Aims & Objectives

Intubation of children in the emergency setting is a high risk, low incidence event. Standardisation of clinical practice has been hampered by a lack of high-quality evidence to support one technique over another.

We aim to report clinician preference in intubation practice of children in emergency departments (EDs) and intensive care units (ICUs) in Australia and New Zealand as baseline information to allow targeted research focused on improving the safety of paediatric emergency airway management.

Methods

A voluntary questionnaire was undertaken by medical staff in EDs and ICUs associated with the Paediatric Research in Emergency Departments International Collaborative (PREDICT) and Australia and New Zealand Intensive Care Society Paediatric Study Group (ANZICS PSG) research networks. Respondents reported on their individual intubation practices.

Results

A total of 502 clinicians were invited to complete the survey between May and October 2018 with 336 (66.9%) responding. There was marked variation in practice between ED clinicians and ICU clinicians in the in the techniques used for pre-oxygenation, the frequency of use of apnoeic oxygenation, and the reported use of video laryngoscopy.

Conclusions

This survey highlights the self-reported variations in clinical practice in the intubation of children in the emergency and intensive care settings in Australia and New Zealand. While there is unlikely to be a one-size-fits-all approach to paediatric airway management, there is a paucity of high-quality evidence to support clinicians in adopting a best practice approach. Targeted research into preoxygenation techniques, the role and method of apnoeic oxygenation, and the role of VL in paediatric intubation is warranted.

Aims & Objectives

To determine the association of VIS to adverse outcomes in pediatric septic shock patients who are admitted in the Philippine Children's Medical Center.

Methods

This is a prospective cohort study of all septic shock PICU patients aged 1 month to 18 years old. Vasoactive Inotropic Score (VIS) was calculated at 0, 6, 12, 24, and 48 hours post PICU admission as described by Gaies, et. al. Demographic and clinical data were collected. Primary outcomes were ventilator days and ICU length of stay. Secondary outcomes were death during hospitalization, cardiac arrest, and need for intubation. STATA 13.1 was used for data analysis and a P value <0.05 was considered significant.

Results

Eighty-four patients met the inclusion criteria and were enrolled in the study with the median age of 36 months. Sixty-two patients were intubated, 34 went to cardiac arrest and 33 died during the hospitalization. Fourteen patients were ventilated for >=6 days and 20 stayed in the PICU for >=12 days. This study showed a strong association between VIS at 0, 6, 12, 24, 48 hours and maximum VIS with the secondary outcomes specifically risk of intubation, cardiac arrest, and death during hospitalization. Results showed that initial upto maximal VIS within 48 hours may capture a component of illness in pediatric sepsis that highlights cardiovascular instability.

Conclusions

VIS is easily measured and if validated in pediatric sepsis, has the potential to standardize the quantification of hemodynamic support, identify, and stratify high-risk patient populations, and be used as a surrogate outcome measure.

Aims & Objectives

A paediatric Major Haemorrhage Protocol (MHP) has been in place at our hospital since 2014, including a Paediatric ROTEM guided transfusion algorithm (Figure 1).

Aim: To describe the use of ROTEM in the critically bleeding paediatric population at an Australian Major Trauma Centre

Objective: To establish rates of acute traumatic coagulopathy identified by our algorithm

Methods

A retrospective review of electonic data extracts of blood product usage, ROTEM results and trauma presentations was undertaken for the period 29 May 2014 until 31 December 2017. Data linkage between the electronic medical record, blood-bank and trauma registry information systems was undertaken.

Results

In the dataset 171 children had a ROTEM performed for traumatic injury. Most children had a single ROTEM (141/171,82.5%), with 14/171(8.2%) having 2 ROTEMs and 16/171 (9.4%) requiring 3 or more ROTEM tests. Hyperfibrinolysis meeting treatment threshold was detected in 37/171 children (31.6%). Hypofibrinogenaemia meeting treatment threshold was detected in 56/171 (47.9%). Initial haemoglobin and platelets were normal for most trauma presentations (88% and 96%). Standard laboratory coagulation profiles were available for 132/171(77.2%), with the first measured fibrinogen level reported as <2g/L in 17/132(12.8%).

Conclusions

The use of ROTEM at the point-of-care in paediatric major hamorrhage is an emerging practice. The adoption of ROTEM guided MHP into paediatric practice may improve the early detection of coagulation deficiencies and allow for more targeted replacement of coagulation factors, with the potential for more efficent control of non-surgical bleeding along with reducing waste and exposure to blood products that are not specifically indicated nor required.

Aims & Objectives

In Western Australia variations exist in the paediatric population, healthcare services and early warning systems (EWS) used. The ESCALATION project aimed to develop a uniform evidence-based paediatric EWS inclusive of family participation.

Methods

A prospective mixed methods implementation study was conducted in 2019. The central EWS component, the track and trigger age-specific charts included family or clinician concern. The intention of the family concern variable was to indicate worsening in a child’s condition from the perspective of the family. Family resources as posters and brochures were used to promote family involvement. The System was trialled in six purposively selected metropolitan and country sites to evaluate feasibility and acceptability by chart utilisation audits, staff surveys/focus groups and interviews with parents whose children were inpatients.

Results

Clinician or family concern featured in 36/ 249 (14.5%) charts audited, with 93/ 186 (50%) staff surveyed agreeing that the family concern variable assisted in obtaining parents’ views about a child’s condition. Staff focus group participants were positive about the variable although Emergency Department staff reported they assumed family concern to always be present. Eleven mothers and two fathers were interviewed; all were positive about the inclusion of the family concern variable. Information displayed on posters supported parents to articulate concerns, although some held reservations about anticipated negative staff responses.

Conclusions

Incorporating family concern into the WA paediatric EWS is feasible and acceptable to stakeholders and users. Feedback from this study led to further refinement of the tool in preparation for state-wide implementation.

Aims & Objectives

Ketamine is commonly used for induction before tracheal intubation in haemodynamically unstable patients. Our primary objective was to compare our standard induction method (Ketamine and Rocuronium) with the other anaesthetic agents regarding:

The rate of Induction-Associated Complications (IAC).

Tracheal Intubation-Associated Complications (TIAC).

Methods

A prospective observational study of all eligible paediatric patients from 23 hospitals in the West Midlands’ region (UK) who were intubated and retrieved by the (KIDS Intensive Care and Decision Support) Service between May 2019 and November 2019.

Results

Data for 102 out of 144 eligible patients (71%) were available. At least one comorbidity was present in 60%, and hypoxia/hypoxemia was the main reason for intubation in 36% of the patients. Prior to induction, 48 patients (47%) were pre-defined as haemodynamically unstable. Of the 67/102 (66%) patients who used Ketamine for induction, a higher rate of IACs in the haemodynamically stable group was observed {17/38, (45%) VS 4/16 (25%), OR: 2.4, 95%CI: 0.7-8.9, P:0.18} compared to a lower occurrence of IACs in the haemodynamically unstable patients {(21/29 (72%) VS 15/19 (79%), OR: 1.4, 95%CI: 0.36-5.6}. The most significant IACs were hypotension and desaturation <90% (22.5% each). No significant association between TIACs, and the number of the intubation’s attempts were found (1&2 attempts 44/91 (48%) VS ≥3 attempts 6/11 (54%), P:0.7).

Conclusions

IACs and TIACs are common in the acutely ill paediatric patients who require tracheal intubation during retrieval despite precautionary measures. Ketamine may still be a drug of choice in those haemodynamically unstable, however, a large-scale national review may be required.