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Gelbart B, Shann F. The combination of systemic corticosteroids and inhaled adrenaline for bronchiolitis. Lancet 2024; 403:1335. [PMID: 38582555 DOI: 10.1016/s0140-6736(23)01224-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 06/12/2023] [Indexed: 04/08/2024]
Affiliation(s)
- Ben Gelbart
- Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC 3052, Australia.
| | - Frank Shann
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
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2
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Long E, Borland ML, George S, Jani S, Tan E, Neutze J, Phillips N, Kochar A, Craig S, Lithgow A, Rao A, Dalziel S, Oakley E, Hearps S, Singh S, Gelbart B, McNab S, Balamuth F, Weiss S, Kuppermann N, Williams A, Babl FE. Sepsis epidemiology in Austral ian and New Zealand children (SENTINEL): protocol for a multicountry prospective observational study. BMJ Open 2024; 14:e077471. [PMID: 38216206 PMCID: PMC10806766 DOI: 10.1136/bmjopen-2023-077471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 12/20/2023] [Indexed: 01/14/2024] Open
Abstract
INTRODUCTION Sepsis affects 25.2 million children per year globally and causes 3.4 million deaths, with an annual cost of hospitalisation in the USA of US$7.3 billion. Despite being common, severe and expensive, therapies and outcomes from sepsis have not substantially changed in decades. Variable case definitions, lack of a reference standard for diagnosis and broad spectrum of disease hamper efforts to evaluate therapies that may improve sepsis outcomes. This landscape analysis of community-acquired childhood sepsis in Australia and New Zealand will characterise the burden of disease, including incidence, severity, outcomes and cost. Sepsis diagnostic criteria and risk stratification tools will be prospectively evaluated. Sepsis therapies, quality of care, parental awareness and understanding of sepsis and parent-reported outcome measures will be described. Understanding these aspects of sepsis care is fundamental for the design and conduct of interventional trials to improve childhood sepsis outcomes. METHODS AND ANALYSIS This prospective observational study will include children up to 18 years of age presenting to 12 emergency departments with suspected sepsis within the Paediatric Research in Emergency Departments International Collaborative network in Australia and New Zealand. Presenting characteristics, management and outcomes will be collected. These will include vital signs, serum biomarkers, clinician assessment of severity of disease, intravenous fluid administration for the first 24 hours of hospitalisation, organ support therapies delivered, antimicrobial use, microbiological diagnoses, hospital and intensive care unit length-of-stay, mortality censored at hospital discharge or 30 days from enrolment (whichever comes first) and parent-reported outcomes 90 days from enrolment. We will use these data to determine sepsis epidemiology based on existing and novel diagnostic criteria. We will also validate existing and novel sepsis risk stratification criteria, characterise antimicrobial stewardship, guideline adherence, cost and report parental awareness and understanding of sepsis and parent-reported outcome measures. ETHICS AND DISSEMINATION Ethics approval was received from the Royal Children's Hospital of Melbourne, Australia Human Research Ethics Committee (HREC/69948/RCHM-2021). This included incorporated informed consent for follow-up. The findings will be disseminated in a peer-reviewed journal and at academic conferences. TRIAL REGISTRATION NUMBER ACTRN12621000920897; Pre-results.
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Affiliation(s)
- Elliot Long
- Department of Emergency Medicine, The Royal Children’s Hospital, Parkville, Victoria, Australia
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Parkville, Victoria, Australia
| | - Meredith L Borland
- Department of Emergency Medicine, Perth Children’s Hospital, Perth, Western Australia, Australia
- Division of Emergency Medicine and Paediatrics, University of Western Australia, Perth, Western Australia, Australia
| | - Shane George
- Division of Emergency Medicine and Children’s Critical Care, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Medicine and Menzies Institute Queensland, Griffith University, Southport, Queensland, Australia
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
| | - Shefali Jani
- Department of Emergency Medicine, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Eunicia Tan
- Kidz first Middlemore Hospital, Auckland, New Zealand
| | | | - Natalie Phillips
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
- Emergency Department, Queensland Children’s Hospital, South Brisbane, Queensland, Australia
| | - Amit Kochar
- Department of Emergency Medicine, Women and Children’s Hospital, Adelaide, South Australia, Australia
- Department of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Simon Craig
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Emergency Medicine, Monash Medical Centre, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Anna Lithgow
- Department of Paediatrics, The Royal Darwin Hospital, Tiwi, Northern Territory, Australia
| | - Arjun Rao
- Department of Emergency Medicine, Sydney Children’s Hospital, Randwick, New South Wales, Australia
- School of Women’s and Children’s Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Stuart Dalziel
- Emergency Department, Starship Children’s Hospital, Auckland, New Zealand
- Department of Surgery and Paediatrics, The University of Auckland, Auckland, New Zealand
| | - Ed Oakley
- Department of Emergency Medicine, The Royal Children’s Hospital, Parkville, Victoria, Australia
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Stephen Hearps
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Parkville, Victoria, Australia
| | - Sonia Singh
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- University of California Davis School of Medicine, Sacremento, California, USA
| | - Ben Gelbart
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Parkville, Victoria, Australia
- Intensive Care Unit, The Royal Children’s Hospital, Parkville, Victoria, Australia
| | - Sarah McNab
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of General Medicine, The Royal Children’s Hospital, Parkville, Victoria, Australia
| | - Fran Balamuth
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott Weiss
- Nemours Children’s Health and Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine and University of California Davis Health, Sacremento, California, USA
| | - Amanda Williams
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children’s Hospital, Parkville, Victoria, Australia
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
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Gist KM, Menon S, Anton-Martin P, Bigelow AM, Cortina G, Deep A, De la Mata-Navazo S, Gelbart B, Gorga S, Guzzo I, Mah KE, Ollberding NJ, Shin HS, Thadani S, Uber A, Zang H, Zappitelli M, Selewski DT. Time to Continuous Renal Replacement Therapy Initiation and 90-Day Major Adverse Kidney Events in Children and Young Adults. JAMA Netw Open 2024; 7:e2349871. [PMID: 38165673 PMCID: PMC10762580 DOI: 10.1001/jamanetworkopen.2023.49871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/14/2023] [Indexed: 01/04/2024] Open
Abstract
Importance In clinical trials, the early or accelerated continuous renal replacement therapy (CRRT) initiation strategy among adults with acute kidney injury or volume overload has not demonstrated a survival benefit. Whether the timing of initiation of CRRT is associated with outcomes among children and young adults is unknown. Objective To determine whether timing of CRRT initiation, with and without consideration of volume overload (VO; <10% vs ≥10%), is associated with major adverse kidney events at 90 days (MAKE-90). Design, Setting, and Participants This multinational retrospective cohort study was conducted using data from the Worldwide Exploration of Renal Replacement Outcome Collaborative in Kidney Disease (WE-ROCK) registry from 2015 to 2021. Participants included children and young adults (birth to 25 years) receiving CRRT for acute kidney injury or VO at 32 centers across 7 countries. Statistical analysis was performed from February to July 2023. Exposure The primary exposure was time to CRRT initiation from intensive care unit admission. Main Outcomes and measures The primary outcome was MAKE-90 (death, dialysis dependence, or persistent kidney dysfunction [>25% decline in estimated glomerular filtration rate from baseline]). Results Data from 996 patients were entered into the registry. After exclusions (n = 27), 969 patients (440 [45.4%] female; 16 (1.9%) American Indian or Alaska Native, 40 (4.7%) Asian or Pacific Islander, 127 (14.9%) Black, 652 (76.4%) White, 18 (2.1%) more than 1 race; median [IQR] patient age, 8.8 [1.7-15.0] years) with data for the primary outcome (MAKE-90) were included. Median (IQR) time to CRRT initiation was 2 (1-6) days. MAKE-90 occurred in 630 patients (65.0%), of which 368 (58.4%) died. Among the 601 patients who survived, 262 (43.6%) had persistent kidney dysfunction. Of patients with persistent dysfunction, 91 (34.7%) were dependent on dialysis. Time to CRRT initiation was approximately 1 day longer among those with MAKE-90 (median [IQR], 3 [1-8] days vs 2 [1-4] days; P = .002). In the generalized propensity score-weighted regression, there were approximately 3% higher odds of MAKE-90 for each 1-day delay in CRRT initiation (odds ratio, 1.03 [95% CI, 1.02-1.04]). Conclusions and Relevance In this cohort study of children and young adults receiving CRRT, longer time to CRRT initiation was associated with greater risk of MAKE-90 outcomes, in particular, mortality. These findings suggest that prospective multicenter studies are needed to further delineate the appropriate time to initiate CRRT and the interaction between CRRT initiation timing and VO to continue to improve survival and reduce morbidity in this population.
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Affiliation(s)
- Katja M Gist
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shina Menon
- Seattle Children's Hospital, University of Washington, Seattle
| | | | - Amee M Bigelow
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus
| | | | - Akash Deep
- King's College Hospital, London, England
| | - Sara De la Mata-Navazo
- Gregorio Marañón University Hospital; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Ben Gelbart
- Royal Children's Hospital, University of Melbourne, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Stephen Gorga
- University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor
| | | | - Kenneth E Mah
- Stanford University School of Medicine, Palo Alto, California
| | - Nicholas J Ollberding
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - H Stella Shin
- Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Sameer Thadani
- Baylor College of Medicine, Texas Children's Hospital, Houston
| | - Amanda Uber
- University of Nebraska Medical Center, Children's Hospital & Medical Center, Omaha
- University of Utah, Primary Children's Hospital, Salt Lake City
| | - Huaiyu Zang
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Gelbart B, Marchesini V, Kapalavai SK, Veysey A, Serratore A, Appleyard J, Bellomo R, Butt W, Duke T. Agreement Between Measured Weight and Fluid Balance in Mechanically Ventilated Children in Intensive Care. Pediatr Crit Care Med 2023; 24:e459-e467. [PMID: 37102717 DOI: 10.1097/pcc.0000000000003258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
OBJECTIVES To investigate the agreement between change in body weight (BW) and fluid balance (FB), and the precision and safety of BW measurement in mechanically ventilated infants in intensive care. DESIGN Prospective observational study. SETTING Tertiary PICU. PATIENTS Infants following cardiac surgery, at baseline, 24 hours, and 48 hours. INTERVENTIONS BW and FB measurement at three time points. MEASUREMENTS AND MAIN RESULTS Between May 2021 and September 2022, we studied 61 children. The median age was 8 days (interquartile range [IQR], 1.0-14.0 d). The median BW at baseline was 3,518 g (IQR, 3,134-3,928 g). Change in BW was -36 g (IQR, -145 to 105 g) and -97 g (IQR, -240 to -28 g) between baseline and 24 hours, and between 24 and 48 hours, respectively. Change in FB was -82 mL (IQR, -173 to 12 mL) and -107 mL (IQR, -226 to 103) between baseline and 24 hours, and between 24 and 48 hours, respectively. In Bland-Altman analyses, the mean bias between BW and FB at 24 and 48 hours was 54 g (95% CI, 12-97) and -43 g (95% CI, -108 to 23), respectively. This exceeded 1% of the median BW, and limits of agreement ranged from 7.6% to 15% of baseline BW. The precision of paired weight measurements, performed sequentially at each time interval, was high (median difference of ≤1% of BW at each time point). The median weight of connected devices ranged from 2.7% to 3% of BW. There were no episodes of tube or device dislodgments and no change in vasoactive therapies during weight measurements. CONCLUSIONS There is moderate agreement between the changes in FB and BW, albeit greater than 1% of baseline BW, and the limits of this agreement are wide. Weighing mechanically ventilated infants in intensive care is a relatively safe and precise method for estimating change in fluid status. Device weight represents a relatively large proportion of BW.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit, University of Melbourne, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - Vanessa Marchesini
- Paediatric Intensive Care Unit, Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Sudeep Kumar Kapalavai
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Andrea Veysey
- Paediatric Intensive Care Unit, Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Alyssa Serratore
- Paediatric Intensive Care Unit, Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Jessica Appleyard
- Paediatric Intensive Care Unit, Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Rinaldo Bellomo
- Paediatric Intensive Care Unit, University of Melbourne, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
- Paediatric Intensive Care Unit, Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Parkville, VIC, Australia
- Intensive Care Unit, Austin Hospital, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Warwick Butt
- Paediatric Intensive Care Unit, University of Melbourne, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - Trevor Duke
- Paediatric Intensive Care Unit, University of Melbourne, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
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Gilholm P, Ergetu E, Gelbart B, Raman S, Festa M, Schlapbach LJ, Long D, Gibbons KS. Adaptive Clinical Trials in Pediatric Critical Care: A Systematic Review. Pediatr Crit Care Med 2023; 24:738-749. [PMID: 37195182 DOI: 10.1097/pcc.0000000000003273] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
OBJECTIVES This systematic review investigates the use of adaptive designs in randomized controlled trials (RCTs) in pediatric critical care. DATA SOURCES PICU RCTs, published between 1986 and 2020, stored in the www.PICUtrials.net database and MEDLINE, EMBASE, CENTRAL, and LILACS databases were searched (March 9, 2022) to identify RCTs published in 2021. PICU RCTs using adaptive designs were identified through an automated full-text screening algorithm. STUDY SELECTION All RCTs involving children (< 18 yr old) cared for in a PICU were included. There were no restrictions to disease cohort, intervention, or outcome. Interim monitoring by a Data and Safety Monitoring Board that was not prespecified to change the trial design or implementation of the study was not considered adaptive. DATA EXTRACTION We extracted the type of adaptive design, the justification for the design, and the stopping rule used. Characteristics of the trial were also extracted, and the results summarized through narrative synthesis. Risk of bias was assessed using the Cochrane Risk of Bias Tool 2. DATA SYNTHESIS Sixteen of 528 PICU RCTs (3%) used adaptive designs with two types of adaptations used; group sequential design and sample size reestimation. Of the 11 trials that used a group sequential adaptive design, seven stopped early due to futility and one stopped early due to efficacy. Of the seven trials that performed a sample size reestimation, the estimated sample size decreased in three trials and increased in one trial. CONCLUSIONS Little evidence of the use of adaptive designs was found, with only 3% of PICU RCTs incorporating an adaptive design and only two types of adaptations used. Identifying the barriers to adoption of more complex adaptive trial designs is needed.
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Affiliation(s)
- Patricia Gilholm
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Endrias Ergetu
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital Melbourne, Parkville, VIC, Australia
| | - Sainath Raman
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Marino Festa
- Kids Critical Care Research, Paediatric Intensive Care Unit, Children's Hospital at Westmead, Westmead, NSW, Australia
- Sydney Children's Hospital Network, Sydney, NSW, Australia
| | - Luregn J Schlapbach
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Debbie Long
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kristen S Gibbons
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Gelbart B, Bellomo R. Fluid Accumulation in Children. Crit Care Med 2023; 51:e169-e170. [PMID: 37439648 DOI: 10.1097/ccm.0000000000005880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital, Department of Paediatrics and Department of Critical Care, University of Melbourne, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Rinaldo Bellomo
- Paediatric Intensive Care Unit, Royal Children's Hospital, Department of Paediatrics and Department of Critical Care, University of Melbourne, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Intensisve Care Unit, Austin Hospital, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Gelbart B, Shann F. Severe bronchiolitis in infants less than 12 months old. Intensive Care Med 2023; 49:886-887. [PMID: 37160592 DOI: 10.1007/s00134-023-07083-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 05/11/2023]
Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, 3052, Australia.
| | - Frank Shann
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, 3052, Australia
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Gelbart B, Kapalavai SK, Marchesini V, Presneill J, Veysey A, Serratore A, Appleyard J, Bellomo R, Butt W, Duke T. A Clinical Score for Quantifying Edema in Mechanically Ventilated Children With Congenital Heart Disease in Intensive Care. Crit Care Explor 2023; 5:e0924. [PMID: 37637355 PMCID: PMC10456982 DOI: 10.1097/cce.0000000000000924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Standardized clinical measurements of edema do not exist. OBJECTIVES To describe a 19-point clinical edema score (CES), investigate its interobserver agreement, and compare changes between such CES and body weight. DESIGN SETTING AND PARTICIPANTS Prospective observational study in a tertiary PICU of mechanically ventilated children with congenital heart disease. MAIN OUTCOMES AND MEASURES Differences in the median CES between observer groups. RESULTS We studied 61 children, with a median age of 8.0 days (interquartile range, 1.0-14.0 d). A total of 539 CES were performed by three observer groups (medical 1 [reference], medical 2, and bedside nurse) at 0, 24, and 48 hours from enrollment. Overall, there was close agreement between observer groups in mean, median, and upper quartile of CES scores, with least agreement observed in the lower quartile of scores. Across all quartiles of CES, after adjusting for baseline weight, cardiac surgical risk, duration of cardiopulmonary bypass, or peritoneal dialysis during the study, observer groups returned similar mean scores (medical 2: 25th centile +0.1 [95% CI, -0.2 to 0.5], median +0.6 [95% CI, -0.4 to 1.5], 75th centile +0.1 [95% CI, -1.1 to 1.4] and nurse: 25th centile +0.5 [95% CI, 0.0-0.9], median +0.7 [95% CI, 0.0-1.5], 75th centile -0.2 [95% CI, -1.3 to 1.0]) Within a multivariable mixed-effects linear regression model, including adjustment for baseline CES, each 1 point increase in CES was associated with a 12.1 grams (95% CI, 3.2-21 grams) increase in body weight. CONCLUSIONS AND RELEVANCE In mechanically ventilated children with congenital heart disease, three groups of observers tended to agree when assessing overall edema using an ordinal clinical score assessed in six body regions, with agreement least at low edema scores. An increase in CES was associated with an increase in body weight, suggesting some validity for quantifying edema. Further exploration of the CES as a rapid clinical tool is indicated.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit, University of Melbourne, Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Sudeep Kumar Kapalavai
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Vanessa Marchesini
- Paediatric Intensive Care Unit, Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Jeffrey Presneill
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Andrea Veysey
- Paediatric Intensive Care Unit, Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Alyssa Serratore
- Paediatric Intensive Care Unit, Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Jessica Appleyard
- Paediatric Intensive Care Unit, Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Hospital, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Warwick Butt
- Paediatric Intensive Care Unit, University of Melbourne, Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Trevor Duke
- Paediatric Intensive Care Unit, University of Melbourne, Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia
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George S, Gibbons K, Williams T, Humphreys S, Gelbart B, Le Marsney R, Craig S, Tingay D, Chavan A, Schibler A. Transnasal Humidified Rapid Insufflation Ventilatory Exchange in children requiring emergent intubation (Kids THRIVE): a statistical analysis plan for a randomised controlled trial. Trials 2023; 24:369. [PMID: 37259146 DOI: 10.1186/s13063-023-07330-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 04/25/2023] [Indexed: 06/02/2023] Open
Abstract
The placement of an endotracheal tube for children with acute or critical illness is a low-frequency and high-risk procedure, associated with high rates of first-attempt failure and adverse events, including hypoxaemia. To reduce the frequency of these adverse events, the provision of oxygen to the patient during the apnoeic phase of intubation has been proposed as a method to prolong the time available for the operator to insert the endotracheal tube, prior to the onset of hypoxaemia. However, there are limited data from randomised controlled trials to validate the efficacy of this technique in children. The technique known as transnasal humidified rapid insufflation ventilatory exchange (THRIVE) uses high oxygen flow rates (approximately 2 L/kg/min) delivered through nasal cannulae during apnoea. It has been shown to at least double the amount of time available for safe intubation in healthy children undergoing elective surgery. The technique and its application in real time have not previously been studied in acutely ill or injured children presenting to the emergency department or admitted to an intensive care unit. The Kids THRIVE trial is a multicentre, international, randomised controlled trial (RCT) in children less than 16 years old undergoing emergent intubation in either the intensive care unit or emergency department of participating hospitals. Participants will be randomised to receive either the THRIVE intervention or standard care (no apnoeic oxygenation) during their intubation. The primary objective of the trial is to determine if the use of THRIVE reduces the frequency of oxygen desaturation and increases the frequency of first-attempt success without hypoxaemia in emergent intubation of children compared with standard practice. The secondary objectives of the study are to assess the impact of the use of THRIVE on the rate of adverse events, length of mechanical ventilation and length of stay in intensive care. In this paper, we describe the detailed statistical analysis plan as an update of the previously published protocol.
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Affiliation(s)
- Shane George
- Departments of Emergency Medicine, Children's Critical Care, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, QLD, Australia.
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia.
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Gold Coast Campus, Southport, Australia.
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia
| | - Tara Williams
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia
- Division of Critical Care Medicine, Queensland Children's Hospital, South Brisbane, Australia
| | - Susan Humphreys
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia
- Division of Critical Care Medicine, Queensland Children's Hospital, South Brisbane, Australia
| | - Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Renate Le Marsney
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia
| | - Simon Craig
- Paediatric Emergency Department, Monash Medical Centre, Monash Emergency Research Collaborative, Monash Health, Clayton, VIC, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - David Tingay
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Department of Neonatology, The Royal Children's Hospital, Melbourne, VIC, Australia
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Arjun Chavan
- Paediatric Intensive Care Unit, Townsville University Hospital, Townsville, Australia
| | - Andreas Schibler
- St Andrew's War Memorial Hospital, Brisbane, Australia
- Critical Care Research Group, St Andrew's War Memorial Hospital, Brisbane, Australia
- Wesley Medical Research, Auchenflower, Queensland, Australia
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10
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Subhi R, Gelbart B, Ching N, Thompson J, Osowicki J, Rozen TH, Shanthikumar S, Teague W, Duke T. Characteristics, management and changing incidence of children with empyema in a paediatric intensive care unit. J Paediatr Child Health 2022; 58:1046-1052. [PMID: 35191560 PMCID: PMC9305239 DOI: 10.1111/jpc.15905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 01/06/2022] [Accepted: 01/26/2022] [Indexed: 11/29/2022]
Abstract
AIM Paediatric intensive care unit (PICU) admissions for empyema increased following the 13-valent pneumococcal conjugate vaccine (PCV13). We describe the clinical characteristics, management and outcomes for children with empyema and compare incidence before and after PCV13. METHODS Retrospective study of patients <18 years admitted to The Royal Children's Hospital Melbourne PICU with empyema between January 2016 and July 2019. We investigated the incidence of empyema during two time periods: 2007-2010 (pre-PCV13) and 2016-2019 (post-PCV13). RESULTS Seventy-one children (1.9% of all PICU admissions) were admitted to PICU with empyema between 2016 and 2019. Sixty-one (86%) had unilateral disease, 11 (16%) presented with shock and 44 (62%) were ventilated. Streptococcus pneumoniae and group A Streptococcus were the most commonly identified pathogens. Forty-five (63%) were managed with video-assisted thoracoscopic surgery (VATS). There was a 31% reduction in empyema hospitalisations as a proportion of all hospitalisations (IRR 0.69, 95% CI 0.59-0.8), but a 2.8-fold increase in empyema PICU admissions as a proportion of all PICU admissions (95% CI 2.2-3.5, P < 0.001). For the PICU cohort, this was accompanied by reduction in PIM2 probability of death (median 1% vs. 1.9%, P = 0.02) and duration of intubation (median 69 h vs. 126.5 h, P = 0.045). CONCLUSIONS In children with empyema in PICU 62% required ventilation, 16% had features of shock and 63% received VATS. Empyema admissions, as a proportion of all PICU admissions, increased in the era post-PCV13 compared to pre-PCV13 despite no increase in illness severity at admission.
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Affiliation(s)
- Rami Subhi
- Paediatric Intensive Care UnitRoyal Children's HospitalMelbourneVictoriaAustralia,Infection and ImmunityMurdoch Children's Research InstituteMelbourneVictoriaAustralia,Department of PaediatricsUniversity of MelbourneMelbourneVictoriaAustralia
| | - Ben Gelbart
- Paediatric Intensive Care UnitRoyal Children's HospitalMelbourneVictoriaAustralia,Department of PaediatricsUniversity of MelbourneMelbourneVictoriaAustralia,Clinical SciencesMurdoch Children's Research InstituteMelbourneVictoriaAustralia
| | - Natasha Ching
- Microbiology, Department of PathologyLaboratory ServicesMelbourneVictoriaAustralia,Infection and ImmunityMonash Children's HospitalMelbourneVictoriaAustralia,General PaediatricsMonash Children's HospitalMelbourneVictoriaAustralia,Department of PaediatricsMonash UniversityMelbourneVictoriaAustralia
| | - Jenny Thompson
- Paediatric Intensive Care UnitRoyal Children's HospitalMelbourneVictoriaAustralia
| | - Joshua Osowicki
- Infection and ImmunityMurdoch Children's Research InstituteMelbourneVictoriaAustralia,Department of PaediatricsUniversity of MelbourneMelbourneVictoriaAustralia,Infectious Diseases Unit, Department of General MedicineRoyal Children's HospitalMelbourneVictoriaAustralia
| | - Thomas H Rozen
- Paediatric Intensive Care UnitRoyal Children's HospitalMelbourneVictoriaAustralia,Department of PaediatricsUniversity of MelbourneMelbourneVictoriaAustralia
| | - Shivanthan Shanthikumar
- Infection and ImmunityMurdoch Children's Research InstituteMelbourneVictoriaAustralia,Department of PaediatricsUniversity of MelbourneMelbourneVictoriaAustralia,Respiratory and Sleep MedicineRoyal Children's HospitalMelbourneVictoriaAustralia
| | - Warwick Teague
- Department of PaediatricsUniversity of MelbourneMelbourneVictoriaAustralia,Clinical SciencesMurdoch Children's Research InstituteMelbourneVictoriaAustralia,Department of Paediatric Surgery, Trauma ServiceRoyal Children's HospitalMelbourneVictoriaAustralia
| | - Trevor Duke
- Paediatric Intensive Care UnitRoyal Children's HospitalMelbourneVictoriaAustralia,Department of PaediatricsUniversity of MelbourneMelbourneVictoriaAustralia,Discipline of Child Health, School of Medicine and Health SciencesUniversity of Papua New GuineaPort MoresbyPapua New Guinea
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11
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Gelbart B, McSharry B, Delzoppo C, Erickson S, Lee K, Butt W, Rea M, Wang X, Beca J, Kazemi A, Shann F. Pragmatic Randomized Trial of Corticosteroids and Inhaled Epinephrine for Bronchiolitis in Children in Intensive Care. J Pediatr 2022; 244:17-23.e1. [PMID: 35093318 DOI: 10.1016/j.jpeds.2022.01.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/22/2021] [Accepted: 01/18/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine whether the combination of systemic corticosteroids and nebulized epinephrine, compared with standard care, reduces the duration of positive pressure support in children with bronchiolitis admitted to intensive care. STUDY DESIGN We performed a pragmatic, multicenter, open-label, randomized trial between July 2013 and November 2019 in children younger than 18 months old with a clinical diagnosis of bronchiolitis. The intervention group received the equivalent of 13 mg/kg prednisolone over 3 days, then 1 mg/kg daily for 3 days, plus 0.05 mL/kg of nebulized 1% epinephrine made up to 6 ml with 0.9% saline via jet nebulizer and mask using oxygen at 12 l/min every 30 minutes for 5 doses, then 1-4 hourly for 3 days, then as required for 3 days. The primary outcome was clinician-managed duration of positive pressure support in intensive care defined as high-flow nasal-prong oxygen, nasopharyngeal continuous positive airway pressure, or mechanical ventilation. RESULTS In total, 210 children received positive pressure support. In the corticosteroid-epinephrine group, 107 children received positive pressure support for a geometric mean of 26 (95% CI, 22-32) hours compared with 40 (95% CI 34-47) hours in 103 controls, adjusted ratio 0.66 (95% CI 0.51-0.84), P = .001. In the intervention group, 41 (38%) children experienced at least 1 adverse event, compared with 39 (38%) in the control group. CONCLUSIONS In children with severe bronchiolitis, the duration of clinician-managed pressure support was reduced by regular treatment with systemic corticosteroids and inhaled epinephrine compared with standard care. CLINICAL TRIAL REGISTRATION Australian Clinical Trials Research Network: ACTRN12613000316707.
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Affiliation(s)
- Ben Gelbart
- Royal Children's Hospital Paediatric Intensive Care Unit, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia.
| | - Brent McSharry
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, Australia
| | - Carmel Delzoppo
- Royal Children's Hospital Paediatric Intensive Care Unit, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Simon Erickson
- Paediatric Critical Care Unit, Perth Children's Hospital, Perth, Australia
| | - Katherine Lee
- Department of Paediatrics, University of Melbourne, Melbourne, Australia; Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Australia
| | - Warwick Butt
- Royal Children's Hospital Paediatric Intensive Care Unit, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Miriam Rea
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, Australia
| | - Xiaofang Wang
- Department of Paediatrics, University of Melbourne, Melbourne, Australia; Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Australia
| | - John Beca
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, Australia
| | - Alex Kazemi
- Intensive Care Unit, Middlemore Hospital, Auckland, Australia
| | - Frank Shann
- Royal Children's Hospital Paediatric Intensive Care Unit, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia
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12
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Gelbart B, Masterson K, Serratore A, Zampetti M, Veysey A, Longstaff S, Bellomo R, Butt W, Duke T. Precision of weight measurement in critically ill infants: a technical report. CRIT CARE RESUSC 2021; 23:414-417. [PMID: 38046691 PMCID: PMC10692624 DOI: 10.51893/2021.4.tn] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: To investigate the precision of weight measurements in critically ill infants in a paediatric intensive care unit (PICU). Design: Prospective cohort study. Setting: Royal Children's Hospital PICU. Participants: Mechanically ventilated infants admitted to the Royal Children's Hospital PICU between September 2020 and February 2021. Main outcome measures: Mean percentage difference and agreement of consecutive weight measurements. Results: Thirty infants were enrolled, of which 17 were receiving post-surgical care for congenital heart disease and four were receiving extracorporeal membrane oxygenation (ECMO). The median age was 13 days (interquartile range [IQR], 3.1-52.4 days). The mean difference in weight was 1.3% (standard deviation [SD], 1.0%), and the test-retest agreement intraclass correlation was 0.99 (95% CI, 0.99-0.99; P < 0.01). The percentage difference between measurements was ≤ 2.5% in 26/30 (87%) children, and the range was < 0.1% to 3.6%. In 26 children not receiving ECMO, the mean difference in weight was 1.1% (SD, 1.0%). There were no complications. Conclusions: Weighing mechanically ventilated, critically ill infants in intensive care can be performed safely, with a mean difference between consecutive weights of 1.3%, making it a potentially useful additional measure of fluid accumulation.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Kate Masterson
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Alyssa Serratore
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Michael Zampetti
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Andrea Veysey
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Stacey Longstaff
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation (DARE) Centre, University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Warwick Butt
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Trevor Duke
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
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13
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Weiss SL, Balamuth F, Long E, Thompson GC, Hayes KL, Katcoff H, Cook M, Tsemberis E, Hickey CP, Williams A, Williamson-Urquhart S, Borland ML, Dalziel SR, Gelbart B, Freedman SB, Babl FE, Huang J, Kuppermann N. PRagMatic Pediatric Trial of Balanced vs nOrmaL Saline FlUid in Sepsis: study protocol for the PRoMPT BOLUS randomized interventional trial. Trials 2021; 22:776. [PMID: 34742327 PMCID: PMC8572061 DOI: 10.1186/s13063-021-05717-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/11/2021] [Indexed: 12/24/2022] Open
Abstract
Background/aims Despite evidence that preferential use of balanced/buffered fluids may improve outcomes compared with chloride-rich 0.9% saline, saline remains the most commonly used fluid for children with septic shock. We aim to determine if resuscitation with balanced/buffered fluids as part of usual care will improve outcomes, in part through reduced kidney injury and without an increase in adverse effects, compared to 0.9% saline for children with septic shock. Methods The Pragmatic Pediatric Trial of Balanced versus Normal Saline Fluid in Sepsis (PRoMPT BOLUS) study is an international, open-label pragmatic interventional trial being conducted at > 40 sites in the USA, Canada, and Australia/New Zealand starting on August 25, 2020, and continuing for 5 years. Children > 6 months to < 18 years treated for suspected septic shock with abnormal perfusion in an emergency department will be randomized to receive either balanced/buffered crystalloids (intervention) or 0.9% saline (control) for initial resuscitation and maintenance fluids for up to 48 h. Eligible patients are enrolled and randomized using serially numbered, opaque envelopes concurrent with clinical care. Given the life-threatening nature of septic shock and narrow therapeutic window to start fluid resuscitation, patients may be enrolled under “exception from informed consent” in the USA or “deferred consent” in Canada and Australia/New Zealand. Other than fluid type, all decisions about timing, volume, and rate of fluid administration remain at the discretion of the treating clinicians. For pragmatic reasons, clinicians will not be blinded to study fluid type. Anticipated enrollment is 8800 patients. The primary outcome will be major adverse kidney events within 30 days (MAKE30), a composite of death, renal replacement therapy, and persistent kidney dysfunction. Additional effectiveness, safety, and biologic outcomes will also be analyzed. Discussion PRoMPT BOLUS will provide high-quality evidence for the comparative effectiveness of buffered/balanced crystalloids versus 0.9% saline for the initial fluid management of children with suspected septic shock in emergency settings. Trial registration PRoMPT BOLUS was first registered at ClinicalTrials.gov (NCT04102371) on September 25, 2019. Enrollment started on August 25, 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05717-4.
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Affiliation(s)
- Scott L Weiss
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,The Children's Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia, PA, USA.
| | - Fran Balamuth
- The Children's Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia, PA, USA.,Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia.,Departments of Pediatrics and Critical Care, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Graham C Thompson
- Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Katie L Hayes
- The Children's Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia, PA, USA
| | - Hannah Katcoff
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marlena Cook
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Elena Tsemberis
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher P Hickey
- The Children's Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia, PA, USA
| | - Amanda Williams
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Sarah Williamson-Urquhart
- Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Meredith L Borland
- Divisions of Emergency Medicine and Pediatrics, Perth Children's Hospital, School of Medicine at the University of Western Australia, Crawley, Australia
| | - Stuart R Dalziel
- Departments of Surgery and Pediatrics: Child and Youth Health, Starship Children's Hospital, University of Auckland, Auckland, New Zealand
| | - Ben Gelbart
- Departments of Pediatrics and Critical Care, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Society Paediatric Study Group, Camberwell, Australia.,Paediatric Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia.,Departments of Pediatrics and Critical Care, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Jing Huang
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine and Pediatrics, UC Davis School of medicine and UC Davis Health, Sacramento, CA, USA
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14
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Gelbart B, Vidmar S, Stephens D, Cheng D, Thompson J, Segal A, Gadish T, Carlin J. Characteristics and outcomes of children receiving intensive care therapy within 12 hours following a medical emergency team event. CRIT CARE RESUSC 2021; 23:254-261. [PMID: 38046070 PMCID: PMC10692518 DOI: 10.51893/2021.3.oa2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: To describe characteristics and outcomes of children requiring intensive care therapy (ICT) within 12 hours following a medical emergency team (MET) event. Design: Retrospective cohort study. Setting: Quaternary paediatric hospital. Patients: Children experiencing a MET event. Measurements and main results: Between July 2017 and March 2019, 890 MET events occurred in 566 patients over 631 admissions. Admission to intensive care followed 183/890 (21%) MET events. 76/183 (42%) patients required ICT, defined as positive pressure ventilation or vasoactive support in intensive care, within 12 hours. Older children had a lower risk of requiring ICT than infants aged < 1 year (age 1-5 years [risk difference, -6.4%; 95% CI, -11% to -1.6%; P = 0.01] v age > 5 years [risk difference, -8.0%; 95% CI, -12% to -3.8%; P < 0.001]), while experiencing a critical event increased this risk (risk difference, 16%; 95% CI, 3.3-29%; P = 0.01). The duration of respiratory support and intensive care length of stay was approximately double in patients requiring ICT (ratio of geometric means, 2.0 [95% CI, 1.4-3.0] v 2.1 [95% CI, 1.5-2.8]; P < 0.001) and the intensive care mortality increased (risk difference, 9.6%; 95% CI, 2.4-17%; P = 0.01). Heart rate, oxygen saturation and respiratory rate were the most commonly measured vital signs in the 6 hours before the MET event. Conclusions: Approximately one-fifth of MET events resulted in intensive care admission and nearly half of these required ICT within 12 hours. This group had greater duration of respiratory support, intensive care and hospital length of stay, and higher mortality. Age < 1 year and a critical event increased the risk of ICT.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Suzanna Vidmar
- Clinical Epidemiology Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - David Stephens
- Decision Support Unit, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Daryl Cheng
- Department of Paediatrics, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Jenny Thompson
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Ahuva Segal
- Royal Children's Hospital, Melbourne, VIC, Australia
| | - Tali Gadish
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - John Carlin
- Clinical Epidemiology Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
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15
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Fahey KP, Gelbart B, Oberender F, Thompson J, Rozen T, James C, McLaren C, Sniderman J, Uahwatanasakul W. Interhospital transport of children with bronchiolitis by a statewide emergency transport service. CRIT CARE RESUSC 2021; 23:292-299. [PMID: 38046083 PMCID: PMC10692503 DOI: 10.51893/2021.3.oa6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To investigate the rate of interhospital emergency transport for bronchiolitis and intensive care admission following the introduction of high flow nasal cannula and standardised paediatric observation and response charts. Design: Retrospective cohort study. Setting: A statewide paediatric intensive care transport service and its two referral paediatric intensive care units (PICUs) in Victoria, Australia. Participants: Children less than 2 years old emergently transported with bronchiolitis during two time periods: 2008-2012 and 2015-2019. Main outcome measures: Incidence rates of bronchiolitis transport episodes, PICU admissions and respiratory support. Results: 802 children with bronchiolitis were transported during the study period, 233 in the first period (2008-2012) and 569 in the second period (2015-2019). The rate of interhospital transport for bronchiolitis increased from 32.9 to 71.8 per 100 000 children aged 0-2 years. The population-adjusted rate of PICU admission increased from 16.2 to 36.6 per 100 000 children aged 0-2 years. Metropolitan hospitals were the predominant referral source and this increased from 60.1% of transports to 78.6% (P < 0.001). In children admitted to a PICU, the administration of high flow nasal cannula during transport increased significantly from 1.7% to 75.9% (P < 0.001) and a concomitant reduction in continuous positive airway pressure and mechanical ventilation occurred (40-12.4% and 27-6.9% respectively; P < 0.001). The proportion of mechanical ventilation as well as PICU and hospital length of stay decreased over time. Conclusions: The population-adjusted rate of interhospital transport and admission to the PICU for bronchiolitis increased over time. This occurred despite a lower rate of non-invasive and invasive mechanical ventilation during transport and in the PICU.
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Affiliation(s)
- Kieren P. Fahey
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, VIC, Australia
- Department of Paediatrics, Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
| | - Felix Oberender
- Paediatric Intensive Care Unit, Monash Children’s Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Jenny Thompson
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, VIC, Australia
| | - Tom Rozen
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
| | - Christopher James
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
| | - Catriona McLaren
- Paediatric Intensive Care Unit, Monash Children’s Hospital, Melbourne, VIC, Australia
| | - Jonathan Sniderman
- Department of Critical Care, Paediatrics, Schulich School of Medicine and Dentistry, London, On, Canada
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16
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Kimura S, Gelbart B, Chiletti R, Stephens D, Butt W. Carboxyhemoglobin levels in children during extracorporeal membrane oxygenation support: a retrospective study. Perfusion 2021; 37:797-804. [PMID: 34233534 DOI: 10.1177/02676591211027776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Hemolysis is a common complication of extracorporeal membrane oxygenation (ECMO). There are few data on whether carboxyhemoglobin (COHb), a potential marker of hemolysis, are elevated during ECMO support. METHODS We conducted a single-center, retrospective study comparing peak COHb levels of children pre-, during, and post-ECMO from January 2017 to August 2020. RESULTS There were 154 ECMO runs in 147 children (154 PICU admissions) included in the study. The median age was 3.5 (IQR 0.2, 39.2) months. Veno-arterial ECMO was the predominant mode: 146/154 (94.8%). Eighty-seven children (56.5%) underwent cardiac surgery. Peak COHb levels during ECMO were statistically significantly higher compared to pre ECMO (COHb 1.8% (IQR 1.4, 2.6) vs COHb 1.2% (IQR 0.7, 1.7), p < 0.001) and post ECMO (COHb 1.6% (IQR 1.3, 2.2), p = 0.009). Children with COHb ⩾2% were younger and had longer duration of ECMO support. Plasma hemoglobin weakly correlated with COHb level (r = 0.14; p = 0.04). CONCLUSIONS Carboxyhemoglobin levels increased during ECMO support compared to the pre and post ECMO period. Younger age and longer ECMO duration were associated with COHb levels ⩾2%. Plasma hemoglobin weakly correlated with COHb level.
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Affiliation(s)
- Satoshi Kimura
- Department of Pediatric Intensive Care Unit, The Royal Children's Hospital, Parkville, VIC, Australia.,Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Ben Gelbart
- Department of Pediatric Intensive Care Unit, The Royal Children's Hospital, Parkville, VIC, Australia.,Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Parkville, VIC, Australia.,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Roberto Chiletti
- Department of Pediatric Intensive Care Unit, The Royal Children's Hospital, Parkville, VIC, Australia.,Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - David Stephens
- Decision Support Unit, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Warwick Butt
- Department of Pediatric Intensive Care Unit, The Royal Children's Hospital, Parkville, VIC, Australia.,Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Parkville, VIC, Australia
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17
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Raman S, Brown G, Long D, Gelbart B, Delzoppo C, Millar J, Erickson S, Festa M, Schlapbach LJ. Priorities for paediatric critical care research: a modified Delphi study by the Australian and New Zealand Intensive Care Society Paediatric Study Group. CRIT CARE RESUSC 2021; 23:194-201. [PMID: 38045513 PMCID: PMC10692499 DOI: 10.51893/2021.2.oa6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Most interventions in paediatric critical care lack high grade evidence. We aimed to identify the key research priorities and key clinical outcome measures pertinent to research in paediatric intensive care patients. Design: Modified three-stage Delphi study combining staged online surveys, followed by a face-to-face discussion and final voting. Setting: Paediatric intensive care units in Australia and New Zealand. Participants: Medical and nursing staff working in intensive care. Main outcome measurements: Self-reported priorities for research. Results: 193 respondents provided a total of 267 research questions and 234 outcomes. In Stage 3, the top 56 research questions and 50 outcomes were discussed face to face, which allowed the identification of the top 20 research questions with the Hanlon prioritisation score and the top 20 outcomes. Topics centred on the use of intravenous fluids (restrictive v liberal fluids, use of fluid resuscitation bolus, early inotrope use, type of intravenous fluid, and assessment of fluid responsiveness), and patient- and family-centred outcomes (health-related quality of life, liberation) emerged as priorities. While mortality, length of stay, and organ support/organ dysfunction were considered important and the most feasible outcomes, long term quality of life and neurodevelopmental measures were rated highly in terms of their importance. Conclusions: Using a modified Delphi method, this study provides guidance towards prioritisation of research topics in paediatric critical care in Australia and New Zealand, and identifies study outcomes of key relevance to clinicians and experts in the field.
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Affiliation(s)
- Sainath Raman
- Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland, Children’s, Hospital, Brisbane, QLD, Australia
| | - Georgia Brown
- University of Melbourne, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Debbie Long
- Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland, Children’s, Hospital, Brisbane, QLD, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Ben Gelbart
- University of Melbourne, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Carmel Delzoppo
- University of Melbourne, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Johnny Millar
- University of Melbourne, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Simon Erickson
- Paediatric Intensive Care Unit, Perth Children’s Hospital, Perth, WA, Australia
| | - Marino Festa
- Paediatric Intensive Care Unit, Children’s Hospital Westmead, Sydney, NSW, Australia
- Kids Critical Care Research Group, Kids Research, Sydney Children’s Hospitals Network, Sydney, NSW, Australia
| | - Luregn J. Schlapbach
- Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland, Children’s, Hospital, Brisbane, QLD, Australia
- Pediatric and Neonatal Intensive Care Unit, University Children’s Hospital Zurich, and Children’s Research Center, University of Zurich, Zurich, Switzerland
| | - for the Australian and New Zealand Intensive Care Society Paediatric Study Group (ANZICS PSG)
- Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland, Children’s, Hospital, Brisbane, QLD, Australia
- University of Melbourne, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Perth Children’s Hospital, Perth, WA, Australia
- Paediatric Intensive Care Unit, Children’s Hospital Westmead, Sydney, NSW, Australia
- Kids Critical Care Research Group, Kids Research, Sydney Children’s Hospitals Network, Sydney, NSW, Australia
- Pediatric and Neonatal Intensive Care Unit, University Children’s Hospital Zurich, and Children’s Research Center, University of Zurich, Zurich, Switzerland
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18
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George S, Long E, Gelbart B, Dalziel SR, Babl FE, Schibler A. Intubation practices for children in emergency departments and intensive care units across Australia and New Zealand: A survey of medical staff. Emerg Med Australas 2020; 32:1052-1058. [PMID: 32969150 DOI: 10.1111/1742-6723.13620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 05/28/2020] [Accepted: 08/06/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE 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. The aim of the present study is to determine clinician preference in intubation practice of children in EDs and ICUs in Australia and New Zealand to provide baseline information to allow future targeted research focused on improving the safety and efficacy of paediatric emergency airway management. METHODS The present study was a voluntary questionnaire undertaken by medical staff at registrar level or above 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, with a focus on pre-oxygenation and apnoeic oxygenation techniques, and the use of video laryngoscopy. RESULTS A total of 502 clinicians were invited to complete the survey between May and October 2018 with 336 (66.9%) responded. There was marked variation in practice between ED clinicians and ICU clinicians in the techniques used for pre-oxygenation, the frequency of use of apnoeic oxygenation and the reported use of video laryngoscopy. CONCLUSIONS Within Australia and New Zealand there is considerable variation in paediatric emergency airway clinical practice, in particular with respect to pre-oxygenation, apnoeic oxygenation and use of video laryngoscopy. Definitive clinical trials are required to best inform clinical practice in this area.
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Affiliation(s)
- Shane George
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Department of Children's Critical Care, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Paediatric Critical Care Research Group, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Brisbane, Queensland, Australia
| | - Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ben Gelbart
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Paediatric Intensive Care, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Department of Paediatrics Child and Youth Health, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andreas Schibler
- Paediatric Critical Care Research Group, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, Queensland, Australia
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19
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Patricios J, Saggers R, Gelbart B, van Zuydam J. 'Make exercise the elixir across an economic divide': A message to COVID-19 decision makers. S Afr J Sports Med 2020; 32:v32i1a8310. [PMID: 36818979 PMCID: PMC9924509 DOI: 10.17159/2078-516x/2020/v32i1a8310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
South Africa, like other countries around the world, has used a lockdown strategy to address the initial phases of the COVID-19 epidemic. The significant restrictions on population movement have included initially limiting exercise to the home. There is substantial evidence for the many benefits of exercise. This study specifically emphasises the benefits of exercise to the immune system, particularly for those most vulnerable to the effects of the SARS-CoV-2 virus and proposes measures to improve access to exercise in a demographically diverse and economically disparate society.
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Affiliation(s)
- J Patricios
- Wits Institute for Sport and Health (WISH), School of Therapeutic Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa
| | - R Saggers
- Wits Institute for Sport and Health (WISH), School of Therapeutic Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa,Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa
| | - B Gelbart
- Wits Institute for Sport and Health (WISH), School of Therapeutic Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa,Department of Orthopaedics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa
| | - J van Zuydam
- Wits Institute for Sport and Health (WISH), School of Therapeutic Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,
South Africa
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20
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Yi Goh MZ, Hutchinson A, Gelbart B, Kinney S. Challenging routine hourly vital sign documentation in the paediatric intensive care unit. Aust Crit Care 2020. [DOI: 10.1016/j.aucc.2020.04.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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21
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Yi Goh MZ, Hutchinson A, Gelbart B, Kinney S. Establishing a suitable frequency of vital sign documentation in the paediatric intensive care unit. Aust Crit Care 2020. [DOI: 10.1016/j.aucc.2020.04.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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22
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Moynihan KM, Alexander PMA, Schlapbach LJ, Millar J, Jacobe S, Ravindranathan H, Croston EJ, Staffa SJ, Burns JP, Gelbart B. Epidemiology of childhood death in Australian and New Zealand intensive care units. Intensive Care Med 2019; 45:1262-1271. [DOI: 10.1007/s00134-019-05675-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 06/19/2019] [Indexed: 11/30/2022]
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23
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Khoo B, Buratto E, Fricke TA, Gelbart B, Brizard CP, Brink J, d'Udekem Y, Konstantinov IE. Outcomes of surgery for infective endocarditis in children: A 30-year experience. J Thorac Cardiovasc Surg 2019; 158:1399-1409. [PMID: 31383559 DOI: 10.1016/j.jtcvs.2019.06.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 05/26/2019] [Accepted: 06/10/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Infective endocarditis (IE) is rare in children. Limited data have been reported on long-term outcomes of children who undergo surgery for IE. METHODS Data were retrospectively obtained from medical records for all children who underwent surgery for IE. RESULTS Between 1987 and 2017, 138 children with IE required surgery (mean age, 8.3 ± 6.5 years). The majority of children (80.4% [111 out of 138]) had underlying cardiac structural anomalies. Prior heart surgery was performed in 50.7% of patients (70 out of 138), including 19.6% (27 out of 138) who had valve replacement. Operative mortality was 5.8% (8 out of 138). Mean follow-up time was 9.7 ± 7.6 years. Long-term survival at 5 and 25 years was 91.5% (95% confidence interval, 85.1%-95.2%) and 79.1% (95% confidence interval, 66.3%-87.5%), respectively. Risk factors associated with death were: age (hazard ratio [HR], 0.88; P = .015), prosthetic valve IE (HR, 3.86; P = .02), coagulase-negative staphylococci (HR, 4.52; P = .015), increased duration of preoperative antibiotic therapy (HR, 1.02; P = .009), shock (HR, 3.68; P = .028), and aortic valve replacement (HR, 3.22; P = .044). In patients with left-sided IE, risk factors independently associated with death were heart failure (HR, 18.8; P = .025) and vegetation size adjusted to body surface area (HR, 1.06; P = .008). Freedom from recurrent endocarditis was 94.7% (95% confidence interval, 87.7%-97.8%) at 25 years. CONCLUSIONS Children undergoing surgery for IE had good long-term survival and recurrence of IE was uncommon. Surgery during the active phase of endocarditis did not increase risk of mortality or reoperation. In patients with left-sided IE, vegetation size adjusted for patient body surface area was identified as a risk factor for death, and a useful indicator of prognosis.
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Affiliation(s)
- Brandon Khoo
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
| | - Edward Buratto
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia; Department of Pediatrics, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Tyson A Fricke
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia; Department of Pediatrics, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Ben Gelbart
- Department of Pediatrics, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia; Department of Intensive Care, The Royal Children's Hospital, Melbourne, Australia
| | - Christian P Brizard
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia; Department of Pediatrics, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Johann Brink
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia; Department of Pediatrics, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Yves d'Udekem
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia; Department of Pediatrics, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Igor E Konstantinov
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia; Department of Pediatrics, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia; Melbourne Children's Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
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24
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Gelbart B, Bitker L, Segal A, Hutchinson A, Soh N, Maybury T. Haemodynamic response to fluid boluses in children after cardiac surgery: a technical report. CRIT CARE RESUSC 2019; 21:132-138. [PMID: 31142244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To describe the haemodynamic response to fluid boluses (FB) in children after cardiac surgery. DESIGN A prospective observational pilot study. SETTING Single-centre, paediatric cardiac intensive care unit. PARTICIPANTS Children after cardiac surgery. INTERVENTIONS FB of 0.9% saline, 4% albumin or modified ultrafiltrate blood administered in less than 30 minutes. MAIN OUTCOME MEASURES Heart rate, arterial blood pressure, central venous pressure, oesophageal temperature, and end-tidal carbon dioxide were measured continuously and reported minutely from 5 minutes before and 30 minutes after FB. A mean arterial pressure (MAP)-responsive episode was defined as a 10% increase in MAP from baseline. RESULTS There were 21 FB recorded in 9 patients. Most patients (n = 8) weighed ≤ 6 kg, and three had univentricular circulation. Fourteen FB (67%) were 4% albumin and 15 (71%) were ≤ 7.5 mL/kg. There were nine MAP-responsive episodes (43%). Episodes of MAP responsiveness had a median MAP increment from baseline of 5 mmHg (interquartile range [IQR], 5-7) and 5 mmHg (IQR, 2-17) at 15 minutes and 30 minutes, respectively, significantly higher when compared with non-responsive episodes (median, 1 mmHg [IQR, -2 to 3]; and median, -1 mmHg [IQR, -3 to 1]; P < 0.01). In MAP-responsive episodes, median time to response was 6 minutes (IQR, 3-12) and seven episodes (78%) dissipated at a median of 2 minutes after response (IQR, 1-8). MAP response was not associated with fluid volume nor fluid composition. CONCLUSION In this study, the haemodynamic response to FB in children is infrequent and unsustained. Larger studies are required to demonstrate the pattern of haemodynamic response of FB in critically ill children.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia.
| | - Laurent Bitker
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Ahuva Segal
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Adrian Hutchinson
- Division of Information and Communication Technology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Norman Soh
- Division of Information and Communication Technology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Tim Maybury
- Biomedical Engineering Department, Royal Children's Hospital, Melbourne, VIC, Australia
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25
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Weiss MJ, Domínguez-Gil B, Lahaie N, Nakagawa TA, Scales A, Hornby L, Green M, Gelbart B, Hawkins K, Dhanani S, Dipchand AI, Shemie SD. Development of a multinational registry of pediatric deceased organ donation activity. Pediatr Transplant 2019; 23:e13345. [PMID: 30724003 DOI: 10.1111/petr.13345] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/13/2018] [Accepted: 11/29/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are no currently agreed upon international standards for reporting of pediatric deceased organ donation activity. This leads to difficulty in comparisons between jurisdictions for both researchers and policy stakeholders. The goal of this project was to develop and test a standardized registry for pediatric deceased donation activity. METHODS Four countries (Canada, Spain, USA, and the UK) with geographical and practice diversity were approached to participate. Iterative exchanges were used to create data fields and definitions that were acceptable to all participants. Data from 2011 to 2015 (inclusive) were requested from national health databases and analyzed on a secure, web-based survey platform. RESULTS Data were obtained from three of the four countries (Canada unable to provide). Total pediatric donation rates were stable over the 5-year period, but with variation between countries. pDCD rates were the most variable, representing 32.2% of total pediatric donation in the UK, 14.4% in the United States, and 2.6% in Spain during the studied period. Most organs from pediatric donors were allocated to adult recipients, though the rates of allocation of pediatric kidneys to pediatric recipients ranged from 7% in the United States to 40% in Spain. DISCUSSION In this limited cohort of three countries, we demonstrated substantial variation in pediatric donation rates and practice. These data highlight opportunities for practice improvement such as the development of rigorous clinical practice guidelines. Future development of this registry will seek to engage more countries, and address barriers that prevented full participation of approached jurisdictions.
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Affiliation(s)
- Matthew J Weiss
- Division of Pediatric Intensive Care, Centre-Mère Enfant Soleil du CHU de Québec, Québec City, Québec, Canada.,Department of Pediatrics, Faculté de Médecine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, CHU de Québec-Université Laval Research Center, Traumatology-Emergency-Critical Care Medicine, Université Laval, Québec City, Québec, Canada.,Deceased Donation, Transplant Québec, Montréal, Québec, Canada.,Canadian Donation and Transplant Research Program, Edmonton, Alberta, Canada.,Deceased Donation, Canadian Blood Services, Ottawa, Ontario, Canada
| | | | - Nick Lahaie
- Deceased Donation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Thomas A Nakagawa
- Department of Anesthesiology and Critical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Angie Scales
- National Health Service, Blood and Transplant, Bristol, UK
| | - Laura Hornby
- Deceased Donation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Meagan Green
- Deceased Donation, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Ben Gelbart
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Kay Hawkins
- National Health Service, Blood and Transplant, Bristol, UK
| | - Sonny Dhanani
- Canadian Donation and Transplant Research Program, Edmonton, Alberta, Canada.,Deceased Donation, Canadian Blood Services, Ottawa, Ontario, Canada.,Division of Critical Care, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Anne I Dipchand
- Department of Paediatrics, Labatt Family Heart Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sam D Shemie
- Deceased Donation, Canadian Blood Services, Ottawa, Ontario, Canada.,Division of Critical Care, Montreal Children's Hospital, McGill University Health Centre and Research Institute, Montréal, Québec, Canada.,Department of Pediatrics, McGill University, Montréal, Québec, Canada
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26
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Schlapbach LJ, Gelbart B, Festa M, Kanthimathinathan HK, Peters MJ. Global paediatric critical care research: mind the gaps. Intensive Care Med 2019; 45:753-754. [PMID: 30840117 DOI: 10.1007/s00134-019-05571-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Luregn J Schlapbach
- Paediatric Critical Care Research Group, Child Health Research Center, Faculty of Medicine, The University of Queensland, Brisbane, Australia. .,Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, 4101, Australia.
| | - Ben Gelbart
- University of Melbourne, Melbourne, Australia.,Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Marino Festa
- Paediatric Intensive Care Unit, Children's Hospital Westmead, Sydney, Australia.,Kids Critical Care Research Group, Kids Research, Sydney Children's Hospitals Network, Sydney, Australia
| | | | | | - M J Peters
- Respiratory, Critical Care and Anaesthesia Unit, University College London Great Ormond Street, Institute of Child Health, London, UK.,Paediatric Intensive Care Unit, Great Ormond St Hospital NHS Foundation Trust, London, UK
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27
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George S, Humphreys S, Williams T, Gelbart B, Chavan A, Rasmussen K, Ganeshalingham A, Erickson S, Ganu SS, Singhal N, Foster K, Gannon B, Gibbons K, Schlapbach LJ, Festa M, Dalziel S, Schibler A. Transnasal Humidified Rapid Insufflation Ventilatory Exchange in children requiring emergent intubation (Kids THRIVE): a protocol for a randomised controlled trial. BMJ Open 2019; 9:e025997. [PMID: 30787094 PMCID: PMC6398737 DOI: 10.1136/bmjopen-2018-025997] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Emergency intubation of children with abnormal respiratory or cardiac physiology is a high-risk procedure and associated with a high incidence of adverse events including hypoxemia. Successful emergency intubation is dependent on inter-related patient and operator factors. Preoxygenation has been used to maximise oxygen reserves in the patient and to prolong the safe apnoeic time during the intubation phase. Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) prolongs the safe apnoeic window for a safe intubation during elective intubation. We designed a clinical trial to test the hypothesis that THRIVE reduces the frequency of adverse and hypoxemic events during emergency intubation in children and to test the hypothesis that this treatment is cost-effective compared with standard care. METHODS AND ANALYSIS The Kids THRIVE trial is a multicentre randomised controlled trial performed in participating emergency departments and paediatric intensive care units. 960 infants and children aged 0-16 years requiring emergency intubation for all reasons will be enrolled and allocated to THRIVE or control in a 1:1 allocation with stratification by site, age (<1, 1-7 and >7 years) and operator (junior and senior). Children allocated to THRIVE will receive weight appropriate transnasal flow rates with 100% oxygen, whereas children in the control arm will not receive any transnasal oxygen insufflation. The primary outcomes are defined as follows: (1) hypoxemic event during the intubation phase defined as SpO2 <90% (patient-dependent variable) and (2) first intubation attempt success without hypoxemia (operator-dependent variable). Analyses will be conducted on an intention-to-treat basis. ETHICS AND DISSEMINATION Ethics approval for the protocol and consent process has been obtained (HREC/16/QRCH/81). The trial has been actively recruiting since May 2017. The study findings will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ACTRN12617000147381.
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Affiliation(s)
- Shane George
- Children’s Critical Care Service, Gold Coast University Hospital, Southport, Queensland, Australia
- School of Medicine, Griffith University, Southport, Queensland, Australia
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Paediatric Study Group, Australia and New Zealand Intensive Care Society (ANZICS PSG), Melbourne, Victoria, Australia
| | - Susan Humphreys
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - Tara Williams
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Arjun Chavan
- Paediatric Intensive Care Unit, The Townsville Hospital, Townsville, Queensland, Australia
| | - Katie Rasmussen
- Critical Care Division, Queensland Children’s Hospital, Brisbane, Queensland, Australia
- Paediatric Emergency Research Unit, Centre for Children’s Health Research, Children’s Health Queensland, Brisbane, Queensland, Australia
| | | | - Simon Erickson
- Paediatric Critical Care, Perth Children’s Hospital, Perth, Western Australia, Australia
| | - Subodh Suhas Ganu
- Department of Paediatric Critical Care Medicine, Women’s and Children’s Hospital, North Adelaide, South Australia, Australia
| | - Nitesh Singhal
- Paediatric Intensive Care Unit, Royal Alexandra Hospital for Children, Westmead, New South Wales, Australia
| | - Kelly Foster
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Paediatric Emergency Research Unit, Centre for Children’s Health Research, Children’s Health Queensland, Brisbane, Queensland, Australia
| | - Brenda Gannon
- Centre for the Business and Economics of Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Kristen Gibbons
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - Luregn J Schlapbach
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - Marino Festa
- Paediatric Study Group, Australia and New Zealand Intensive Care Society (ANZICS PSG), Melbourne, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Alexandra Hospital for Children, Westmead, New South Wales, Australia
| | - Stuart Dalziel
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Starship Children’s Hospital, Auckland, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Andreas Schibler
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Study Group, Australia and New Zealand Intensive Care Society (ANZICS PSG), Melbourne, Victoria, Australia
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Gelbart B, Bitker L, Segal A, Soh N, Maybury T, Hutchinson A. Haemodynamic Response to Fluid Bolus Therapy in Children Following Cardiac Surgery. Aust Crit Care 2019. [DOI: 10.1016/j.aucc.2018.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Darvall JN, Durie M, Pilcher D, Wigmore G, French C, Karalapillai D, McGain F, Newbigin E, Byrne T, Sarode V, Gelbart B, Casamento A, Dyett J, Crosswell A, Vetro J, McCaffrey J, Taori G, Subramaniam A, MacIsaac C, Cross A, Ku D, Bellomo R. Intensive care implications of epidemic thunderstorm asthma. CRIT CARE RESUSC 2018; 20:294-303. [PMID: 30482137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To investigate the environmental precipitants, treatment and outcome of critically ill patients affected by the largest and most lethal reported epidemic of thunderstorm asthma. DESIGN, SETTING AND PARTICIPANTS Retrospective multicentre observational study. Meteorological, airborne particulate and pollen data, and a case series of 35 patients admitted to 15 intensive care units (ICUs) due to the thunderstorm asthma event of 21-22 November 2016, in Victoria, Australia, were analysed and compared with 1062 total ICU-admitted Australian patients with asthma in 2016. MAIN OUTCOME MEASURES Characteristics and outcomes of total ICU versus patients with thunderstorm asthma, the association between airborne particulate counts and storm arrival, and ICU resource utilisation. RESULTS All 35 patients had an asthma diagnosis; 13 (37%) had a cardiac or respiratory arrest, five (14%) died. Compared with total Australian ICU-admitted patients with asthma in 2016, patients with thunderstorm asthma had a higher mortality (15% v 1.3%, P < 0.001), were more likely to be male (63% v 34%, P < 0.001), to be mechanically ventilated, and had shorter ICU length of stay in survivors (median, 31.8 hours [interquartile range (IQR), 14.8-43.6 hours] v 40.7 hours [IQR, 22.3-75.1 hours]; P = 0.025). Patients with cardiac arrest were more likely to be born in Asian or subcontinental countries (5/10 [50%] v 4/25 [16%]; relative risk, 3.13; 95% CI, 1.05-9.31). A temporal link was demonstrated between airborne particulate counts and arrival of the storm. The event used 15% of the public ICU beds in the region. CONCLUSION Arrival of a triggering storm is associated with an increase in respirable airborne particles. Affected critically ill patients are young, have a high mortality, a short duration of bronchospasm, and a prior diagnosis of asthma is common.
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Affiliation(s)
- Jai N Darvall
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Vic, Australia.
| | - Matthew Durie
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - David Pilcher
- Department of Intensive Care, Alfred Hospital, Melbourne, Vic, Australia
| | - Geoffrey Wigmore
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Craig French
- Department of Intensive Care, Western Health, Melbourne, Vic, Australia
| | | | - Forbes McGain
- Department of Intensive Care, Western Health, Melbourne, Vic, Australia
| | - Edward Newbigin
- School of BioSciences, University of Melbourne, Melbourne, Vic, Australia
| | - Timothy Byrne
- Department of Intensive Care, Alfred Hospital, Melbourne, Vic, Australia
| | - Vineet Sarode
- Department of Intensive Care, Cabrini Hospital, Melbourne, Vic, Australia
| | - Ben Gelbart
- Centre for Integrated Critical Care, University of Melbourne, Melbourne, Vic, Australia
| | - Andrew Casamento
- Department of Intensive Care, Austin Hospital, Melbourne, Vic, Australia
| | - John Dyett
- Intensive Care Service, Box Hill Hospital, Eastern Health, Melbourne, Vic, Australia
| | - Ashley Crosswell
- Department of Intensive Care, St Vincent's Hospital, Melbourne, Vic, Australia
| | - Joseph Vetro
- Intensive Care Service, Box Hill Hospital, Eastern Health, Melbourne, Vic, Australia
| | - Joseph McCaffrey
- Department of Intensive Care, University Hospital Geelong, Geelong, Vic, Australia
| | - Gopal Taori
- Department of Intensive Care, Monash Hospital, Melbourne, Vic, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care, Frankston Hospital, Melbourne, Vic, Australia
| | - Christopher MacIsaac
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Anthony Cross
- School of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - David Ku
- Department of Intensive Care, Dandenong Hospital, Melbourne, Vic, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Vic, Australia
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Gelbart B, Schlapbach L, Ganeshalingham A, Ganu S, Erickson S, Oberender F, Hoq M, Williams G, George S, Festa M. Fluid bolus therapy in critically ill children: a survey of practice among paediatric intensive care doctors in Australia and New Zealand. CRIT CARE RESUSC 2018; 20:131-138. [PMID: 29852852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Fluid bolus therapy (FBT) is a widely used intervention in paediatric critical illness. The aim of this study was to describe the attitudes and practices towards FBT of paediatric intensive care doctors in Australia and New Zealand. DESIGN An internet-based survey of paediatric intensive care doctors in Australia and New Zealand between 7 and 30 November 2016. SETTING Paediatric intensive care units with greater than 400 admissions annually. PARTICIPANTS Paediatric intensive care specialists and junior medical staff. MAIN OUTCOME MEASURES Preferences for FBT and markers of fluid responsiveness. RESULTS There were 106/175 respondents (61%); 0.9% saline and 4% albumin are used frequently or almost always by 86% and 57% of respondents respectively. The preferred volume and duration were 10 mL/kg in less than 10 minutes. The highest rated markers of fluid responsiveness were heart rate and blood pressure - rated as "good" or "very good" by 75% and 58% of respondents respectively. Central venous saturations and serum lactate were the highest rated biochemical markers. The most frequently expected magnitude of change for heart rate and blood pressure was 6-15% by 89% and 76% of respondents respectively. The preferred fluid composition for sepsis, trauma, traumatic brain injury and acute lung injury was 0.9% saline, and 4% albumin for post-operative cardiac surgery. CONCLUSIONS Paediatric intensive care doctors prefer 0.9% saline and 4% albumin for FBT. Heart rate and blood pressure are the most preferred markers to assess fluid responsiveness. Preferences for FBT in specific conditions exist.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, Vic, Australia.
| | - Luregn Schlapbach
- Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland, Brisbane, Qld, Australia
| | | | - Subodh Ganu
- Women's and Children's Hospital Network, Adelaide, SA, Australia
| | - Simon Erickson
- Paediatric Intensive Care Unit, Princess Margaret Hospital for Children, Perth, WA, Australia
| | | | - Monsurul Hoq
- Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Gary Williams
- Paediatric Intensive Care Unit, Sydney Children's Hospital, Randwick, Sydney, NSW, Australia
| | - Shane George
- Gold Coast University Hospital, Southport, Qld, Australia
| | - Marino Festa
- Paediatric Intensive Care Unit, Children's Hospital at Westmead, Sydney, NSW, Australia
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Thien F, Beggs PJ, Csutoros D, Darvall J, Hew M, Davies JM, Bardin PG, Bannister T, Barnes S, Bellomo R, Byrne T, Casamento A, Conron M, Cross A, Crosswell A, Douglass JA, Durie M, Dyett J, Ebert E, Erbas B, French C, Gelbart B, Gillman A, Harun NS, Huete A, Irving L, Karalapillai D, Ku D, Lachapelle P, Langton D, Lee J, Looker C, MacIsaac C, McCaffrey J, McDonald CF, McGain F, Newbigin E, O'Hehir R, Pilcher D, Prasad S, Rangamuwa K, Ruane L, Sarode V, Silver JD, Southcott AM, Subramaniam A, Suphioglu C, Susanto NH, Sutherland MF, Taori G, Taylor P, Torre P, Vetro J, Wigmore G, Young AC, Guest C. The Melbourne epidemic thunderstorm asthma event 2016: an investigation of environmental triggers, effect on health services, and patient risk factors. Lancet Planet Health 2018; 2:e255-e263. [PMID: 29880157 DOI: 10.1016/s2542-5196(18)30120-7] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/28/2018] [Accepted: 05/16/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND A multidisciplinary collaboration investigated the world's largest, most catastrophic epidemic thunderstorm asthma event that took place in Melbourne, Australia, on Nov 21, 2016, to inform mechanisms and preventive strategies. METHODS Meteorological and airborne pollen data, satellite-derived vegetation index, ambulance callouts, emergency department presentations, and data on hospital admissions for Nov 21, 2016, as well as leading up to and following the event were collected between Nov 21, 2016, and March 31, 2017, and analysed. We contacted patients who presented during the epidemic thunderstorm asthma event at eight metropolitan health services (each including up to three hospitals) via telephone questionnaire to determine patient characteristics, and investigated outcomes of intensive care unit (ICU) admissions. FINDINGS Grass pollen concentrations on Nov 21, 2016, were extremely high (>100 grains/m3). At 1800 AEDT, a gust front crossed Melbourne, plunging temperatures 10°C, raising humidity above 70%, and concentrating particulate matter. Within 30 h, there were 3365 (672%) excess respiratory-related presentations to emergency departments, and 476 (992%) excess asthma-related admissions to hospital, especially individuals of Indian or Sri Lankan birth (10% vs 1%, p<0·0001) and south-east Asian birth (8% vs 1%, p<0·0001) compared with previous 3 years. Questionnaire data from 1435 (64%) of 2248 emergency department presentations showed a mean age of 32·0 years (SD 18·6), 56% of whom were male. Only 28% had current doctor-diagnosed asthma. 39% of the presentations were of Asian or Indian ethnicity (25% of the Melbourne population were of this ethnicity according to the 2016 census, relative risk [RR] 1·93, 95% CI 1·74-2·15, p <0·0001). Of ten individuals who died, six were Asian or Indian (RR 4·54, 95% CI 1·28-16·09; p=0·01). 35 individuals were admitted to an intensive care unit, all had asthma, 12 took inhaled preventers, and five died. INTERPRETATION Convergent environmental factors triggered a thunderstorm asthma epidemic of unprecedented magnitude, tempo, and geographical range and severity on Nov 21, 2016, creating a new benchmark for emergency and health service escalation. Asian or Indian ethnicity and current doctor-diagnosed asthma portended life-threatening exacerbations such as those requiring admission to an ICU. Overall, the findings provide important public health lessons applicable to future event forecasting, health care response coordination, protection of at-risk populations, and medical management of epidemic thunderstorm asthma. FUNDING None.
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Affiliation(s)
- Francis Thien
- Eastern Health, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia.
| | | | - Danny Csutoros
- Department of Health and Human Services, Melbourne, VIC, Australia
| | - Jai Darvall
- Melbourne Health, Melbourne, VIC, Australia; The University of Melbourne, Melbourne, VIC, Australia
| | - Mark Hew
- Alfred Health, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | - Janet M Davies
- Queensland University of Technology, Brisbane, QLD, Australia; Metro North Hospital and Health Service, Brisbane, QLD, Australia
| | - Philip G Bardin
- Monash Health, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | | | | | - Rinaldo Bellomo
- The University of Melbourne, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia; Austin Health, Melbourne, VIC, Australia
| | | | | | | | | | | | - Jo A Douglass
- Melbourne Health, Melbourne, VIC, Australia; The University of Melbourne, Melbourne, VIC, Australia
| | | | - John Dyett
- Eastern Health, Melbourne, VIC, Australia
| | | | | | | | - Ben Gelbart
- Royal Children's Hospital, Melbourne, VIC, Australia
| | | | | | - Alfredo Huete
- University of Technology Sydney, Sydney, NSW, Australia
| | - Louis Irving
- Melbourne Health, Melbourne, VIC, Australia; The University of Melbourne, Melbourne, VIC, Australia
| | | | - David Ku
- Monash Health, Melbourne, VIC, Australia
| | | | | | - Joy Lee
- Alfred Health, Melbourne, VIC, Australia
| | - Clare Looker
- Department of Health and Human Services, Melbourne, VIC, Australia
| | | | | | - Christine F McDonald
- The University of Melbourne, Melbourne, VIC, Australia; Austin Health, Melbourne, VIC, Australia
| | | | | | - Robyn O'Hehir
- Alfred Health, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | - David Pilcher
- Alfred Health, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia; The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation (CORE), Melbourne, VIC, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - Paul Torre
- Environmental Protection Authority Victoria, Melbourne, VIC, Australia
| | | | | | - Alan C Young
- Eastern Health, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | - Charles Guest
- Department of Health and Human Services, Melbourne, VIC, Australia
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Nguyen T, Cranswick N, Rosenbaum J, Gelbart B, Tosif S. Chronic use of teething gel causing salicylate toxicity. J Paediatr Child Health 2018; 54:576-578. [PMID: 29488345 DOI: 10.1111/jpc.13861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/10/2017] [Accepted: 11/29/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Trung Nguyen
- Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Noel Cranswick
- Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Clinical Pharmacology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Jeremy Rosenbaum
- Department of Gastroenterology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Shidan Tosif
- Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
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Abstract
Sepsis is a leading cause of morbidity and mortality in children with a worldwide prevalence in pediatric intensive care units of approximately 8%. Fluid bolus therapy (FBT) is a first line therapy for resuscitation of septic shock and has been a recommendation of international guidelines for nearly two decades. The evidence base supporting these guidelines are based on limited data including animal studies and case control studies. In recent times, evidence suggesting harm from fluid in terms of morbidity and mortality have generated interest in evaluating FBT. In view of this, studies of fluid restrictive strategies in adults and children have emerged. The complexity of studying FBT relates to several points. Firstly, the physiological and haemodynamic response to FBT including magnitude and duration is not well described in children. Secondly, assessment of the circulation is based on non-specific clinical signs and limited haemodynamic monitoring with limited physiological targets. Thirdly, FBT exists in a complex myriad of pathophysiological responses to sepsis and other confounding therapies. Despite this, a greater understanding of the role of FBT in terms of the physiological response and possible harm is warranted. This review outlines current knowledge and future direction for FBT in sepsis.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit Royal Children's Hospital, Melbourne, VIC, Australia.,Murdoch Childrens Research Institute, Melbourne, VIC, Australia.,The University of Melbourne, Melbourne, VIC, Australia
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Bihari S, Gelbart B, Seppelt I, Thompson K, Watts N, Prakash S, Festa M, Bersten A. Maintenance fluid practices in paediatric intensive care units in Australia and New Zealand. CRIT CARE RESUSC 2017; 19:310-317. [PMID: 29202257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Maintenance fluid administration is a common practice in paediatric intensive care units (PICUs), contributing to daily fluid intake and fluid balance, but little is known about this practice. OBJECTIVES To determine the volume and type of maintenance fluid delivered to PICU patients, and to assess changes in practice compared with a previous time point. METHODS A prospective, observational, single-day, point prevalence study of paediatric patients from 11 Australian and New Zealand PICUs, conducted in 2014. RESULTS Seventy-two patients were enrolled. The median age and weight of infants aged < 1 year (n = 34) were 2 months (interquartile range [IQR],1-4) and 5 kg (IQR, 4-6), respectively; while in children ≥ 1 year of age (n = 38), these were 4 years (IQR, 2-8) and 17 kg (IQR, 12-23), respectively. On the study day, 19 infants (56%) and 19 children aged ≥ 1 year (50%) received maintenance fluids. Infants received a median of 23 mL/kg (IQR, 12-45) of maintenance fluid in addition to 51 mL/kg (IQR, 40-72) of fluid and nutrition from other sources; maintenance fluids contributed 29% (IQR, 13%-60%) of the total daily fluid intake. Children ≥ 1 year of age received a median of 18 mL/kg (IQR, 9-37) of maintenance fluid in addition to 39 mL/kg (IQR, 25-53) of fluid and nutrition from other sources; maintenance fluids contributed 33% (IQR, 17%-69%) of the total daily fluid intake. When compared with similar data from 2011, there was no change in the amount of maintenance fluid given, which was administered mostly as isotonic fluids. CONCLUSION Maintenance fluid contributes about a third of total fluid administration in children in Australian and New Zealand PICUs and is mostly administered as isotonic solutions.
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Affiliation(s)
- Shailesh Bihari
- Department of ICCU, Flinders Medical Centre, Adelaide, SA, Australia.
| | - Ben Gelbart
- Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Ian Seppelt
- Critical Care and Trauma Division, The George Institute for Global Health, Sydney, NSW, Australia
| | - Kelly Thompson
- Critical Care and Trauma Division, The George Institute for Global Health, Sydney, NSW, Australia
| | - Nicola Watts
- Critical Care and Trauma Division, The George Institute for Global Health, Sydney, NSW, Australia
| | - Shivesh Prakash
- Department of ICCU, Flinders Medical Centre, Adelaide, SA, Australia
| | - Marino Festa
- Kids Research Institute, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Andrew Bersten
- Department of ICCU, Flinders Medical Centre, Adelaide, SA, Australia
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Corkery-Lavender T, Millar J, Cavazzoni E, Gelbart B. Patterns of organ donation in children in Australia and New Zealand. CRIT CARE RESUSC 2017; 19:296-302. [PMID: 29202255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Paediatric organ donation (OD) represents a small proportion of total OD in Australia and New Zealand. Our aim was to describe the patterns of paediatric OD, specifically, the demographic characteristics and donation outcomes over two time periods. DESIGN We performed a retrospective study using national OD and intensive care registry data from intensive care units in Australia and New Zealand from 1 January 2000 to 31 December 2015. Data were analysed between two time periods. Paediatric data were compared with adult data. PARTICIPANTS Organ donors aged under 16 years in paediatric and mixed adult and paediatric ICUs. RESULTS There were 267 paediatric organ donors, representing 5.4% of all donors. The rate of OD as a percentage of ICU deaths was comparable to adults (6.0% v 4.6%; P < 0.001). Over the entire period, donations after brain death totalled 244 (91.4%), and donations after circulatory death (DCDs) totalled 23 (8.6%). DCDs increased from 0.7% to 17% between the time periods (P < 0.001). Children aged under 2 years had a lower rate of donation than the general paediatric cohort (1.2% v 6.0%; P < 0.001). CONCLUSIONS Paediatric OD rates have not changed over time but are comparable to adults when expressed as a percentage of ICU deaths. Paediatric DCD has increased significantly over time.
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Affiliation(s)
| | - Johnny Millar
- Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
| | | | - Ben Gelbart
- Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
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Abstract
Fluid bolus therapy (FBT) is a cornerstone of the management of the septic child, but clinical research in this field is challenging to perform, and hard to interpret. The evidence base for independent benefit from liberal FBT in the developed world is limited, and the Fluid Expansion as Supportive Therapy (FEAST) trial has led to conservative changes in the World Health Organization-recommended approach to FBT in resource-poor settings. Trials in the intensive care unit (ICU) and emergency department settings post-FEAST have continued to explore liberal FBT strategies as the norm, despite a strong signal associating fluid accumulation with pulmonary pathology in the paediatric population. Modern clinical trial methodology may ameliorate the traditional challenges of performing randomised interventional trials in critically ill children. Such trials could examine differing strategies of fluid resuscitation, or compare early FBT to early vasoactive agent use. Given the ubiquity of FBT and the potential for harm, appropriately powered examinations of the efficacy of FBT compared to alternative interventions in the paediatric emergency and ICU settings in the developed world appear justified and warranted.
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Affiliation(s)
- N J Glassford
- Registrar and Clinical Research Fellow, Department of Intensive Care, Austin Hospital, PhD Candidate, Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Melbourne, Victoria
| | - B Gelbart
- Staff Specialist, Department of Intensive Care, Royal Children's Hospital, Honorary Fellow, Murdoch Childrens Research Institute, Melbourne, Victoria
| | - R Bellomo
- Director of Intensive Care Research, Department of Intensive Care, Austin Hospital, Co-director and Honorary Professor, Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Professor of Intensive Care, School of Medicine, The University of Melbourne, Melbourne, Victoria
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Abstract
Paediatric organ donation represents a small fraction of overall organ donation in Australia and New Zealand and indeed world-wide. Many factors contribute to low donation rates including low paediatric intensive care mortality, consent rates and medical suitability relating to disease, age and size. In the past decade, the re-emergence of donation after circulatory death has changed the landscape for the paediatric population. This article reviews the current status and challenges of organ donation for the paediatric population.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital, Murdoch Children's Research Institute, DonateLife, Victoria, Melbourne, Victoria, Australia
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38
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Schlapbach LJ, Straney L, Gelbart B, Alexander J, Franklin D, Beca J, Whitty JA, Ganu S, Wilkins B, Slater A, Croston E, Erickson S, Schibler A. Burden of disease and change in practice in critically ill infants with bronchiolitis. Eur Respir J 2017; 49:49/6/1601648. [DOI: 10.1183/13993003.01648-2016] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 03/03/2017] [Indexed: 11/05/2022]
Abstract
Bronchiolitis represents the most common cause of non-elective admission to paediatric intensive care units (ICUs).We assessed changes in admission rate, respiratory support, and outcomes of infants <24 months with bronchiolitis admitted to ICU between 2002 and 2014 in Australia and New Zealand.During the study period, bronchiolitis was responsible for 9628 (27.6%) of 34 829 non-elective ICU admissions. The estimated population-based ICU admission rate due to bronchiolitis increased by 11.76 per 100 000 each year (95% CI 8.11–15.41). The proportion of bronchiolitis patients requiring intubation decreased from 36.8% in 2002, to 10.8% in 2014 (adjusted OR 0.35, 95% CI 0.27–0.46), whilst a dramatic increase in high-flow nasal cannula therapy use to 72.6% was observed (p<0.001). We observed considerable variability in practice between units, with six-fold differences in risk-adjusted intubation rates that were not explained by ICU type, size, or major patient factors. Annual direct hospitalisation costs due to severe bronchiolitis increased to over USD30 million in 2014.We observed an increasing healthcare burden due to severe bronchiolitis, with a major change in practice in the management from invasive to non-invasive support that suggests thresholds to admittance of bronchiolitis patients to ICU have changed. Future studies should assess strategies for management of bronchiolitis outside ICUs.
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Gelbart B, Corkery-Lavender T, Millar J, Cavazzoni E. Epidemiology of paediatric organ donation in Australia and New Zealand. Aust Crit Care 2017. [DOI: 10.1016/j.aucc.2017.02.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Gelbart B, De Marco R, Hussey A, Namachivayam S, Flett T, McRae R, Quinlan C, Duke T. Characteristics and outcomes in rhabdomyolysis in a paediatric intensive care unit. Aust Crit Care 2017. [DOI: 10.1016/j.aucc.2017.02.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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41
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Schlapbach L, Straney L, Gelbart B, Alexander J, Franklin D, Beca J, Whitty J, Ganu S, Wilkins B, Slater A, Croston E, Erickson S. Burden of disease and change in practice in critically ill infants with bronchiolitis in Australia and New Zealand 2002 to 2014. Aust Crit Care 2017. [DOI: 10.1016/j.aucc.2017.02.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Abstract
Croup remains the commonest reason for acute upper airway obstruction in children, yet there are scarce contemporary data of airway management in those requiring intubation. We performed a retrospective analysis of the intensive care management of children intubated for croup in two quaternary Paediatric Intensive Care Units: Royal Children's Hospital Melbourne, Australia and Alberta Children's Hospital Calgary, Canada. Patients intubated for less than three days were compared with those intubated for greater than three days. Patients less than 10 kg body weight were compared to those greater than 10 kg. Demographic, clinical and microbiological data were recorded. Seventy-seven cases of croup requiring intubation were identified. The median duration of intubation was 60 hours. Parainfluenza was the most common viral aetiology, detected in 30% of cases. Antibiotics were prescribed in 51% of patients. Corticosteroids were prescribed pre intubation in two-thirds of patients and all post intubation, with the median dose being prednisolone 3 mg/kg/day. Primary extubation failure occurred in 6.5% of patients. Neither the duration of intubation nor patient size were associated with extubation failure. An air leak test was performed in 69% of patients and poorly predicted extubation success. One non-urgent tracheostomy was performed and there was one death from hypoxic ischaemic encephalopathy. Endotracheal tube leak is poorly recorded and may not predict successful extubation.
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Affiliation(s)
- B Gelbart
- Paediatric Intensive Care, Royal Children's Hospital, Melbourne, Victoria, Murdoch Children's Research Institute Melbourne Victoria
| | - S Parsons
- Alberta Children's Hospital, Calgary, Alberta, Canada
| | - A Sarpal
- Children's Hospital London Health Sciences Centre, Ontario, Canada
| | - P Ninova
- Department of Pediatrics, Alberta Children's Hospital, Calgary Alberta, Canada
| | - W Butt
- Paediatric Intensive Care Unit, Melbourne, Victoria
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43
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Gelbart B, Creati B. Anaesthesia training in a private healthcare facility. Anaesth Intensive Care 2013; 41:429-431. [PMID: 23659410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Abstract
AIM To assess the quality of neonatal resuscitation using video recordings in a perinatal centre. METHODS Video recording was performed during high-risk deliveries between August 2007 and January 2008. Video recordings of neonatal resuscitations were assessed using a scoring tool previously used to assess resuscitation performance. Qualitative assessments and observations of team function and technical aspects of management were also recorded. Apgar scores documented in the Medical History and those derived from the video record were compared. RESULTS Twenty video recordings of neonatal resuscitations were assessed. Of the assessed domains; invasive ventilation and administration of surfactant were performed best with median scores of 100%. Performed least well were preparation and initial steps as well as the assessment and communication of heart rate (HR); 69% and 75%, respectively. Apgar scores were overestimated by a median value of 2 points at both 1 and 5 min (P < 0.001). Errors during resuscitation included inadequate oropharyngeal suction, aggressive stimulation, poor communication of heart rate and inadequate non-invasive ventilation. Failure to detect deterioration was also observed. CONCLUSION Video recording identified strengths and weaknesses in the performance of neonatal resuscitation and can facilitate targeted education and quality assurance programmes.
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Affiliation(s)
- Ben Gelbart
- Mercy Hospital for Women, 163 Studley Road Heidelberg 3084, Victoria, Australia.
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45
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Crawford NW, Yeo V, Hunt RW, Barfield C, Gelbart B, Buttery JP. Immunisation practices in infants born prematurely: neonatologists' survey and clinical audit. J Paediatr Child Health 2009; 45:602-9. [PMID: 19751374 DOI: 10.1111/j.1440-1754.2009.01573.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To determine Australian neonatologists' recommendations for the immunisation of ex-preterm infants and compare their actual immunisation status with recommended Australian guidelines. METHODS A self-administered nine-part questionnaire of current immunisation practices was sent to all Neonatologists in Australia (2006). A complementary retrospective immunisation audit was conducted in two tertiary neonatal units in Melbourne. Hospital records and the Australian Childhood Immunisation Register (ACIR) were reviewed; consenting parents were interviewed and primary care physicians' vaccination records were requested. A random sample of preterm infants born between July 2003 and June 2005 at <32 weeks' gestation were selected. RESULTS (i) Neonatologists Survey: The response rate was 68% and the majority of neonatologists (89%) were aware of the current guidelines, but adherence to them varied from 43% to 79%. One-fifth of neonatologists personally do not receive annual influenza vaccination; and (ii) Immunisation Audit: Conducted between October 2006-May 2007 it included: 100 hospital records; 97 ACIR records; 47 parent interviews and 43 primary care vaccination records. Overall vaccination coverage was 90% at 12 months of age. Only 20% (10/50) of infants with chronic lung disease received an influenza vaccination. Vaccines were delayed by greater than one month in 15% of participants for the 2 month DTPa vaccine and 43% at 6 months. CONCLUSIONS The neonatologists survey highlighted variable adherence with immunisation guidelines. The audit confirmed preterm infants are frequently experiencing delayed vaccination and recommended additional vaccinations are often not being received. Formulation of strategies to ensure complete and timely immunisation are required, including better utilisation of the ACIR.
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Affiliation(s)
- Nigel W Crawford
- National Health and Medical Research Council (NHMRC) Centre for Clinical Research Excellence in Child and Adolescent Immunisation, Murdoch Children's Research Institute, Department of General Medicine, Royal Children's Hospital (RCH), Parkville, Victoria, Australia.
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46
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Abstract
As guidelines for neonatal resuscitation evolve from a growing evidence base, clinicians must ensure that practice is closely aligned with the available evidence, based on methodologically sound and ethically conducted research. This paper reviews ethical, legal and risk-management issues arising during the design of a quality-assurance project to make video recordings of neonatal resuscitations after high-risk deliveries. The issues, which affect patients, researchers, staff and the hospital at large, include the following: 1) Informed consent for research involving emergency procedures is often not possible, for lack of time to provide sufficient information. The mental capacity of the subject or parent may be compromised by the impending emergency, and freedom of choice is threatened by the time pressure to consent. 2) Video recording of the inevitable medical errors raises issues of whether participating staff may be identifiable and accountable, affecting their willingness to participate in such research. The approach to staff participation and identification is reviewed. 3) The use of video data for education threatens the privacy of research subjects. The ethics of maintaining privacy is balanced with the ethics of using the data to improve practice of resuscitation. 4) The research subjects (patients, or the staff whose performance is being monitored) must be defined. 5) There are legal and ethical aspects of management and ownership of data. 6) The role of the Human Research Ethics Committee in protecting the research subject and possibly the medicolegal interests of the hospital is discussed. This paper reviews the literature and discusses the issues.
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Affiliation(s)
- B Gelbart
- Royal Children's Hospital, Flemington Road, Parkville, Melbourne, Australia.
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47
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Gelbart B, Connell TG, Konstantinov IE, Phillips R, Starr M. Kingella kingae endocardial abscess and cerebral infarction in a previously well immunocompetent child. BMJ Case Rep 2009; 2009:bcr09.2009.2238. [PMID: 22190987 DOI: 10.1136/bcr.09.2009.2238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Kingella kingae is an emerging paediatric pathogen that most commonly is associated with relatively benign osteoarticular disease in children. This report concerns a 1-year-old child with Kingella kingae endocarditis and perivalvular abscess complicated by septic cerebral emboli and osteomyelitis leading to long-term neurological sequelae, highlighting the capacity of this organism to cause severe invasive disease in children.
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Affiliation(s)
- Ben Gelbart
- Royal Children's Hospital, Infectious Diseases Unit and Department of General Medicine, Flemington Road Parkville, Melbourne, Victoria, 3052, Australia
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49
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Abstract
AIM To document the burden of disease caused by an outbreak of rotavirus (RV) gastroenteritis in a remote Aboriginal community. METHODS During an outbreak of RV gastroenteritis, data were collected from patients notes, hospital and laboratory data. Age, date of presentation, severity of illness, number of total presentations, presentations per patient, total clinic hours per presentation, stool analysis, treatment and outcomes were measured. These data were compared with a time period of equal duration in order to establish a baseline burden of gastroenteritis. RESULTS In a remote Aboriginal community 26 patients were managed for acute diarrhoea between 19 September 2005 and 5 October 2005. Gastroenteritis was the diagnosis in 24 cases for which there were 55 presentations. Stool specimens were analysed in 14 (58%) cases. RV was identified in eight (57%) of these specimens. The majority (80%) had mild disease. Moderate disease was noted in 15% and 5% were follow-up reviews. There were no severe cases of gastroenteritis. Four patients required evacuation to hospital. From a total of 607 presentations to the clinic during this time period, 55 (9%) were managed for acute diarrhoea. In the comparative time period there were five (0.9%) cases of acute diarrhoea from a total of 571 presentations. CONCLUSION Rotavirus gastroenteritis places a large burden on remote Aboriginal communities and health-care centres in the form of morbidity, overworked clinic staff, economic cost and reduced capacity for primary health-care duties.
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Affiliation(s)
- Ben Gelbart
- Centre for Disease Control, Royal Darwin Hospital Campus, Casuarina, Northern Territory, Australia.
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