Can critical care transport be safely reduced in children intubated during emergency management of status epilepticus in the United Kingdom: a national audit with case-control analysis.

OBJECTIVE: This study describes the baseline clinical characteristics, predictors of successful extubation at referring hospitals and short-term outcomes of children intubated for status epilepticus and referred to United Kingdom (UK) paediatric critical care transport teams (PCCTs). DESIGN: Multicentre audit with case-control analysis, conducted between 1 September 2018 and 1 September 2020. SETTING: This study involved 10 UK PCCTs. PATIENTS: Children over 1 month of age intubated during emergency management for status epilepticus (SE), referred to UK PCCTs. Patients with trauma, requiring time-critical neurosurgical intervention or those with a tracheostomy were excluded. INTERVENTIONS: No interventions were implemented. MEASUREMENTS AND MAIN RESULTS: Out of the 1622 referrals for SE, 1136 (70%) were intubated at referral. The median age was 3 years (IQR 1.25-6.54 years). Among the intubated children, 396 (34.8%) were extubated locally by the referring team, with 19 (4.8%) requiring reintubation. Therefore, the overall rate of successful extubation was 33% (377/1136). There was significant variation between PCCTs, with local extubation rates ranging from 2% to 74%. Multivariable analyses showed region/PCCT, contributing diagnosis, acute changes on CT, preceding encephalopathy and type of continuous sedation (midazolam) used postintubation were significantly associated with transfer to a critical care unit. CONCLUSION: This study highlights wide regional variation in early extubation practices. Regions with high successful extubation rates have established extubation guidelines from PCCTs. Successful extubation represents critical care transports that have been avoided.

Development of the Children's ACuTe UltraSound (CACTUS) point-of-care ultrasound (POCUS)-accredited training in the UK: a descriptive study.

Point-of-care ultrasound (POCUS) is an established, evidence-supported tool that can be used in neonatal and paediatric medicine, offering clinicians immediate diagnostic insights, assessment of interventions and improved safety profiles and success rate of various procedures. Its effective use requires an established education programme, governance and standardisation to ensure competence in this skill. While adult clinical practice has established POCUS training protocols, this had not been replicated in paediatrics. This article describes the development and launch of the UK's inaugural accredited paediatric-specific POCUS curriculum and training pathway: the 'Children's ACuTe UltraSound' course, addressing this significant gap in paediatric healthcare education and describing the training delivered and available for paediatricians and allied health professionals working with children.

Continuous Drug Delivery is Significantly Affected by Relative Height Changes Between Patient and Syringe Driver.

OBJECTIVE: Syringe drivers are the principle method of giving small-volume continuous infusions of important drugs to patients. Many of these drugs are critical for the maintenance of normal physiology. Anecdotal evidence abounds of severe patient instability on movement of syringe drivers during infusion. We aimed to define the variation in drug delivery seen in three syringe drivers, with changes in relative height between the syringe driver and the end of the giving set. DESIGN: Three syringe drivers (Alaris CC [Becton Dickinson], Perfusor Space [B Braun], and Synamed µSP6000 [Arcomed]) were analyzed for reliability of flow at 0.5, 1, 2, and 5 mL/h. SETTING AND SUBJECTS: This is an in vitro investigation. INTERVENTIONS: A small air bubble was introduced into the giving set, and the progression of this was documented before and after a vertical movement of the syringe driver by 25 or 50 cm upward or downward relative to the delivery port. MEASUREMENTS AND MAIN RESULTS: For all pumps, delivery was interrupted on movement of the pumps downward, and a bolus was given with movement of the pump upward. Delivery halted at lower pump speeds for longer than higher pump speeds. The maximum delivery interruption was 11.8 minutes. Boluses given on moving the pump up were calculated as the equivalent number of minutes needed to deliver the bolus volume at steady state. The maximum bolus given was equivalent to 15.8 minutes of delivery. We were unable to eliminate the effects seen by very slow, steady movement of the pumps up or down. Static height differences made no difference to delivery. CONCLUSIONS: Syringe drivers should not be moved vertically in relation to the patient. Critical drug delivery is interrupted for up to 12 minutes with relative downward movements, and significant boluses of drugs are given with relative upward movements. As far as possible, elimination of relative height movements is advised, and extreme caution is necessary if any movements are unavoidable.

Acute Kidney Injury in Pediatric Inflammatory Multisystem Syndrome Temporally Associated With Severe Acute Respiratory Syndrome Coronavirus-2 Pandemic: Experience From PICUs Across United Kingdom.

OBJECTIVES: To study the prevalence, evolution, and clinical factors associated with acute kidney injury in children admitted to PICUs with pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2. DESIGN: Multicenter observational study. SETTING: Fifteen PICUs across the United Kingdom. PATIENTS: Patients admitted to United Kingdom PICUs with pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2 between March 14, 2020, and May 20, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Deidentified data collected as part of routine clinical care were analyzed. All children were diagnosed and staged for acute kidney injury based on the level of serum creatinine above the upper limit of reference interval values according to published guidance. Severe acute kidney injury was defined as stage 2/3 acute kidney injury. Uni- and multivariable analyses were performed to study the association between demographic data, clinical features, markers of inflammation and cardiac injury, and severe acute kidney injury. Over the study period, 116 patients with pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2 were admitted to 15 United Kingdom PICUs. Any-stage acute kidney injury occurred in 48 of 116 patients (41.4%) and severe acute kidney injury in 32 of 116 (27.6%) patients, which was mostly evident at admission (24/32, 75%). In univariable analysis, body mass index, hyperferritinemia, high C-reactive protein, Pediatric Index of Mortality 3 score, vasoactive medication, and invasive mechanical ventilation were associated with severe acute kidney injury. In multivariable logistic regression, hyperferritinemia was associated with severe acute kidney injury (compared with nonsevere acute kidney injury; adjusted odds ratio 1.04; 95% CI, 1.01-1.08; p = 0.04). Severe acute kidney injury was associated with longer PICU stay (median 5 days [interquartile range, 4-7 d] vs 3 days [interquartile range, 1.5-5 d]; p < 0.001) and increased duration of invasive mechanical ventilation (median 4 days [interquartile range, 2-6 d] vs 2 days [interquartile range, 1-3 d]; p = 0.04). CONCLUSIONS: Severe acute kidney injury occurred in just over a quarter of children admitted to United Kingdom PICUs with pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2. Hyperferritinemia was significantly associated with severe acute kidney injury. Severe acute kidney injury was associated with increased duration of stay and ventilation. Although short-term outcomes for acute kidney injury in pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2 appear good, long-term outcomes are unknown.

International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC).

BACKGROUND: Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children. METHODS: Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document. RESULTS: Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C). CONCLUSIONS: Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children. Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLAvoting method. AGREE statement was followed to prepare this document. Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C). Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

Pressure-related flow rates for continuous renal replacement therapy in very small children: an in vitro study.

OBJECTIVE: Continuous renal replacement therapy (CRRT) is extremely challenging in very small children, as most CRRT intravascular access devices are too large. We aimed to quantify flow rates through several alternative intravascular devices. DESIGN: Experimental in vitro study simulating CRRT. SETTING: Whole milk and equine blood were used as human blood substitutes due to similar viscosity. Milk under gravity pressure was run through a standard CRRT circuit. Equine blood was run through a working CRRT machine. SUBJECTS: Eight intravenous access devices used in paediatrics, with a variety of connectors. INTERVENTIONS: Devices were tested with milk for flow between 50 and 200 mm Hg pressure, and with blood for pressure at flows between 20 and 50 mL/min. MAIN OUTCOME MEASURES: Flows at each input pressure with milk, and pressures at each flow rate with blood. RESULTS: With both experimental systems, 8Fr and 6.5Fr haemodialysis catheters, and 18G and 20G cannulae allowed excellent low pressure flow rates. 5Fr triple central catheter, 5Fr and 4Fr umbilical venous catheter, and 5Fr haemodialysis catheters did not allow flows at reasonable pressures for CRRT. A three-way tap did not impede flows, but a needle-free valve did. Flows increased with pressure non-linearly, presumably due to increasing turbulence. CONCLUSIONS: In very small patients needing CRRT, where large haemodialysis catheters cannot be used due to the patient size, we advise the use of two 18G cannulae in different sites. A three-way tap can be added, but not any other connectors. In vitro this system gave suitable flow rates with some flexibility for in vivo variations.