56 (0.57,4.28; p-value 0.38). Alcohol use had a univariate OR 1.24 (0.39,3.91; p-value 0.71). Narcotic use had a Univariate OR 6.18 (1.49,25.6; p-value 0.012). Diabetic patients had a univariate OR of 1.42 (0.45,4.48; p-value 0.55). Chronic pain had a univariate OR of 3.11 (1.04,9.28; p-value 0.042). Females had a univariate OR 0.98 (0.37,2.63; p-value 0.95).ConclusionThis study identified potential characteristics for having POPI. The incidence of POPI was statistically significant in patients with hand and forearm IVs compared to AC IV sites, larger IV gauges, history of depression/anxiety, history of chronic narcotic use, fibromyalgia, and chronic pain syndromes. This shows the potential of premedicating with analgesics or using AC sites on these select patients to help reduce the risk of POPI.

Evaluation of the safety and efficacy of peripheral vasopressors to decrease central line placement and associated bloodstream infections.

In 2020, as a result of evidence of demonstrated safety of an initial pilot program, our institution set out to implement a peripheral vasopressor infusion protocol. To evaluate the use of peripheral lines for vasopressor administration to reduce placement of unnecessary central lines and central line days. This is an Institutional Review Board approved, single center retrospective chart review conducted as pre/post-analysis. Our hospital is a quaternary care, level 1 trauma center in Hartford, Connecticut that serves 100,000-120,000 patients annually. Patients >18years admitted to an intensive care unit (ICU) were included if meeting protocol specific inclusion criteria pertaining to moderate expected duration and dose of vasopressor. Patients were excluded if vasculature not supportive of placement of two peripheral intravenous (PIV) sites, PIV sites without brisk blood return, had a limb restriction, or metacarpal line. All analyses were conducted with SPSS v. 26 (IBM; Armonk, NY 2019), using an a priori alpha level of 0.05 such that all results yielding p < .05 were deemed statistically significant. Primary efficacy outcomes of this study are number of central lines placed and number of central line days. The primary safety outcome is the number of extravasation events attributed to peripheral administration of vasopressors. Overall, 146 patients avoided central line placement constituting a 58.4% (p < .001) decrease in central line placement with peripheral vasopressor use. Out of 382 administrations there were a total of 14 extravasation events that occurred with peripheral vasopressor use in the post-intervention group. Implementation was associated with a statistically significant reduction in CLABSI occurrence. The results of this analysis demonstrate that vasopressors can peripherally administered safely, when proximal to the antecubital fossa, at lower doses, and for short durations of infusion with minimal adverse events.

Safety of Intravenous Push Valproate Compared with Intravenous Piggyback at a Tertiary Academic Medical Center.

Data are limited regarding the safety associated with administering valproate sodium by intravenous push (IVP) compared with intravenous piggyback (IVPB). The objective of this retrospective pre-post analysis was to compare the safety profile of valproate administration via IVPB from March to May 2022 and IVP from June to August 2022. A total of 890 IVPB and 440 IVP administrations were included. The major endpoint of this analysis was the incidence of infusion site reactions (infiltration or phlebitis). The incidence of documented intravenous (IV) site reactions demonstrated minimal differences between both IVPB and IVP administration cohorts. Based on the Naranjo algorithm, all IVPB and IVP infusion site reactions were classified as possible or doubtful. Additional safety endpoints included bradycardia, hypotension, or sedation attributable to valproate sodium administration. Similar safety profiles were observed, including valproate-associated bradycardia, hypotension, and sedation events. All safety events were further classified as possible or doubtful by the Naranjo algorithm. Time from pharmacist verification to valproate administration was also collected. The mean time from pharmacist order verification to valproate administration was significantly faster in the IVP cohort compared to the IVPB cohort. IVP valproate administration may be considered safe, allowing for more optimal clinical and operational outcomes in the acute care setting.

Thermal imaging of local skin temperature as part of quality and safety assessment of injectable drugs

Injection of high-quality drugs can occasionally cause unexpected and unexplained local complications. As the current standard for drug quality control does not include an assessment of the local irritation effects of drugs, this effect may cause postinjection complications. Simultaneously, local irritation effects of the drugs can be assessed based on local tissue inflammation. The dynamics of local temperature can assess inflammation. Infrared monitoring of local skin temperature dynamics at subcutaneous, intramuscular, and intravenous injection sites of drugs under experimental and clinical conditions can improve their quality and safety. Therefore, there is a need to include dynamic thermography in the standard of biological evaluation of the quality and safety of drugs in the dosage form “solution for injections.” This eliminates the local irritation and necrotizing activity of drugs and minimizes the development of local pain syndrome, aseptic inflammation, necrosis, and abscess.

Predictive Factors for Infusion Site Induration After Outpatient Chemotherapy in Japan: A Secondary Analysis

Even in the absence of extravasation, some patients develop induration at the peripheral intravenous catheterization site prior to the next day's treatment. Infusion site induration commonly affects patients who undergo repeated chemotherapy administrations. Vessel health is crucial for the continuation of chemotherapy. However, there is no effective method to prevent induration. Hence, this study aimed to investigate the factors that could cause induration for preventing its occurrence. This study was a secondary analysis of a prospective observational study. All participants were undergoing outpatient chemotherapy. Participant characteristics and related catheterization data were collected on the treatment day as baseline, and induration incidence was recorded on the subsequent treatment day. Receiver operating characteristic (ROC) analysis was performed to determine the sensitivity and specificity of cutoff points of the vein and catheter diameter ratios for distinguishing between developed induration and not developed induration. Additionally, cox regression analysis with multiple imputation was used to investigate the factors that predicted induration. Seventy-one patients participated in the study. The cutoff point of the vein/catheter diameter ratio calculated using ROC analysis was ≥3.7. The ratio of larger-diameter veins to catheter diameter of ≥3.7 times was negatively associated with induration in both complete case analysis (HR: 0.11; p=0.034) and multiple imputation analysis (HR: 0.12; p=.049). Selecting the vein with 3.7 times higher diameter than the catheter diameter for the catheterization site may help prevent induration on the next treatment day.

Abstract 14769: Peripheral Venous Pressure Measured With a Novel Miniature Pressure Transducer Correlates With Central Venous Pressure in Heart Failure, Heart Transplant, and Left Ventricular Assist Device Patients

Introduction: Peripheral venous pressure (PVP) has been shown to accurately correlate with central venous pressure (CVP) when measured using a conventional manometer and pressure tubing. We investigated the correlation between PVP as measured by a novel pressure transducer and CVP in heart failure (HF), heart transplant (HTx), and left ventricular assist device (LVAD) patients. Methods: A prospective, cross-sectional study examining PVP from February 2022 to May 2023 was conducted. The analysis was limited to patients undergoing right heart catheterization (RHC) admitted for HF, post-HTx monitoring, or LVAD hemodynamic testing. PVP was transduced from an antecubital or more distal peripheral intravenous (IV) catheter site using a miniature digital, disposable pressure transducer (Centurion Compass Universal HG, Medline). Pressures were compared using Pearson’s correlation coefficient. Results: 99 patients were enrolled with a mean age of 62 ± 12 years and a mean ejection fraction (EF) of 41 ± 21%. 74% of the patients had heart failure, 17% were HTx patients, and 9% were LVAD patients. The PVP measured with the novel pressure transducer was found to be highly correlated to CVP measured by RHC (r=0.80, p &lt; 0.0001) (Figure). High correlation was also noted when broken down by HF (r=0.77, p &lt; 0.0001), HTx (r=0.95, p &lt; 0.0001), and LVAD groups (r=0.90, p &lt; 0.0003). There was a high degree of correlation for HF patients with EF &lt; 50% (r=0.74, p &lt; 0.0001) and EF &gt; 50% (r=0.90, p &lt; 0.0001). A high degree of correlation was found for all peripheral IV insertion sites: antecubital (r=0.86, p=0.000071), forearm (r=0.76, p&lt;0.00001), and hand (r=0.84, p&lt;0.00001). Conclusions: There is a high degree of correlation between PVP measured by a novel pressure transducer and CVP in HF, HTx, and LVAD patients. PVP measurements using this transducer are a reliable estimate of volume status in these patient populations.

Radiopharmaceutical administration practices-Are they best practice?

The nuclear medicine community has stated that they are using best practices to gain venous access and administer radiopharmaceuticals, and therefore do not contribute to extravasations. We tested this hypothesis qualitatively and quantitatively by evaluating four different perspectives of current radiopharmaceutical administration practices: (1) clinical observations of nuclear medicine technologists on the job, (2) quality improvement (QI) projects, (3) a high-level survey of current practices in 10 acute care hospitals, (4) intravenous (IV) access site data for 29,343 procedures. These four areas were compared to the gold standard of pharmaceutical administration techniques. From clinical observations of radiopharmaceutical administrations in adult populations, technologists extensively used 24-gauge peripheral intravenous catheters (PIVCs) and butterfly needles. They also performed direct puncture (straight stick). Technologists predominantly chose veins in areas of flexion (hand, wrist, and antecubital fossa), rather than forearm vessels for IV access placement; in many circumstances, antecubital fossa vessels are chosen first, often without prior assessment for other suitable vessels. For selecting the injection vein, technologists sometimes used infrared vein finders but primarily performed blind sticks. Review of QI projects suggested that smaller gauge needles were contributing factors to extravasations. Additionally, the review of surveys from 10 hospitals revealed an absence of formalized protocols, training, knowledge, and skills necessary to ensure the safety/patency of IV devices prior to the administration of radiopharmaceuticals. Finally, findings from a review of IV access data for 29,343 procedures supported the observations described above. We expect that nuclear medicine technologists have the best intentions when providing patient care, but many do not follow venous access best practices; they lack formal protocols, have not received the latest comprehensive training, and do not use the best placement tools and monitoring equipment. Thus, the presumption that most nuclear medicine technologists use best practices may not be accurate. In order to improve radiopharmaceutical administration and patient care, the nuclear medicine community should update technical standards to address the most recent peripheral IV access and administration best practices, provide technologists with vascular visualization tools and the proper training, develop and require annual vascular access competency, and provide active monitoring with center and patient-specific data to create ongoing feedback.

DETERMINE PRE-ANALYTICAL ERRORS ' PERCENTAGE IN CLINICAL BIOCHEMISTRY LABS AND DEVELOP REMEDIAL PROCEDURES FOR THEIR PREVENTION

Diagnostic inaccuracies pose a formidable issue in Laboratory Medicine, necessitating immediate initiatives to expand understanding and minimize these discrepancies. Our study delves into the nuances of errors associated with laboratory testing processes, from the test request to result interpretation, underlining the imperative for reducing such errors. Our investigation seeks to identify the incidence of errors in a round-the-clock lab setting over four months, covering pre-analytical, analytical, and post-analytical phases.Over a span period from Jan 2021 to Jan 2022, a broad spectrum of errors within pre-analytical, analytical, and post-analytical phases was methodically logged using a bespoke proforma. The collected data was systematically analyzed utilizing SPSS version 22.All venous and arterial blood samples were processed in the 24-hour lab throughout this period. From the 185,012 samples received, 2,450 were deemed unsuitable for testing, accounting for a 1.32% rejection rate. These samples were disqualified due to an array of pre-analytical errors, including misidentification (0.07%), incorrect tube usage (0.11%), missing samples (0.07%), drawing from an intravenous site (0.10%), inadequate sample volume (0.51%), improper timing of sample collection (0.10%), hemolysed samples (0.31%), and lipemic samples (0.11%).Utilizing an agreed list of evidence-based Quality Indicators, compliant with the current International Standard (ISO 15189:2012), for incorporation into accreditation programs of clinical laboratories stands as a potent approach to augment quality, mitigate error risks, and bolster patient safety.

Effect of Peripherally Infused Norepinephrine on Reducing Central Venous Catheter Utilization.

The purpose of this retrospective study was to evaluate the impact of peripherally administered norepinephrine on avoiding central venous catheter insertion while maintaining safety of the infusion. An institutional guideline allows peripheral infusion of norepinephrine via dedicated, 16- to 20-gauge, mid-to-upper arm intravenous (IV) catheters for up to 24 hours. The primary outcome was the need for central venous access in patients initially started on peripherally infused norepinephrine. A total of 124 patients were evaluated (98 initially on peripherally infused norepinephrine vs 26 with central catheter only administration). Thirty-six (37%) of the 98 patients who were started on peripheral norepinephrine avoided the need for central catheter placement, which was associated with $8,900 in direct supply cost avoidance. Eighty (82%) of the 98 patients who started peripherally infused norepinephrine required the vasopressor for ≤12 hours. No extravasation or local complications were observed in any of the 124 patients, regardless of site of infusion. Administration of norepinephrine via a dedicated peripheral IV site appears safe and may lead to a reduction in the need for subsequent central venous access. To achieve timely resuscitation goals, as well as to minimize complications associated with central access, initial peripheral administration should be considered for all patients.

Massaging as a pain-relieving intervention before performing intravenous access

PurposePain is “an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of damage”. Stimulating the skin by rubbing, stroking, massaging, or applying pressure near the injection site is pain-relieving. Needle-related procedures induce anxiety, distress, and fear in children and adults. The present study aimed to test the effectiveness of massaging the access site in reducing pain associated with intravenous access. DesignAfter obtaining institutional ethics committee approval, this prospective randomized single-blinded study was performed on 250 ASA I-II patients 18 to 65 years old, scheduled for elective minor general surgery under general anaesthesia. MethodsPatients were randomized into the Massaging Group (MG) and the Control Group (CG). A Situational Trait Anxiety Inventory (STAI) was conducted to evaluate the anxiety levels of the patients. In addition, the skin adjacent to the intravenous access site was massaged for 15 s in circular motions with moderate intensity by the investigator's right thumb before performing the intravenous access in the MG. The CG did not receive any massage adjacent to the access site. The primary endpoint, the intensity of perceived pain, was rated on a non-graduated 10-cm Visual Analogue Score (VAS). FindingsThe groups' demographic data and STAI I-II scores were similar. There was a significant difference between the VAS scores of the two groups (p < 0.05). ConclusionsOur results support massaging as an effective pain-relieving technique before intravenous intervention. As massaging is a universal and non-invasive intervention that requires no advanced preparation, we recommend massaging before each intravenous cannulation to reduce pain caused by intravenous access.

Stability Study and Simultaneous Determination of Norepinephrine, Moxifloxacin, and Piperacillin + Tazobactam Mixtures Applied in Intensive Care Medicine

Background: In intensive care units intravenous medicine may be used in simultaneous infusion in the same intravenous site. Sometimes, the physical compatibility and stability of the combined solutions are unknown. Objective: The objective was to develop, optimize and validate a simple, fast and sensitive stability- indicating high-performance liquid chromatography (HPLC) for simultaneous quantification of binary mixtures of norepinephrine, piperacillin + tazobactam, moxifloxacin for intravenous (IV) administration in different diluents and physical compatibility with mannitol. Methods: The HPLC method was performed on a C18LUNA (4.6x250 mm 5-Micron) column, using acetonitrile: methanol: phosphate buffer pH 3.0 (20:30:50) as eluent and validated according to ICH guidelines and applied to mixtures of norepinephrine, moxifloxacin, piperacillin, tazobactam and mannitol at 0, 2, 6, 9 and 24 h. The substances and their mixtures were also evaluated by visual inspection and pH over time. Results: The analytical method developed was specific, linear, precise, accurate and robust. No visual changes were observed in the mixtures over time, maintaining the pH values (except for piperacillin + tazobactam which changed 0.5 in 24 h) and losses of less than 10% of content over the 24 h under analyzed conditions. Conclusion: The proposed method is suitable for simultaneous analysis of norepinephrine, moxifloxacin, piperacillin and tazobactam. All tested mixtures were compatible and stable for up to 24h, which is an important result for increasing patient safety in clinical practice since it has not been reported in the literature yet. The method can be further investigated and used for different concentration and diluent combinations.

Harvest and Application of Bone Marrow Aspirate Concentrate to Address Acetabular Chondral Damage During Hip Arthroscopy.

Harvest and Application of Bone Marrow Aspirate Concentrate to Address Acetabular Chondral Damage During Hip Arthroscopy.

Purple Glove Syndrome- A Catastrophic Complication of Phenytoin Injection

Purple Glove Syndrome (PGS) is a rare complication of intravenous phenytoin administration which is illustrated by delayed soft tissue injury of the skin conterminous to the point or distal to the site of intravenous phenytoin infusion. The clinical features of PGS include pain, oedema, and bluish discolouration over the extremity. The present case report describes about a 60-year-old male, who presented to the Emergency Department with the chief complaints of generalised tonic clonic seizures, lasting for 10 mins, for which he was managed with inj. phenytoin sodium. The computed tomography scan of brain revealed right-sided subdural haematoma. After 24 hours of hospital stay, the patient started complaining of severe pain in the arm and forearm. There was purple-bluish discolouration around the intravenous site, peripheral oedema and pain. The various risk factors linked to PGS, include old age and large and multiple doses of phenytoin.

Multifocal Cutaneous Mucormycoses of Skin and Soft Tissue at Intravenous Injection Sites by Saksenaea vasiformis in an Immunocompetent Host.

Multifocal Cutaneous Mucormycoses of Skin and Soft Tissue at Intravenous Injection Sites by Saksenaea vasiformis in an Immunocompetent Host.

Are Diagnostic Computed Tomography Chest Scans Sufficient for Detecting Supraclavicular in Initial Breast Cancer Staging?

<h3>Purpose/Objective(s)</h3> Initial staging workup strategies for locally advanced or suspected stage IV breast cancer can include computed tomography (CT) of the chest, abdomen, pelvis (CAP) and bone scan or, alternatively, a whole-body positron emission tomography/computed tomography (PET/CT). Variations in intravenous contrast injection site and bolus timing, arm positioning, and acquisition techniques on a CT chest scan could limit visualization of supraclavicular (SCV) and supracricoid cervical lymph nodes, which are critical for staging, prognosis, and treatment recommendations. The study's purpose is to determine whether there is a difference between the incidences of SCV and cervical lymphadenopathy detected on staging CT CAP versus PET/CT scans. <h3>Materials/Methods</h3> The records of consecutive newly diagnosed breast cancer patients who received initial staging scans at a single institution from 2012 to 2017 were reviewed in a HIPAA compliant, institutional review board-approved study. De-identified information was reviewed for inclusion: new breast cancer diagnosis, >18 years old, and availability of staging. Exclusion criteria were prior breast cancer treatment, re-staging for known recurrence, and nondiagnostic imaging examinations. Radiology reports were searched for SCV and cervical lymphadenopathy to determine the incidence detected by each imaging modality. A board certified neuroradiologist reviewed and characterized scans that noted cervical or SCV lymphadenopathy. <h3>Results</h3> The initial search resulted in 3,126 PET/CT and 631 CT CAP scans with 588 patients fulfilling the inclusion criteria. PET/CT scans had been performed in 539 patients and 49 received CT CAP and bone scans. The two groups were well matched by stage (Table 1). Metastatic cervical lymphadenopathy was detected by PET-CT in 50 patients (7.9%) versus two (3.7%) with CT CAP. Out of the 50 patients who had cervical lymphadenopathy detected by PET-CT, 30 (60%) had metastatic cervical lymphadenopathy above the level of the lung apex, the typical upper extent of a CT chest field of view. Although 25 (50%) patients had additional areas of distant metastatic disease, cervical lymphadenopathy above the thoracic inlet was the only site of distant metastasis for 13 patients (26%), and would not have been detectable by CT CAP. <h3>Conclusion</h3> PET/CT detected more cervical and SCV lymphadenopathy than CT CAP in initial staging scans for breast cancer, with 60% of those detected on PET/CTs in areas that would have been occult on standard CT chest scans. Such nodal involvement constituted the only site of distant metastatic disease in 26% of the patients. Thus, dedicated CT neck imaging may be a reasonable addition to CT CAP as an initial staging strategy to determine accurate staging and radiation treatment field volumes and borders.

P44 Rapidly progressive cutaneous ulceration in a toddler

Abstract Introduction/Background Pyoderma gangrenosum is a rare ulcerative inflammatory cutaneous condition of unknown aetiology which is uncommon in childhood. Only 4% of reported cases occur in individuals younger than 15. The initial lesion in PG is commonly a painful hemorrhagic nodule or pustule that rapidly progresses into a large necrotic boggy ulcer that may resolve with cribriform scars. About 50% of patients with PG are associated with an underlying systemic disease, including inflammatory bowel disease, hematologic malignancies disease, and arthritis. It may occur in the context of classic syndromes like PAPA. Description/Method A 3-year-old male child was admitted to the Rheumatology ward with fever and generalized ulcers for two months. The ulcers started as multiple small pustules over the buttock, bilateral thigh, and extensor aspect of upper limbs and evolved into large ulcers within two months. Ulcers were round to oval in shape with irregular margins, undermined edges and violaceous borders. He also developed similar ulcers at intravenous cannula sites over the dorsum of hands suggesting the pathergy phenomenon. Laboratory reports suggested increased inflammatory markers. Skin biopsy showed dense dermal neutrophilic infiltration without vasculitis, suggesting pyoderma gangrenosum. Bacterial fungal and tubercular cultures from the biopsy tissue were normal. Bone marrow examination ruled out hematopoietic malignancy. Colonoscopy was normal ruling out subclinical IBD. Whole exome sequencing for auto inflammatory panel didn’t reveal any pathogenic variant. Diagnosis was considered as childhood-onset idiopathic pyoderma gangrenosum. The child was started on steroids along with cyclosporine, ulcers slowly started to heal over a period of two months and started to recur on the buttocks at sites of minor trauma. Discussion/Results The most common underlying etiologies in pediatric PG are IBD (inflammatory bowel disease), hematologic malignancies, immune deficiencies, vasculitis, PAPA syndrome (pyogenic arthritis, pyoderma gangrenosum and acne), SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis), and as well as PASH (pyoderma gangrenousm, acne and hidradenitis suppurevitiva). Idiopathic cases account for 49% of cases. Adult PG, most commonly occurs in lower limbs, but lesions in pediatric PG are multiple and disseminated without any specific location. Cyclosporine, Methotrexate, Mycophenolate mofetil, and cyclophosphamide can be used as steroid-sparing agents.TNF inhibitors and Anakinra can be used as biological agents. Key learning points/Conclusion Pediatric PG can be misdiagnosed due to its rarity and atypical presentation; a thorough clinically oriented workup is mandatory to make the correct diagnosis and choose the appropriate treatment. Treating a resistant PG can be challenging. Further growth in the field of genomic sequencing paves the way for a new diagnosis.

Use of Albumin as a Resuscitative Fluid in the Intensive Care Unit.

Use of Albumin as a Resuscitative Fluid in the Intensive Care Unit.

Subcutaneous Nodules in a 28-week-old Girl.

Subcutaneous Nodules in a 28-week-old Girl.