Verbal Autopsy to Assess Postdischarge Mortality in Children With Suspected Sepsis in Uganda

BACKGROUND

Reducing child mortality in low-income countries is constrained by a lack of vital statistics. In the absence of such data, verbal autopsies provide an acceptable method to determining attributable causes of death. The objective was to assess potential causes of pediatric postdischarge mortality in children younger than age 5 years (under-5) originally admitted for suspected sepsis using verbal autopsies.

METHODS

Secondary analysis of verbal autopsy data from children admitted to 6 hospitals across Uganda from July 2017 to March 2020. Structured verbal autopsy interviews were conducted for all deaths within 6 months after discharge. Two physicians independently classified a primary cause of death, up to 4 alternative causes, and up to 5 contributing conditions using the Start-Up Mortality List, with discordance resolved by consensus.

RESULTS

Verbal autopsies were completed for 361 (98.6%) of the 366 (5.9%) children who died among 6191 discharges (median admission age: 5.4 months [interquartile range, 1.8-16.7]; median time to mortality: 28 days [interquartile range, 9-74]). Most deaths (62.3%) occurred in the community. Leading primary causes of death, assigned in 356 (98.6%) of cases, were pneumonia (26.2%), sepsis (22.1%), malaria (8.5%), and diarrhea (7.9%). Common contributors to death were malnutrition (50.5%) and anemia (25.7%). Reviewers were less confident in their causes of death for neonates than older children (P < .05).

CONCLUSIONS

Postdischarge mortality frequently occurred in the community in children admitted for suspected sepsis in Uganda. Analyses of the probable causes for these deaths using verbal autopsies suggest potential areas for interventions, focused on early detection of infections, as well as prevention and treatment of underlying contributors such as malnutrition and anemia.

The Reviewer Academy of the Society of Critical Care Medicine: Key Principles and Strategic Plan

The Society of Critical Care Medicine (SCCM) Reviewer Academy seeks to train and establish a community of trusted, reliable, and skilled peer reviewers with diverse backgrounds and interests to promote high-quality reviews for each of the SCCM journals. Goals of the Academy include building accessible resources to highlight qualities of excellent manuscript reviews; educating and mentoring a diverse group of healthcare professionals; and establishing and upholding standards for insightful and informative reviews. This manuscript will map the mission of the Reviewer Academy with a succinct summary of the importance of peer review, process of reviewing a manuscript, and the expected ethical standards of reviewers. We will equip readers to target concise, thoughtful feedback as peer reviewers, advance their understanding of the editorial process and inspire readers to integrate medical journalism into diverse professional careers.

Haemodynamic support for paediatric septic shock: a global perspective

Septic shock is a leading cause of hospitalisation, morbidity, and mortality for children worldwide. In 2020, the paediatric Surviving Sepsis Campaign (SSC) issued evidence-based recommendations for clinicians caring for children with septic shock and sepsis-associated organ dysfunction based on the evidence available at the time. There are now more trials from multiple settings, including low-income and middle-income countries (LMICs), addressing optimal fluid choice and amount, selection and timing of vasoactive infusions, and optimal monitoring and therapeutic endpoints. In response to developments in adult critical care to trial personalised haemodynamic management algorithms, it is timely to critically reassess the current state of applying SSC guidelines in LMIC settings. In this Viewpoint, we briefly outline the challenges to improve sepsis care in LMICs and then discuss three key concepts that are relevant to management of children with septic shock around the world, especially in LMICs. These concepts include uncertainties surrounding the early recognition of paediatric septic shock, choices for initial haemodynamic support, and titration of ongoing resuscitation to therapeutic endpoints. Specifically, given the evolving understanding of clinical phenotypes, we focus on the controversies surrounding the concepts of early fluid resuscitation and vasoactive agent use, including insights gained from experience in LMICs and high-income countries. We outline the key components of sepsis management that are both globally relevant and translatable to low-resource settings, with a view to open the conversation to the large variety of treatment pathways, especially in LMICs. We emphasise the role of simple and easily available monitoring tools to apply the SSC guidelines and to tailor individualised support to the patient's cardiovascular physiology.

Reporting of Social Determinants of Health in Pediatric Sepsis Studies

OBJECTIVE

Standardized, consistent reporting of social determinants of health (SDOH) in studies on children with sepsis would allow for: 1) understanding the association of SDOH with illness severity and outcomes, 2) comparing populations and extrapolating study results, and 3) identification of potentially modifiable socioeconomic factors for policy makers. We, therefore, sought to determine how frequently data on SDOH were reported, which factors were collected and how these factors were defined in studies of sepsis in children.

DATA SOURCES AND SELECTION

We reviewed 106 articles (published between 2005 and 2020) utilized in a recent systematic review on physiologic criteria for pediatric sepsis.

DATA EXTRACTION

Data were extracted by two reviewers on variables that fell within the World Health Organization's SDOH categories.

DATA SYNTHESIS

SDOH were not the primary outcome in any of the included studies. Seventeen percent of articles (18/106) did not report on any SDOH, and a further 36.8% (39/106) only reported on gender/sex. Of the remaining 46.2% of articles, the most reported SDOH categories were preadmission nutritional status (35.8%, 38/106) and race/ethnicity (18.9%, 20/106). However, no two studies used the same definition of the variables reported within each of these categories. Six studies reported on socioeconomic status (3.8%, 6/106), including two from upper-middle-income and four from lower middle-income countries. Only three studies reported on parental education levels (2.8%, 3/106). No study reported on parental job security or structural conflict.

CONCLUSIONS

We found overall low reporting of SDOH and marked variability in categorizations and definitions of SDOH variables. Consistent and standardized reporting of SDOH in pediatric sepsis studies is needed to understand the role these factors play in the development and severity of sepsis, to compare and extrapolate study results between settings and to implement policies aimed at improving socioeconomic conditions related to sepsis.

Burden and severity of deranged electrolytes and kidney function in children seen in a tertiary hospital in Kano, northern Nigeria

INTRODUCTION

Derangement in serum electrolytes and kidney function is often overlooked, especially in resource-constrained settings, and associated with increased risk of morbidity and mortality. This study aimed to describe the burden of derangements in serum electrolytes and kidney function in children presenting to a tertiary hospital in Nigeria.

METHODS

The laboratory records of all children who had serum electrolytes urea and creatinine ordered on their first presentation to hospital between January 1 and June 30, 2017 were retrospectively reviewed. Basic demographic data including admission status (inpatient or outpatient) were recordedandserum levels of sodium, potassium, chloride and bicarbonate were assessed for derangements usingnormal values from established reference ranges. Results of repeat samples were excluded. Kidney function was classified based on the serum creatinine relative to normal values for age and sex.

RESULTS

During the study period, 1909 children (60.3% male); median (IQR) age 42 (11.9) months had serum chemistry and 1248 (65.4%) were admitted. Results of their first samples were analyzed. Electrolyte derangements were present in 78.6% of the samples most commonly hyponatraemia (41.1%), low bicarbonate(37.2%), hypochloraemia (33.5%) and hypokalemia(18.9%). Azotaemia was found in 20.1% of the results. Elevated serum creatinine levels were found in 399 children (24.7%), 24.1% of those being in the severe category. Children aged 5 years and younger accounted for 76.4% of those with derangement in kidney function. One hundred and eight outpatients (17.8%) had deranged kidney function.

CONCLUSION

Deranged serum electrolytes and kidney function were common in this cohort.

The Current and Future State of Pediatric Sepsis Definitions: An International Survey

BACKGROUND AND OBJECTIVES

Definitions for pediatric sepsis were established in 2005 without data-driven criteria. It is unknown whether the more recent adult Sepsis-3 definitions meet the needs of providers caring for children. We aimed to explore the use and applicability of criteria to diagnose sepsis and septic shock in children across the world.

METHODS

This is an international electronic survey of clinicians distributed across international and national societies representing pediatric intensive care, emergency medicine, pediatrics, and pediatric infectious diseases. Respondents stated their preferences on a 5-point Likert scale.

RESULTS

There were 2835 survey responses analyzed, of which 48% originated from upper-middle income countries, followed by high income countries (38%) and low or lower-middle income countries (14%). Abnormal vital signs, laboratory evidence of inflammation, and microbiologic diagnoses were the criteria most used for the diagnosis of "sepsis." The 2005 consensus definitions were perceived to be the most useful for sepsis recognition, while Sepsis-3 definitions were stated as more useful for benchmarking, disease classification, enrollment into trials, and prognostication. The World Health Organization definitions were perceived as least useful across all domains. Seventy one percent of respondents agreed that the term sepsis should be restricted to children with infection-associated organ dysfunction.

CONCLUSIONS

Clinicians around the world apply a myriad of signs, symptoms, laboratory studies, and treatment factors when diagnosing sepsis. The concept of sepsis as infection with associated organ dysfunction is broadly supported. Currently available sepsis definitions fall short of the perceived needs. Future diagnostic algorithms should be pragmatic and sensitive to the clinical settings.

Criteria for Pediatric Sepsis-A Systematic Review and Meta-Analysis by the Pediatric Sepsis Definition Taskforce

OBJECTIVE

To determine the associations of demographic, clinical, laboratory, organ dysfunction, and illness severity variable values with: 1) sepsis, severe sepsis, or septic shock in children with infection and 2) multiple organ dysfunction or death in children with sepsis, severe sepsis, or septic shock.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2004, and November 16, 2020.

STUDY SELECTION

Case-control studies, cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years with suspected or confirmed infection, which included the terms "sepsis," "septicemia," or "septic shock" in the title or abstract.

DATA EXTRACTION

Study characteristics, patient demographics, clinical signs or interventions, laboratory values, organ dysfunction measures, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed.

DATA SYNTHESIS

One hundred and six studies met eligibility criteria of which 81 were included in the meta-analysis. Sixteen studies (9,629 patients) provided data for the sepsis, severe sepsis, or septic shock outcome and 71 studies (154,674 patients) for the mortality outcome. In children with infection, decreased level of consciousness and higher Pediatric Risk of Mortality scores were associated with sepsis/severe sepsis. In children with sepsis/severe sepsis/septic shock, chronic conditions, oncologic diagnosis, use of vasoactive/inotropic agents, mechanical ventilation, serum lactate, platelet count, fibrinogen, procalcitonin, multi-organ dysfunction syndrome, Pediatric Logistic Organ Dysfunction score, Pediatric Index of Mortality-3, and Pediatric Risk of Mortality score each demonstrated significant and consistent associations with mortality. Pooled mortality rates varied among high-, upper middle-, and lower middle-income countries for patients with sepsis, severe sepsis, and septic shock (p < 0.0001).

CONCLUSIONS

Strong associations of several markers of organ dysfunction with the outcomes of interest among infected and septic children support their inclusion in the data validation phase of the Pediatric Sepsis Definition Taskforce.

Cough augmentation techniques for people with chronic neuromuscular disorders

BACKGROUND

People with neuromuscular disorders may have a weak, ineffective cough predisposing them to respiratory complications. Cough augmentation techniques aim to improve cough effectiveness and mucous clearance, reduce the frequency and duration of respiratory infections requiring hospital admission, and improve quality of life.

OBJECTIVES

To determine the efficacy and safety of cough augmentation techniques in adults and children with chronic neuromuscular disorders.

SEARCH METHODS

On 13 April 2020, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and ClinicalTrials.gov for randomised controlled trials (RCTs), quasi-RCTs, and randomised cross-over trials.

SELECTION CRITERIA

We included trials of cough augmentation techniques compared to no treatment, alternative techniques, or combinations thereof, in adults and children with chronic neuromuscular disorders.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility, extracted data, and assessed risk of bias. The primary outcomes were the number and duration of unscheduled hospitalisations for acute respiratory exacerbations. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

The review included 11 studies involving 287 adults and children, aged three to 73 years. Inadequately reported cross-over studies and the limited additional information provided by authors severely restricted the number of analyses that could be performed. Studies compared manually assisted cough, mechanical insufflation, manual and mechanical breathstacking, mechanical insufflation-exsufflation, glossopharyngeal breathing, and combination techniques to unassisted cough and alternative or sham interventions. None of the included studies reported on the primary outcomes of this review (number and duration of unscheduled hospital admissions) or listed 'adverse events' as primary or secondary outcome measures. The evidence suggests that a range of cough augmentation techniques may increase peak cough flow compared to unassisted cough (199 participants, 8 RCTs), but the evidence is very uncertain. There may be little to no difference in peak cough flow outcomes between alternative cough augmentation techniques (216 participants, 9 RCTs). There was insufficient evidence to determine the effect of interventions on measures of gaseous exchange, pulmonary function, quality of life, general function, or participant preference and satisfaction.

AUTHORS' CONCLUSIONS

We are very uncertain about the safety and efficacy of cough augmentation techniques in adults and children with chronic neuromuscular disorders and further studies are needed.

Outcomes following admission to paediatric intensive care: A systematic review

AIM

To describe the long-term health outcomes of children admitted to a paediatric intensive care unit.

METHODS

A systematic review of the literature was performed. Studies of children under 18 years of age admitted to a paediatric intensive care unit were included. Studies focussed on neonatal admissions and investigating specific paediatric intensive care unit interventions or admission diagnoses were excluded. A table was created summarising the study characteristics and main findings. Risk of bias was assessed using the Newcastle Ottawa Quality Assessment Scale for observational studies. Primary outcome was short-, medium- and long-term mortality. Secondary outcomes included measures of neurodevelopment, cognition, physical, behavioural and psychosocial function as well as quality of life.

RESULTS

One hundred and eleven studies were included, most were conducted in high-income countries and focussed on short-term outcomes. Mortality during admission ranged from 1.3 to 50%. Mortality in high-income countries reduced over time but this trend was not evident for lower income countries. Higher income countries had lower standardised mortality rates than lower income countries. Children had an ongoing increased risk of death for up to 10 years following intensive care admission as well as increased physical and psychosocial morbidity compared to healthy controls, with associated poorer quality of life.

CONCLUSIONS

There is limited high-level evidence for the long-term health outcomes of children after intensive care admission, with the burden of related morbidity remaining greater in poorly resourced regions. Further research is recommended to identify risk factors and modifiable factors for poor outcomes, which could be targeted in practice improvement initiatives.

A Core Outcome Set for Pediatric Critical Care

OBJECTIVES

More children are surviving critical illness but are at risk of residual or new health conditions. An evidence-informed and stakeholder-recommended core outcome set is lacking for pediatric critical care outcomes. Our objective was to create a multinational, multistakeholder-recommended pediatric critical care core outcome set for inclusion in clinical and research programs.

DESIGN

A two-round modified Delphi electronic survey was conducted with 333 invited research, clinical, and family/advocate stakeholders. Stakeholders completing the first round were invited to participate in the second. Outcomes scoring greater than 69% "critical" and less than 15% "not important" advanced to round 2 with write-in outcomes considered. The Steering Committee held a virtual consensus conference to determine the final components.

SETTING

Multinational survey.

PATIENTS

Stakeholder participants from six continents representing clinicians, researchers, and family/advocates.

MEASUREMENTS AND MAIN RESULTS

Overall response rates were 75% and 82% for each round. Participants voted on seven Global Domains and 45 Specific Outcomes in round 1, and six Global Domains and 30 Specific Outcomes in round 2. Using overall (three stakeholder groups combined) results, consensus was defined as outcomes scoring greater than 90% "critical" and less than 15% "not important" and were included in the final PICU core outcome set: four Global Domains (Cognitive, Emotional, Physical, and Overall Health) and four Specific Outcomes (Child Health-Related Quality of Life, Pain, Survival, and Communication). Families (n = 21) suggested additional critically important outcomes that did not meet consensus, which were included in the PICU core outcome set-extended.

CONCLUSIONS

The PICU core outcome set and PICU core outcome set-extended are multistakeholder-recommended resources for clinical and research programs that seek to improve outcomes for children with critical illness and their families.

The Influence of High Flow Nasal Cannulae on the Outcomes of Severe Respiratory Disease in Children Admitted to a Regional Hospital in South Africa

In settings where access to paediatric intensive care unit (PICU) facilities is constrained and transfer capacity is limited, High Flow Nasal Cannulae (HFNC) might fill an important service gap. The aim of this study was to document the effect of HFNC on the outcomes of children admitted with severe respiratory disease at a regional hospital without a PICU in Cape Town, South Africa. It is a 4-year retrospective analysis documenting two periods of 2 years each, one before (2013-15) and one after (2016-18) the initiation of HFNC use. Patients were between the ages of 2 months and 13 years and had been admitted to a paediatric ward. Outcomes were defined by the need for transfer to a tertiary hospital, the need for invasive ventilation and death. There were 90 instances of HFNC use with a significant reduction in the number of children who were transferred (59 vs. 31), invasively ventilated (20 vs. 6, p ≤ 0.01) and who died (3 vs. 0, p = 0.02). Before HFNC implementation, there was also a significantly greater proportion of transferred children who remained on low flow nasal cannulae (15 vs. 2, p ≤ 0.001) at the tertiary hospital. Children who failed HFNC use tended to do this within a day of initiation (Median 11 vs. 60 h for success, p ≤ 0.001). There were no complications related to its use. We believe that in our setting the utilization of HFNC has helped to timeously and accurately identify children needing to be transferred and may mitigate against severe respiratory disease progression.

Serious adverse drug reactions at two children's hospitals in South Africa

BACKGROUND

The high HIV prevalence in South Africa may potentially be shaping the local adverse drug reaction (ADR) burden. We aimed to describe the prevalence and characteristics of serious ADRs at admission, and during admission, to two South African children's hospitals.

METHODS

We reviewed the folders of children admitted over sequential 30-day periods in 2015 to the medical wards and intensive care units of each hospital. We identified potential ADRs using a trigger tool developed for this study. A multidisciplinary team assessed ADR causality, type, seriousness, and preventability through consensus discussion. We used multivariate logistic regression to explore associations with serious ADRs.

RESULTS

Among 1050 patients (median age 11 months, 56% male, 2.8% HIV-infected) with 1106 admissions we found 40 serious ADRs (3.8 per 100 drug-exposed admissions), including 9/40 (23%) preventable serious ADRs, and 8/40 (20%) fatal or near-fatal serious ADRs. Antibacterials, corticosteroids, psycholeptics, immunosuppressants, and antivirals were the most commonly implicated drug classes. Preterm neonates and children in middle childhood (6 to 11 years) were at increased risk of serious ADRs compared to infants (under 1 year) and term neonates: adjusted odds ratio (aOR) 5.97 (95% confidence interval 1.30 to 27.3) and aOR 3.63 (1.24 to 10.6) respectively. Other risk factors for serious ADRs were HIV infection (aOR 3.87 (1.14 to 13.2) versus HIV-negative) and increasing drug count (aOR 1.08 (1.04 to 1.12) per additional drug).

CONCLUSIONS

Serious ADR prevalence in our survey was similar to the prevalence found elsewhere. In our setting, serious ADRs were associated with HIV-infection and the antiviral drug class was one of the most commonly implicated. Similar to other sub-Saharan African studies, a large proportion of serious ADRs were fatal or near-fatal. Many serious ADRs were preventable.

The Critical Care Society of Southern Africa Consensus Guideline on ICU Triage and Rationing (ConICTri)

Background

In South Africa (SA), administrators and intensive care practitioners are faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience the consequences of limited resources daily. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are routinely necessary in SA, particularly in the publicly funded health sector.

Purpose

The purpose of this guideline is to utilise the relevant recommendations of the associated consensus meeting document and other internationally accepted principles to develop a guideline to inform frontline triage policy and ensure the best utilisation of adult intensive care in SA, while maintaining the fair distribution of available resources.

Recommendations

An overall conceptual framework for the triage process was developed. The components of the framework were developed on the basis that patients should be admitted preferentially when the likely incremental medical benefit derived from ICU admission justifies admission. An estimate of likely resource use should also form part of the triage decision, with those patients requiring relatively less resources to achieve substantial benefit receiving priority for admission. Thus, the triage system should maximise the benefits obtained from ICU resources available for the community. Where possible, practical examples of what the consensus group agreed would be considered appropriate practice under specified South African circumstances were provided, to assist clinicians with practical decision-making. It must be stressed that this guideline is not intended to be prescriptive for individual hospital or regional practice, and hospitals and regions are encouraged to develop specified local guidelines with locally relevant examples. The guideline should be reviewed and revised if appropriate within 5 years.

Conclusion

In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, this guideline has been developed to guide policy-making and assist frontline triage decision-making in SA. This document is not a complete plan for quality practice, but rather a template to support frontline clinicians, guide administrators and inform the public regarding appropriate triage decision-making.

The Critical Care Society of Southern Africa Consensus Statement on ICU Triage and Rationing (ConICTri)

Background

In South Africa (SA), intensive care is faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience daily the consequences of limited resources. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are frequently necessary in SA, particularly in the publicly funded health sector.

Purpose

The purpose of this consensus statement is to examine key questions that arise when considering the status of ICU resources in SA, and more specifically ICU admission, rationing and triage decisions. The accompanying guideline in this issue is intended to guide frontline triage policy and ensure the best utilisation of intensive care in SA, while maintaining a fair distribution of available resources. Fair and efficient triage is important to ensure the ongoing provision of high-quality care to adult patients referred for intensive care.

Recommendations

In response to 14 key questions developed using a modified Delphi technique, 29 recommendations were formulated and graded using an adapted GRADE score. The 14 key questions addressed the status of the provision of ICU services in SA, the degree of resource restriction, the efficiency of resource management, the need for triage, and how triage could be most justly implemented. Important recommendations included the need to formally recognise and accurately quantify the provision of ICU services in SA by national audit; actively seek additional resources from governmental bodies; consider methods to maximise the efficiency of ICU care; evaluate lower level of care alternatives; develop a triage guideline to assist policy-makers and frontline practitioners to implement triage decisions in an efficient and fair way; measure and audit the consequence of triage; and promote research to improve the accuracy and consistency of triage decisions. The consensus document and guideline should be reviewed and revised appropriately within 5 years.

Conclusion

In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, recommendations and a guideline have been developed to guide policy-making and assist frontline triage decision-making in SA. These documents are not a complete plan for quality practice but rather the beginning of a long-term initiative to engage clinicians, the public and administrators in appropriate triage decision-making, and promote systems that will ultimately maximise the efficient and fair use of available ICU resources.

Effects of saline or albumin fluid bolus in resuscitation: evidence from re-analysis of the FEAST trial

BACKGROUND

Fluid resuscitation is the recommended management of shock, but increased mortality in febrile African children in the FEAST trial. We hypothesised that fluid bolus-induced deaths in FEAST would be associated with detectable changes in cardiovascular, neurological, or respiratory function, oxygen carrying capacity, and blood biochemistry.

METHODS

We developed composite scores for respiratory, cardiovascular, and neurological function using vital sign data from the FEAST trial, and used them to compare participants from FEAST with those from four other cohorts and to identify differences between the bolus (n=2097) and no bolus (n=1044) groups of FEAST. We calculated the odds of adverse outcome for each ten-unit increase in baseline score using logistic regression for each cohort. Within FEAST participants, we also compared haemoglobin and plasma biochemistry between bolus and non-bolus patients, assessed the effects of these factors along with the vital sign scores on the contribution of bolus to mortality using Cox proportional hazard models, and used Bayesian clustering to identify subgroups that differed in response to bolus. The FEAST trial is registered with ISRCTN, number ISRCTN69856593.

FINDINGS

Increasing respiratory (odds ratio 1·09, 95% CI 1·07-1·11), neurological (1·26, 1·21-1·31), and cardiovascular scores (1·09, 1·05-1·14) were associated with death in FEAST (all p<0·0001), and with adverse outcomes for specific scores in the four other cohorts. In FEAST, fluid bolus increased respiratory and neurological scores and decreased cardiovascular score at 1 h after commencement of the infusion. Fluid bolus recipients had mean 0·33 g/dL (95% CI 0·20-0·46) reduction in haemoglobin concentration after 8 h (p<0·0001), and at 24 h had a decrease of 1·41 mEq/L (95% CI 0·76-2·06; p=0·0002) in mean base excess and increase of 1·65 mmol/L (0·47-2·8; p=0·0070) in mean chloride, and a decrease of 0·96 mmol/L (0·45 to 1·47; p=0·0003) in bicarbonate. There were similar effects of fluid bolus in three patient subgroups, identified on the basis of their baseline characteristics. Hyperchloraemic acidosis and respiratory and neurological dysfunction induced by saline or albumin bolus explained the excess mortality due to bolus in Cox survival models.

INTERPRETATION

In the resuscitation of febrile children, albumin and saline boluses can cause respiratory and neurological dysfunction, hyperchloraemic acidosis, and reduction in haemoglobin concentration. The findings support the notion that fluid resuscitation with unbuffered electrolyte solutions may cause harm and their use should be cautioned. The effects of lower volumes of buffered solutions should be evaluated further.

FUNDING

Medical Research Council, Department for International Development, National Institute for Health Research, Imperial College Biomedical Research Centre.

Consensus Recommendations for RBC Transfusion Practice in Critically Ill Children From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative

OBJECTIVES

To date, there are no published guidelines to direct RBC transfusion decision-making specifically for critically ill children. We present the recommendations from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

DESIGN

Consensus conference series of multidisciplinary, international experts in RBC transfusion management of critically ill children.

SETTING

Not applicable.

INTERVENTION

None.

SUBJECTS

Children with, or children at risk for, critical illness who receive or are at risk for receiving a RBC transfusion.

METHODS

A panel of 38 content and four methodology experts met over the course of 2 years to develop evidence-based, and when evidence lacking, expert consensus-based recommendations regarding decision-making for RBC transfusion management and research priorities for transfusion in critically ill children. The experts focused on nine specific populations of critically ill children: general, respiratory failure, nonhemorrhagic shock, nonlife-threatening bleeding or hemorrhagic shock, acute brain injury, acquired/congenital heart disease, sickle cell/oncology/transplant, extracorporeal membrane oxygenation/ventricular assist/ renal replacement support, and alternative processing. Data to formulate evidence-based and expert consensus recommendations were selected based on searches of PubMed, EMBASE, and Cochrane Library from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.

MEASUREMENTS AND RESULTS

The Transfusion and Anemia Expertise Initiative consensus conference developed and reached consensus on a total of 102 recommendations (57 clinical [20 evidence based, 37 expert consensus], 45 research recommendations). All final recommendations met agreement, defined a priori as greater than 80%. A decision tree to aid clinicians was created based on the clinical recommendations.

CONCLUSIONS

The Transfusion and Anemia Expertise Initiative recommendations provide important clinical guidance and applicable tools to avoid unnecessary RBC transfusions. Research recommendations identify areas of focus for future investigation to improve outcomes and safety for RBC transfusion.

Recommendations on RBC Transfusion in General Critically Ill Children Based on Hemoglobin and/or Physiologic Thresholds From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative

OBJECTIVES

To present the consensus recommendations and supporting literature for RBC transfusions in general critically ill children from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

DESIGN

Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children.

METHODS

The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based recommendations and research priorities regarding RBC transfusions in critically ill children. The subgroup on RBC transfusion in general critically ill children included six experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 30, 2017, using a combination of keywords to define concepts of RBC transfusion and critically ill children. Recommendation consensus was obtained using the Research and Development/UCLA Appropriateness Method. The results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.

RESULTS

Three adjudicators reviewed 4,399 abstracts; 71 papers were read, and 17 were retained. Three papers were added manually. The general Transfusion and Anemia Expertise Initiative subgroup developed, and all Transfusion and Anemia Expertise Initiative members voted on two good practice statements, six recommendations, and 11 research questions; in all instances, agreement was reached (> 80%). The good practice statements suggest a framework for RBC transfusion in PICU patients. The good practice statements and recommendations focus on hemoglobin as a threshold and/or target. The research questions focus on hemoglobin and physiologic thresholds for RBC transfusion, alternatives, and risk/benefit ratio of transfusion.

CONCLUSIONS

Transfusion and Anemia Expertise Initiative developed pediatric-specific good practice statements and recommendations regarding RBC transfusion management in the general PICU population, as well as recommendations to guide future research priorities. Clinical recommendations emphasized relevant hemoglobin thresholds, and research recommendations emphasized a need for further understanding of physiologic thresholds, alternatives to RBC transfusion, and hemoglobin thresholds in populations with limited pediatric literature.

Acute flaccid paralysis in South African children: Causes, respiratory complications and neurological outcome

AIM

To describe the causes, clinical presentation and neurological outcome of acute flaccid paralysis in children.

METHODS

A retrospective study in a tertiary paediatric hospital in South Africa. Data on clinical presentation, respiratory complications and long-term neurological outcomes of children presenting with acute flaccid paralysis were collected. Logistic regression analysis was applied to determine predictors for the need of mechanical ventilation.

RESULTS

The study included 119 patients, 99 of whom had Guillain-Barré syndrome (GBS); 47 patients (39.5%) required mechanical ventilation. Backward logistic regression analysis revealed that bulbar dysfunction (P < 0.001), autonomic dysfunction (P = 0.003) and upper limb paralysis (P = 0.038) significantly predicted the need for mechanical ventilation. EuroQol-5D scores of self-care problems and usual activities after discharge significantly declined over time.

CONCLUSIONS

In this large series from Africa, GBS was the main cause of acute flaccid paralysis in children and was associated with significant morbidity. Other causes of acute flaccid paralysis mimicking GBS were not uncommon and should be excluded in this setting.

Home Ventilation in South African Children: Do Socioeconomic Factors Matter?

Poor socioeconomic circumstances and poverty are perceived to be barriers to successful home ventilation. Pediatric home ventilation has escalated rapidly in high-income countries but is underreported and underfunded in low-middle income countries. A retrospective chart review covering the past 20 years was carried out at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa, a low-middle income country. Data collection included demographics, socioeconomic and family factors, clinical information, and ventilation-related information. Fifty-five children received home ventilation between 1994 and December 2015 from a median age of 3.5 years (range 0.4-17.6). Thirty-nine (71%) children received invasive ventilation and 16 (29%) children received mask-assisted ventilation. Most common primary diagnosis was a neuromuscular disease (60%). Twenty-six children (47%) were still on home ventilation in December 2015, 8 (15%) had been weaned off ventilation, and 21 (38%) had died. Median time between initiation of ventilation and discharge was 15 days (range 1-52) for mask-assisted ventilation and 88 days (8-991) for tracheostomy-assisted ventilation. Of the total 40 readmissions in the first year of home ventilation, 34 (85%) were emergency readmissions mainly necessitated by respiratory infections (n = 26; 65%). Despite a high prevalence of socioeconomic challenges, 89% of the children were successfully discharged on home ventilation. Main cause of death was acute infections (n = 11; 52%). Pediatric home ventilation in South Africa is feasible despite difficult socioeconomic circumstances. Survival outcome was comparable with that of high-income countries. However, a high level of psychosocial support and interventions is needed.

Retrospective cross-sectional review of survival rates in critically ill children admitted to a combined paediatric/neonatal intensive care unit in Johannesburg, South Africa, 2013-2015

OBJECTIVE

Report on survival to discharge of children in a combined paediatric/neonatal intensive care unit (PNICU).

DESIGN AND SETTING

Retrospective cross-sectional record review.

PARTICIPANTS

All children (medical and surgical patients) admitted to PNICU between 1 January 2013 and 30 June 2015.

OUTCOME MEASURES

Primary outcome-survival to discharge. Secondary outcomes-disease profiles and predictors of mortality in different age categories.

RESULTS

There were 1454 admissions, 182 missing records, leaving 1272 admissions for review. Overall mortality rate was 25.7% (327/1272). Mortality rate was 41.4% (121/292) (95% CI 35.8% to 47.1%) for very low birthweight (VLBW) babies, 26.6% (120/451) (95% CI 22.5% to 30.5%) for bigger babies and 16.2% (86/529) (95% CI 13.1% to 19.3%) for paediatric patients. Risk factors for a reduced chance of survival to discharge in paediatric patients included postcardiac arrest (OR 0.21, 95% CI 0.09 to 0.49), inotropic support (OR 0.085, 95% CI 0.04 to 0.17), hypernatraemia (OR 0.16, 95% CI 0.04 to 0.6), bacterial sepsis (OR 0.32, 95% CI 0.16 to 0.65) and lower respiratory tract infection (OR 0.54, 95% CI 0.30 to 0.97). Major birth defects (OR 0.44, 95% CI 0.26 to 0.74), persistent pulmonary hypertension of the new born (OR 0.44, 95% CI 0.21 to 0.91), metabolic acidosis (OR 0.23, 95% CI 0.12 to 0.74), inotropic support (OR 0.23, 95% CI 0.12 to 0.45) and congenital heart defects (OR 0.29, 95% CI 0.13 to 0.62) predicted decreased survival in bigger babies. Birth weight (OR 0.997, 95% CI 0.995 to 0.999), birth outside the hospital (OR 0.21, 95% CI 0.05 to 0.84), HIV exposure (OR 0.54, 95% CI 0.30 to 0.99), resuscitation at birth (OR 0.49, 95% CI 0.25 to 0.94), metabolic acidosis (OR 0.25, 95% CI 0.10 to 0.60) and necrotising enterocolitis (OR 0.23, 95% CI 0.12 to 0.46) predicted poor survival in VLBW babies.

CONCLUSIONS

Ongoing mortality review is essential to improve provision of paediatric critical care.

Paediatric tracheostomy and ventilation home care with challenging socio-economic circumstances in South Africa

BACKGROUND

Children discharged home with a tracheostomy need a safe home environment and access to health care. We described the indications, clinical characteristics, socio-economic circumstances and outcomes of children enroled in a tracheostomy home care programme in South Africa.

METHODS

We performed a retrospective chart review of children receiving a tracheostomy and enroled in the Breatheasy programme at the Red Cross War Memorial Children's Hospital, Cape Town. Medical and background characteristics were recorded. Influences of socio-economic variables and underlying medical conditions on length of hospital stay, unplanned readmissions and mortality in the first year after discharge were evaluated.

RESULTS

In the period 2008-2012, 157 patients were discharged home with a tracheostomy. Median hospital stay after tracheostomy insertion was significantly longer when parents had incomplete schooling compared to completed secondary school or higher education; 30 days (IQR 21-53) versus 23 days (IQR 16-33), respectively. Unplanned readmissions in the first year were documented for 72 patients (45.9%). The risk for unplanned readmission was 2.6 times higher in families with substance abuse the risk of respiratory infections was two-fold in case of household cigarette smoke exposure (OR 2.3.) Tracheostomy-related mortality was low (1.2%). An underlying medical condition was the only independent significant risk factor for mortality (OR 5.1, 95% CI 1.8-14.3).

CONCLUSION

This study demonstrates that despite difficult socio-economic circumstances, home ventilation of children with a tracheostomy is safe, provided caregivers are adequately trained and supported.

Pathways to Care for Critically Ill or Injured Children: A Cohort Study from First Presentation to Healthcare Services through to Admission to Intensive Care or Death

Purpose

Critically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided.

Methods

A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors.

Results

The study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identification of the critically ill, assessment of severity, inadequate resuscitation, and delays in decision making and referral. Children were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 185 (74%) of children, and death prior to PICU admission was avoidable in 17/30 (56.7%) of children.

Conclusions

The study presents a novel methodology, examining quality of care across an entire system, and highlighting the complexity of the pathway and the modifiable events amenable to interventions, that could reduce mortality and morbidity, and optimize utilization of scarce critical care resources; as well as demonstrating the importance of continuity and quality of care.

The effects of prone and supine positions on the regional distribution of ventilation in infants and children using electrical impedance tomography

Background

Positioning of ill children is often used to optimise ventilation–perfusion matching, thereby improving oxygenation.

Objectives

To determine the effects of supine and prone positions, and different head positions, on the distribution of ventilation in healthy, spontaneously breathing infants and children between the ages of 6 months and 9 years.

Methods

Electrical impedance tomography measurements were recorded from participants in supine and prone positions. Head positions included the head turned to the left and right in supine and prone positions, and in the midline in the supine position. Distribution of ventilation was described using end-expiratory–end-inspiratory relative impedance change.

Results

A total of 56 participants (boys = 31 [55%]; girls = 25 [45%]) were studied. The dorsal lung was significantly better ventilated than the ventral lung (P < 0.001) in both body positions. The majority of participants (83%) had greater ventilation in the dorsal lung in both positions, whilst five participants (10%) demonstrated consistently better ventilation in the non-dependent lung in both positions. Head position had no effect on the distribution of ventilation.

Conclusions

This study demonstrates that the distribution of ventilation in healthy, spontaneously breathing infants and children in supine and prone positions is not as straightforward as previously thought, with no clear reversal of the adult pattern evident.

The Durban World Congress Ethics Round Table Conference Report: I. Differences between withholding and withdrawing life-sustaining treatments

INTRODUCTION

Withholding life-sustaining treatments (WHLST) and withdrawing life-sustaining treatments (WDLST) occur in most intensive care units (ICUs) around the world to varying degrees.

METHODS

Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were approached to participate in an ethics round table. Participants were asked if they agreed with the statement "There is no moral difference between withholding and withdrawing a mechanical ventilator." Differences between WHLST and WDLST were discussed. Official statements relating to WHLST and WDLST from intensive care societies, professional bodies, and government statements were sourced, documented, and compared.

RESULTS

Sixteen respondents stated that there was no moral difference between withholding or withdrawing a mechanical ventilator, 2 were neutral, and 4 stated that there was a difference. Most ethicists and medical organizations state that there is no moral difference between WHLST and WDLST. A review of guidelines noted that all but 1 of 29 considered WHLST and WDLST as ethically or legally equivalent.

CONCLUSIONS

Most respondents, practicing intensivists, stated that there is no difference between WHLST and WDLST, supporting most ethicists and professional organizations. A minority of physicians still do not accept their equivalency.

The Durban World Congress Ethics Round Table Conference Report: III. Withdrawing Mechanical ventilation--the approach should be individualized

PURPOSE

The purpose of this study is to determine the approaches used in withdrawing mechanical ventilator support.

MATERIALS AND METHODS

Speakers from the invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were asked to provide a detailed description of individual approaches to the process of withdrawal of mechanical ventilation.

RESULTS

Twenty-one participants originating from 13 countries, responded to the questionnaire. Four respondents indicated that they do not practice withdrawal of mechanical ventilation, and another 4 indicated that their approach is highly variable depending on the clinical scenario. Immediate withdrawal of ventilation was practiced by a large number of the respondents (7/16; 44%). A terminal wean was practiced by just more than a third of the respondents (6/16; 38%). Extubation was practiced in more than 70% of instances among most of the respondents (9/17; 53%). Two of the respondents (2/17; 12%) indicated that they would extubate all patients, whereas 14 respondents indicated that they would not extubate all their patients. The emphasis was on tailoring the approach used to suit individual case scenarios.

CONCLUSIONS

Withdrawing of ventilator support is not universal. However, even when withdrawing mechanical ventilation is acceptable, the approach to achieve this end point is highly variable and individualized.

Mechanical insufflation-exsufflation for people with neuromuscular disorders

BACKGROUND

People with neuromuscular disorders (NMDs) may have weak respiratory (breathing) muscles which makes it difficult for them to effectively cough and clear mucus from the lungs. This places them at risk of recurrent chest infections and chronic lung disease. Mechanical insufflation-exsufflation (MI-E) is one of a number of techniques available to improve cough efficacy and mucus clearance.

OBJECTIVES

To determine the efficacy and safety of MI-E in people with NMDs.

SEARCH METHODS

On 7 October 2013, we searched the following databases from inception: the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL (The Cochrane Library), MEDLINE, and EMBASE. We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform for ongoing trials. We conducted handsearches of reference lists and conference proceedings.

SELECTION CRITERIA

We considered randomised or quasi-randomised clinical trials, and randomised cross-over trials of MI-E used to assist airway clearance in people with a NMD and respiratory insufficiency. We considered comparisons of MI-E with no treatment, or alternative cough augmentation techniques.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, extracted data, and assessed risk of bias in included studies according to standard Cochrane methodology. The primary outcome was mortality throughout follow-up or at six months follow-up.

MAIN RESULTS

Five studies with a total of 105 participants were found to be eligible for inclusion in this review. All included trials were short-term studies (two days or less), measuring immediate effects of the interventions. There was insufficient detail in the reports to assess methods of randomisation and allocation concealment. All five studies were at a high risk of bias from lack of blinding. The studies did not report on mortality, morbidity, quality of life, serious adverse events or any of the other prespecified outcomes. One study was a randomised cross-over trial conducted over two days, in which investigators applied two interventions twice daily in randomly assigned order, with a reverse cross-over the following day. Four studies applied multiple interventions for cough augmentation to each participant, in random order. One study reported fatigue as an adverse effect of MI-E, using a visual analogue scale. Peak cough expiratory flow (PCEF) was the most common outcome measure and was reported in four studies. Based on three studies, MI-E may improve PCEF compared to an unassisted cough. All interventions increased PCEF to the critical level necessary for mucus clearance. The included studies did not clearly show that MI-E improves cough expiratory flow more than other cough augmentation techniques. Based on one study, which was at risk of assessor bias, the addition of MI-E may reduce treatment time when added to a standard airway clearance regimen with manually assisted cough. MI-E appeared to be as well tolerated as other cough augmentation techniques, based on three studies which reported comfort visual analogue scores.

AUTHORS' CONCLUSIONS

The results of this review do not provide sufficient evidence on which to base clinical practice as we were unable to address important short- and long-term outcomes, including adverse effects of MI-E. There is currently insufficient evidence for or against the use of MI-E in people with NMDs. Further randomised controlled clinical trials are needed to test the safety and efficacy of MI-E.

Continuous flow peritoneal dialysis: first experience in children with acute renal failure

BACKGROUND AND OBJECTIVES

Acute renal failure can be treated with different dialysis modalities, depending on patient characteristics and hospital resources. Peritoneal dialysis (PD) can be first choice in situations like hypotension, disturbed coagulation, or difficult venous access. The main disadvantage of PD is the relatively limited efficacy. The aim of this study was to investigate whether continuous flow peritoneal dialysis (CFPD) is a more effective treatment than conventional PD in acute renal failure.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A pilot study was performed at The Red Cross University Hospital in Cape Town in six patients. Patients were treated with both CFPD and conventional PD for 8 to 16 hours. CFPD was performed with two bedside-placed catheters. After initial filling, dialysate flow rate (100 ml/1.73 m2 per minute) was maintained with an adapted continuous venovenous hemofiltration machine. Ultrafiltration flow rate was set at 2.5 ml/1.73 m2 per minute.

RESULTS

Mean ultrafiltration was 0.20 ml/1.73 m2 per minute with conventional PD versus 1.8 ml/1.73 m2 per minute with CFPD. Mean clearances of urea and creatinine were 5.0 and 7.6 ml/1.73 m2 per minute with conventional PD versus 15.0 and 28.8 ml/1.73 m2 per minute with CFPD, respectively. No complications occurred.

CONCLUSIONS

In this first report of CFPD in six pediatric patients with acute renal failure, CFPD was on average three to five times more effective for urea and creatinine clearance and ultrafiltration than conventional PD, without any complications observed. CFPD has the ability to improve therapy for acute renal failure.

A recruitment manoeuvre performed after endotracheal suction does not increase dynamic compliance in ventilated paediatric patients: a randomised controlled trial

QUESTION

Does a recruitment manoeuvre after suctioning have any immediate or short-term effect on ventilation and gas exchange in mechanically-ventilated paediatric patients?

DESIGN

Randomised controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

Forty-eight paediatric patients with heterogeneous lung pathology. Fourteen patients were subsequently excluded from analysis due to large leaks around the endotracheal tube.

INTERVENTION

The experimental group received a single standardised suctioning procedure followed five minutes later by a standardised recruitment manoeuvre. The control group received only the single suctioning procedure.

OUTCOME MEASURES

Measurements of ventilation (dynamic lung compliance, expiratory airway resistance, mechanical and spontaneous expired tidal volume, respiratory rate) and gas exchange (transcutaneous oxygen saturation) were recorded, on three occasions before and on two occasions after the recruitment manoeuvre, using a respiratory profile monitor.

RESULTS

There was no difference between the experimental and the control group in dynamic compliance, expired airway resistance, or oxygen saturation either immediately after the recruitment manoeuvre, or after 25 minutes. The experimental group decreased mechanical expired tidal volume by 0.3 ml/kg (95% CI 0.1 to 0.6), increased spontaneous expired tidal volume by 0.3 ml/kg (95% CI 0.0 to 0.6), and increased total respiratory rate by 3 bpm (95% CI 1 to 4) immediately after the recruitment manoeuvre compared with the control group, but these differences disappeared after 25 minutes.

CONCLUSION

There is insufficient evidence to support performing recruitment manoeuvres after suctioning infants and children.

Relationship between fluid management, changes in serum sodium and outcome in hypernatraemia associated with gastroenteritis

OBJECTIVE

To describe the relationship between fluid management, serum sodium and outcome in critically ill children with hypernatraemic gastroenteritis.

METHODS

A retrospective study of 57 children with hypernatraemic gastroenteritis admitted to a paediatric intensive care unit in Cape Town, South Africa. Data were collected on fluid management, serum electrolytes and adverse outcome (seizures, new neurological deficit and mortality) and analysed using univariate and multivariate statistics.

RESULTS

Median admission sodium was 165 mmol/L (145-199). Median volume of intravenous rehydration fluid was 6 mL/kg/h (144 mL/kg/day), with sodium concentration of 61 mmol/L (0-154 mmol/L), resulting in a median fall in sodium of 0.6 mmol/L/h (14.4 mmol/L/day). Fourteen children (25%) had seizures during rehydration, four children (7%) died and five children (9%) developed neurological deficit. Median admission sodium in children with adverse outcome was 172 mmol/L, with rate of fall of 0.63 mmol/L/h, compared with median admission sodium of 163 mmol/L and rate of fall of 0.48 mmol/L/h, in children with good outcome (P=0.068 and P=0.08, respectively). Median sodium content of intravenous solution was 61 mmol/L in both groups (P=0.68). Multivariate analysis demonstrated that neither sodium content of intravenous solution (P=0.59), nor rate of fall of sodium (P=0.31), was independently associated with adverse outcome.

CONCLUSIONS

Rehydration in hypernatraemic gastroenteritis using intravenous solutions containing 61 mmol/L sodium would be expected to correct serum sodium at a rate of approximately 0.6 mmol/L/h. Neither sodium content of the intravenous solution, nor rate of correction of sodium, was independently associated with adverse outcome.

The lactate:pyruvate ratio following open cardiac surgery in children

OBJECTIVE

To explore the relationship between lactate:pyruvate ratio, hyperlactataemia, metabolic acidosis, and morbidity.

DESIGN AND SETTING

Prospective observational study in the paediatric intensive care unit (PICU) of a university hospital.

PATIENTS

Ninety-seven children after open cardiac surgery. Most children (94%) fell into low-moderate operative risk categories; observed PICU mortality was 1%.

INTERVENTIONS

Blood was sampled on admission for acid-base analysis, lactate, and pyruvate. Metabolic acidosis was defined as standard bicarbonate lower than 22 mmol/l, raised lactate as higher than 2 mmol/l, and raised lactate:pyruvate ratio as higher than 20.

MEASUREMENTS AND RESULTS

Median cardiopulmonary bypass and aortic cross-clamp times were 80 and 46 min. Metabolic acidosis occurred in 74%, hyperlactataemia in 42%, and raised lactate:pyruvate ratio in 45% of children. In multivariate analysis lactate:pyruvate ratio increased by 6.4 in children receiving epinephrine infusion and by 0.4 per 10 min of aortic cross-clamp. Duration of inotropic support increased by 0.29 days, ventilatory support by 0.27 days, and PICU stay by 0.42 days, for each 1 mmol/l increase in lactate. Neither standard bicarbonate nor lactate:pyruvate ratio were independently associated with prolongation of PICU support.

CONCLUSIONS

Elevated lactate:pyruvate ratio was common in children with mild metabolic acidosis and low PICU mortality. Hyperlactataemia, but not elevated lactate:pyruvate ratio or metabolic acidosis, was associated with prolongation of PICU support. Routine measurement of lactate:pyruvate ratio is not warranted for children in low-moderate operative risk categories.

Short-term mortality and implementation of antiretroviral treatment for critically ill HIV-infected children in a developing country

OBJECTIVE

To describe the short-term outcome of critically ill HIV-infected children with access to highly active antiretroviral therapy (HAART) in a developing region.

METHODS

Prospective observational study conducted in a paediatric teaching hospital in Cape Town, South Africa. All children admitted to the paediatric intensive care unit (PICU) with suspected HIV infection were screened. Data are n (%) with 95% confidence intervals.

RESULTS

Sixty eight of 96 HIV antibody-positive children, median age 3 months, were confirmed HIV-infected. Predicted PICU mortality was 0.42. Fifty one children (75%; 95% CI 65 to 85%) survived to PICU discharge, but hospital survival was only 51% (95% CI 40 to 63%). Limitation of intervention (LOI) decisions were a factor in the majority of PICU and ward deaths. Twenty one PICU survivors (31%; 95% CI 20 to 42%) commenced HAART, and two children were already on treatment. Nineteen children (28%) were considered to be established on HAART after 1 month. Thirteen HIV-infected children (19%; 95% CI 10 to 28%), representing 25% (95% CI 14 to 37%) of all PICU survivors, and 68% (95% CI 48 to 89%) of those PICU survivors who were established on HAART remain well on treatment after median 350 days.

CONCLUSION

The majority of HIV-infected children survived to discharge from PICU, but only half survived to hospital discharge. LOI decisions, usually made in PICU, directly influenced short-term survival and the opportunity to commence HAART. Although few critically ill HIV-infected children survived to become established on HAART, the long-term outcome of children on HAART is encouraging and warrants further investigation.

Surgical treatment for "brain compartment syndrome" in children with severe head injury

OBJECTIVES

Traumatic brain injury accounts for a high percentage of deaths in children. Raised intracranial pressure (ICP) due to brain swelling within the closed compartment of the skull leads to death or severe neurological disability if not effectively treated. We report our experience with 12 children who presented with cerebral herniation due to traumatic brain swelling in whom decompressive craniectomy was used as an emergency.

DESIGN

Prospective, observational.

SETTING

Red Cross Children's Hospital.

SUBJECTS

Children with severe traumatic brain injury and cerebral swelling.

OUTCOME MEASURES

Computed tomography (CT) scanning, ICP control, clinical outcome.

RESULTS

Despite the very poor clinical condition of these children preoperatively, aggressive management of the raised pressure resulted in unexpectedly good outcomes.

CONCLUSION

Aggressive surgical measures to decrease ICP in the emergency situation can be of considerable benefit; the key concepts are selection of appropriate patients and early intervention.

Effect of endotracheal suction on lung dynamics in mechanically-ventilated paediatric patients

Endotracheal suctioning is performed regularly in ventilated infants and children to remove obstructive secretions. The effect of suctioning on respiratory mechanics is not known. This study aimed to determine the immediate effect of endotracheal suctioning on dynamic lung compliance, tidal volume, and airway resistance in mechanically-ventilated paediatric patients by means of a prospective observational clinical study. Lung mechanics were recorded for five minutes before and five minutes after a standardised suctioning procedure in 78 patients intubated with endotracheal tubes < or = 4.0 mm internal diameter. Twenty-four patients with endotracheal tube leaks > or = 20% were excluded from analysis. There was a significant overall decrease in dynamic compliance (p < 0.001) and mechanical expired tidal volume (p = 0.03) following suctioning with no change in the percentage endotracheal tube leak (p = 0.41). The change in dynamic compliance was directly related to both endotracheal tube and catheter sizes. There was no significant change in expiratory or inspiratory airway resistance following suctioning (p > 0.05). Although the majority of patients (68.5%) experienced a drop in dynamic compliance following suctioning, dynamic compliance increased in 31.5% of patients after the procedure. This study demonstrates that endotracheal suctioning frequently causes an immediate drop in dynamic compliance and expired tidal volume in ventilated children with variable lung pathology, intubated with small endotracheal tubes, probably indicating loss of lung volume caused by the suctioning procedure. There is no evidence that suctioning reduces airway resistance.

Hyperchloraemic metabolic acidosis following open cardiac surgery

AIMS

To describe acid-base derangements in children following open cardiac surgery on cardiopulmonary bypass (CPB), using the Fencl-Stewart strong ion approach.

METHODS

Prospective observational study set in the paediatric intensive care unit (PICU) of a university children's hospital. Arterial blood gas parameters, serum electrolytes, strong ion difference, strong ion gap (SIG), and partitioned base excess (BE) were measured and calculated on admission to PICU.

RESULTS

A total of 97 children, median age 57 months (range 0.03-166), median weight 14 kg (range 2.1-50), were studied. Median CPB time was 80 minutes (range 17-232). Predicted mortality was 2% and there was a single non-survivor. These children showed mild metabolic acidosis (median standard bicarbonate 20.1 mmol/l, BE -5.1 mEq/l) characterised by hyperchloraemia (median corrected Cl 113 mmol/l), and hypoalbuminaemia (median albumin 30 g/l), but no significant excess unmeasured anions or cations (median SIG 0.7 mEq/l). The major determinants of the net BE were the chloride and albumin components (chloride effect -4.8 mEq/l, albumin effect +3.4 mEq/l). Metabolic acidosis occurred in 72 children (74%) but was not associated with increased morbidity. Hyperchloraemia was a causative factor in 53 children (74%) with metabolic acidosis. Three (4%) hyperchloraemic children required adrenaline for inotropic support, compared to eight children (28%) without hyperchloraemia. Hypoalbuminaemia was associated with longer duration of inotropic support and PICU stay.

CONCLUSIONS

In these children with low mortality following open cardiac surgery, hypoalbuminaemia and hyperchloraemia were the predominant acid-base abnormalities. Hyperchloraemia was associated with reduced requirement for adrenaline therapy. It is suggested that hyperchloraemic metabolic acidosis is a benign phenomenon that should not prompt escalation of haemodynamic support. By contrast, hypoalbuminaemia, an alkalinising force, was associated with prolonged requirement for intensive care.

Diagnosis and management of community-acquired pneumonia in childhood--South African Thoracic Society Guidelines

BACKGROUND

Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in South African children. The incidence, severity and spectrum of childhood pneumonia have changed owing to the HIV epidemic. Increasing emergence of antimicrobial resistance necessitates a rational approach to the use of antibiotics in pneumonia management.

OBJECTIVE

To develop guidelines for the diagnosis, management and prevention of CAP in South African children.

METHODS

The Paediatric Assembly of the South African Thoracic Society established five expert subgroups to address: (i) epidemiology and aetiology; (ii) diagnosis; (iii) antibiotic treatment; (iv) supportive therapy; and (v) prevention of CAP. Each subgroup developed a position paper based on the available published evidence; in the absence of evidence, expert opinion was accepted. After peer review and revision, the position papers were synthesised into an overall guideline which was further reviewed and revised.

RECOMMENDATIONS

Recommendations based on epidemiological factors include a diagnostic approach, investigations, supportive therapy, appropriate antibiotic treatment and preventive strategies. Specific recommendations for HIV-infected children are provided.

VALIDATION

These guidelines are based on the available evidence supplemented by the consensus opinion of South African experts in paediatrics, paediatric pulmonology, radiology, infectious diseases and microbiology. Published international guidelines have also been consulted.

Imaging findings in a patient with eosinophilic pneumonia (Loffler's syndrome)

Löffler’s syndrome was initiallydescribed as a disorder characterisedby transient pulmonary infiltratesaccompanied by peripheral bloodeosinophilia in asymptomatic ormildly ill patients. Abnormal chestradiographic findings are said tooccur in 95% of patients but there areno descriptions of CT findings. Thereare many causes of this syndrome, butin developing countries the mostcommon presentation remains secondaryto the migratory larvae ofcommon intestinal helminths. Wepresent the clinical and radiologicalfeatures of a boy with clearly definedLöffler's syndrome due to larvalmigration.