Australasian bronchiolitis guideline.

AIM: Bronchiolitis is the most common lower respiratory tract disorder in infants aged less than 12 months, and research has demonstrated that there is substantial variation in practice patterns despite treatment being well defined. In order to align and improve the consistency of the management of bronchiolitis, an evidence-based guideline was developed for the Australasian population. METHODS: The guideline development committee included representation from emergency and paediatric specialty medical and nursing personnel in addition to geographical representation across Australia and New Zealand - rural, remote and metropolitan. Formulation of the guideline included identification of population, intervention, comparator, outcomes and time questions and was associated with an extensive literature search from 2000 to 2015. Evidence was summarised and graded using the National Health and Medical Research Council and Grading of Recommendations Assessment, Development and Evaluation methodology, and consensus within the guideline group was sought using nominal group technique principles to formulate the clinical practice recommendations. The guideline was reviewed and endorsed by key paediatric health bodies. RESULTS: The guideline consists of a usable clinical interface for bedside functionality supported by evidence summary and tables. The Grading of Recommendations Assessment, Development and Evaluation and National Health and Medical Research Council processes provided a systematic and transparent process to review and assess the literature, resulting in a guideline that is relevant to the management of bronchiolitis in the Australasian setting. CONCLUSION: This is the first robust Australasian acute paediatric guideline and provides clear guidance for the management of the vast majority of patients seen in Australasian emergency departments and general paediatric wards with bronchiolitis.

A multicentre randomised controlled trial of levetiracetam versus phenytoin for convulsive status epilepticus in children (protocol): Convulsive Status Epilepticus Paediatric Trial (ConSEPT) - a PREDICT study.

BACKGROUND: Convulsive status epilepticus (CSE) is the most common life-threatening childhood neurological emergency. Despite this, there is a lack of high quality evidence supporting medication use after first line benzodiazepines, with current treatment protocols based solely on non-experimental evidence and expert opinion. The current standard of care, phenytoin, is only 60% effective, and associated with considerable adverse effects. A newer anti-convulsant, levetiracetam, can be given faster, is potentially more efficacious, with a more tolerable side effect profile. The primary aim of the study presented in this protocol is to determine whether intravenous (IV) levetiracetam or IV phenytoin is the better second line treatment for the emergency management of CSE in children. METHODS/DESIGN: 200 children aged between 3 months and 16 years presenting to 13 emergency departments in Australia and New Zealand with CSE, that has failed to stop with first line benzodiazepines, will be enrolled into this multicentre open randomised controlled trial. Participants will be randomised to 40 mg/kg IV levetiracetam infusion over 5 min or 20 mg/kg IV phenytoin infusion over 20 min. The primary outcome for the study is clinical cessation of seizure activity five minutes following the completion of the infusion of the study medication. Blinded confirmation of the primary outcome will occur with the primary outcome assessment being video recorded and assessed by a primary outcome assessment team blinded to treatment allocation. Secondary outcomes include: Clinical cessation of seizure activity at two hours; Time to clinical seizure cessation; Need for rapid sequence induction; Intensive care unit (ICU) admission; Serious adverse events; Length of Hospital/ICU stay; Health care costs; Seizure status/death at one-month post discharge. DISCUSSION: This paper presents the background, rationale, and design for a randomised controlled trial comparing levetiracetam to phenytoin in children presenting with CSE in whom benzodiazepines have failed. This study will provide the first high quality evidence for management of paediatric CSE post first-line benzodiazepines. TRIAL REGISTRATION: Prospectively registered with the Australian and New Zealand Clinical Trial Registry (ANZCTR): ACTRN12615000129583 (11/2/2015). UTN U1111-1144-5272. ConSEPT protocol version 4 (12/12/2014).

Computed tomography for head injuries in children: Change in Australian usage rates over time.

OBJECTIVE: Paediatric head injury is a common presentation to the ED. North American studies demonstrate increasing use of computed tomography (CT) brain scan (CTB) to investigate head injury. No such data exists for Australian EDs. The aim of this study was to describe CTB use in head injury over time in eight Australian EDs. METHODS: Retrospective ED electronic database and medical imaging database audit was undertaken for the years 2001-2010 by International Classification of Diseases (ICD) 9 or 10 code for head injury in children <16 years. EDs and medical imaging departments of eight hospitals in Australia (five tertiary referral and three mixed departments). Data for ED presentations with head injury, and all CTB performed by medical imaging were merged to obtain a data set of CTB performed within 24 h for head injury-related attendances to the ED. Descriptive and comparative analysis of CTB rates was performed. RESULTS: The rate of CTB over the decade was 10.2% (95% confidence interval (CI) 9.9-10.5). The annual rate varied from 9.5% (95% CI 8.2-10.9) to 12.5% (95% CI 11.2-13.9). CTB use did not increase over time. Median year of age at time of CT scan was 4 years, with an interquartile range of 1.5-9.4 years. Overall there was a 9.2% increase in the CTB scan rate for every additional year of age at presentation (95% CI 6.6-12.1; P < 0.001). CONCLUSION: CTB use in head injuries did not increase during the study period, and rates of CTB were less than reported for North America.

Bell's palsy in children: Current treatment patterns in Australia and New Zealand. A PREDICT study.

AIM: The aetiology and clinical course of Bell's palsy may be different in paediatric and adult patients. There is no randomised placebo controlled trial (RCT) to show effectiveness of prednisolone for Bell's palsy in children. The aim of the study was to assess current practice in paediatric Bell's palsy in Australia and New Zealand Emergency Departments (ED) and determine the feasibility of conducting a multicentre RCT within the Paediatric Research in Emergency Departments International Collaborative (PREDICT). METHODS: A retrospective analysis of ED medical records of children less than 18 years diagnosed with Bell's palsy between 1 January, 2012 and 31 December, 2013 was performed. Potential participants were identified from ED information systems using Bell's palsy related search terms. Repeat presentations during the same illness were excluded but relapses were not. Data on presentation, diagnosis and management were entered into an online data base (REDCap). RESULTS: Three hundred and twenty-three presentations were included from 14 PREDICT sites. Mean age at presentation was 9.0 (SD 5.0) years with 184 (57.0%) females. Most (238, 73.7%) presented to ED within 72 h of symptoms, 168 (52.0%) had seen a doctor prior. In ED, 218 (67.5%) were treated with steroids. Prednisolone was usually prescribed for 9 days at around 1 mg/kg/day, with tapering in 35.7%. CONCLUSION: Treatment of Bell's palsy in children presenting to Australasian EDs is varied. Prednisolone is commonly used in Australasian EDs, despite lack of high-level paediatric evidence. The study findings confirm the feasibility of an RCT of prednisolone for Bell's palsy in children.

Early high flow nasal cannula therapy in bronchiolitis, a prospective randomised control trial (protocol): A Paediatric Acute Respiratory Intervention Study (PARIS).

BACKGROUND: Bronchiolitis imposes the largest health care burden on non-elective paediatric hospital admissions worldwide, with up to 15 % of cases requiring admission to intensive care. A number of previous studies have failed to show benefit of pharmaceutical treatment in respect to length of stay, reduction in PICU admission rates or intubation frequency. The early use of non-invasive respiratory support devices in less intensive scenarios to facilitate earlier respiratory support may have an impact on outcome by avoiding progression of the disease process. High Flow Nasal Cannula (HFNC) therapy has emerged as a new method to provide humidified air flow to deliver a non-invasive form of positive pressure support with titratable oxygen fraction. There is a lack of high-grade evidence on use of HFNC therapy in bronchiolitis. METHODS/DESIGN: Prospective multi-centre randomised trial comparing standard treatment (standard subnasal oxygen) and High Flow Nasal Cannula therapy in infants with bronchiolitis admitted to 17 hospitals emergency departments and wards in Australia and New Zealand, including 12 non-tertiary regional/metropolitan and 5 tertiary centres. The primary outcome is treatment failure; defined as meeting three out of four pre-specified failure criteria requiring escalation of treatment or higher level of care; i) heart rate remains unchanged or increased compared to admission/enrolment observations, ii) respiratory rate remains unchanged or increased compared to admission/enrolment observations, iii) oxygen requirement in HFNC therapy arm exceeds FiO2 ≥ 40 % to maintain SpO2 ≥ 92 % (or ≥94 %) or oxygen requirement in standard subnasal oxygen therapy arm exceeds >2L/min to maintain SpO2 ≥ 92 % (or ≥94 %), and iv) hospital internal Early Warning Tool calls for medical review and escalation of care. Secondary outcomes include transfer to tertiary institution, admission to intensive care, length of stay, length of oxygen treatment, need for non-invasive/invasive ventilation, intubation, adverse events, and cost. DISCUSSION: This large multicenter randomised trial will allow the definitive assessment of the efficacy of HFNC therapy as compared to standard subnasal oxygen in the treatment of bronchiolitis. TRIAL REGISTRATION: The trial is registered with the Australian and New Zealand Clinical Trials Registry ACTRN12613000388718 (registered on 10 April 2013).

Effect of a multifaceted intervention on documentation of vital signs and staff communication regarding deteriorating paediatric patients.

AIM: To evaluate the impact of newly designed Paediatric Early Warning Scores and an accompanying education package, COMPASS, on the frequency of documentation of vital signs and communication between health professionals and associated medical review in deteriorating paediatric patients. METHODS: One thousand fifty-nine patients in the pre-intervention phase and 899 in the post-intervention phase were studied. The daily frequency of documentation of vital sign measurement, incidence of health professional communication and related medical reviews following clinical deterioration of a random subgroup of 262 pre-intervention and 221 post-intervention patients were studied in detail. RESULTS: There were no significant differences in hospital mortality, medical emergency team reviews or unplanned admissions to critical care areas between the pre-intervention and post-intervention groups. There were significant increases in the post-intervention group for the median daily frequency of documentation of respiratory effort (0.0 (0-0) to 7.8 (5.8-12.6), P < 0.001), capillary refill (0 (0-0) to 1.1 (0-3.1), P < 0.001), blood pressure (0 (0-1.1) to 0 (0-1.6), P = 0.007) and level of consciousness (0 (0-0) to 7.8 (5.8-12.0), P < 0.001) and appropriate communication concerning patient deterioration 63 (8.5%) to 216 (40.9%), P < 0.001). There was a significant reduction in the number of children fulfilling the medical emergency team criteria (102 (38.9%) to 45 (20.4), P < 0.001). CONCLUSIONS: A multifaceted intervention for the early recognition and response to clinical deterioration in children significantly improved documentation of vital signs, communication and time to medical review.