Shock Index as a Predictor of Morbidity and Mortality in Pediatric Trauma Patients

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Source: Pediatric Emergency Care

Objectives

Compared with unadjusted shock index (SI) (heart rate/systolic blood pressure), age-adjusted SI improves identification of negative outcomes after injury in pediatric patients. We aimed to further evaluate the utility of age-adjusted SI to predict negative outcomes in pediatric trauma.

Methods

We performed an analysis of patients younger than 15 years using the National Trauma Data Bank. Elevated SI was defined as high normal heart rate divided by low-normal blood pressure for age. Our primary outcome measure was mortality. Secondary outcomes included need for a blood transfusion, ventilation, any operating room/interventional radiology procedures, and intensive care unit stay. Multiple logistic regressions were performed.

Results

Twenty-eight thousand seven hundred forty-one cases met the study criteria. The overall mortality rate was 0.7%, and 1.7% had an elevated SI. Patients with an elevated SI were more likely (P < 0.001) to require blood transfusion, ventilation, an operating room/interventional radiology procedure, or an intensive care unit stay. An elevated SI was the strongest predictor for mortality (odds ratio [OR] 22.0) in pediatric trauma patients compared with hypotension (OR, 12.6) and tachycardia (OR, 2.6).

Conclusions

Elevated SI is an accurate and specific predictor of morbidity and mortality in pediatric trauma patients and is superior to tachycardia or hypotension alone for predicting mortality.

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Management of Pain After Pediatric Trauma

Source: Pediatric Emergency Care

Objectives

The primary objective of this study was to evaluate the management of pain after traumatic injury in the pediatric emergency department (ED) as measured by time to analgesic administration and pain resolution, stratified by triage acuity level.

Methods

This is a retrospective descriptive study evaluating the management of children who presented with pain after injury to an urban level 1 trauma center. Consecutive enrollment of 1000 patients identified by ICD-9 codes that included all injuries or external causes for injury (700–999 and all E codes) and who had pain identified by triage pain assessment was performed. For analysis, patients were grouped according to triage level.

Results

Fifty-one percent (511/1000) of patients achieved pain resolution, and an additional 20% (200/1000) of patients had documented improvement in pain score during their ED visit. Triage acuity level 1 group received medications the fastest with a median time of 12 minutes (interquartile range, 10–53 minutes); 65.3% of patients (653/1000) received a pain medication during their ED visit; 54.3% of these patients received oral medications only. Average time to intravenous line placement was 2 hours 35 minutes (SD, 2 hours 55 minutes). Only 1.9% of patients received any medications prior to arrival.

Conclusions

Higher-acuity patients received initial pain medications and had initial pain score decrease before lower-acuity patients. Given the retrospective nature of the study, we were unable to clearly identify barriers that contributed to delay in or lack of pain treatment in our patient population.

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Exploring the human factors of prescribing errors in paediatric intensive care units

Source: BMJ Archives of Disease in Childhood

Abstract

Objective To explore the factors contributing to prescribing error in paediatric intensive care units (PICUs) using a human factors approach based on Reason’s theory of error causation to support planning of interventions to mitigate slips and lapses, rules-based mistakes and knowledge-based mistakes.

 

Methods A hierarchical task analysis (HTA) of prescribing was conducted using documentary analysis. Eleven semistructured interviews with prescribers were conducted using vignettes and were analysed using template analysis. Contributory factors were identified through the interviews and were related to tasks in the HTA by an expert panel involving a PICU clinician, nurse and pharmacist.

 

Results Prescribing in PICU is composed of 30 subtasks. Our findings indicate that cognitive burden was the main contributory factor of prescribing error. This manifested in two ways: physical, associated with fatigue, distraction and interruption, and poor information transfer; and psychological, related to inexperience, changing workload and insufficient decision support information. Physical burden was associated with errors of omission or selection; psychological burden was linked to errors related to a lack of knowledge and/or awareness. Social control through nursing staff was the only identified control step. This control was dysfunctional at times as nurses were part of an informal mechanism to support decision making, was ineffective.

 

Conclusions Cognitive burden on prescribers is the principal latent factor contributing to prescribing error. This research suggests that interventions relating to skill mix, and communication and presentation of information may be effective at mitigating rule and knowledge-based mistakes. Mitigating fatigue and standardising procedures may minimise slips and lapses.

 

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Epidemiology of paediatric chronic fatigue syndrome in Australia

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Image: Pixabay

Source: BMJ Archives of Disease in Childhood

Abstract

Objective To estimate the paediatrician-diagnosed incidence of chronic fatigue syndrome (CFS) in Australia, and describe demographic and clinical features, as well as approaches to diagnosis and management.

 

Methods The Australian Paediatric Surveillance Unit facilitates monthly national surveillance of uncommon conditions seen by paediatricians. Data from young people aged <18 years diagnosed with CFS were collected. Incidence was estimated based on new cases reported from April 2015 to April 2016.

 

Results A total of 164 cases of newly diagnosed CFS in young people aged 4–17 years were identified for inclusion. The estimated national incidence for children aged 4–9 years was 0.25 per 100 000 per annum. In children aged 10–17 years, the estimated incidence of paediatrician-diagnosed cases for Victoria (17.48 per 100 000) was substantially greater than other Australian states (range 1.31–5.51 per 100 000). Most cases were female and Caucasian, most commonly presenting after an infectious illness with symptoms gradual in onset. The majority were diagnosed at least 13 months after symptom onset. Symptoms, associations, investigations and management strategies were highly variable.

 

Conclusions Current findings suggest that, consistent with other countries, the Australian incidence of CFS in children aged <10 years is very low. In contrast, the national incidence of CFS in older children and adolescents (aged 10–17 years) is more unclear, with marked variability between geographical regions apparent. This may be due to variation in service accessibility and clinician understanding of CFS. Accordingly, national initiatives to improve equity of care for children with CFS may be required.

 

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Theophylline and aminophylline for prevention of acute kidney injury in neonates and children: a systematic review

Source: BMJ Archives of Disease in Childhood

Abstract

Objective To compare the efficacy and safety of theophylline or aminophylline for prevention of acute kidney injury (AKI) in neonates and children.

 

Design Systematic review and meta-analysis with application of Grading of Recommendations, Assessment, Development and Evaluation system.

 

Data sources PubMed/MEDLINE, Embase, Google Scholar and Cochrane renal group were searched from 1970 to May 2018.

 

Eligibility criteria Randomised clinical trials and quasi-randomised trials comparing the efficacy and safety of prophylactic theophylline or aminophylline for prevention of AKI in neonates and children were included. The primary outcomes were: incidence of AKI, serum creatinine levels and all-cause mortality.

 

Results A total of nine trials were included in the qualitative synthesis. Six trials including 436 term neonates with birth asphyxia who received a single dose of theophylline were finally included in the meta-analysis. The pooled estimate showed 60% reduction in the incidence of AKI in neonates with severe birth asphyxia (RR: 0.40; 95% CI 0.3 to 0.54; heterogeneity: I2=0%) (moderate quality evidence), decrease in serum creatinine over days 2–5 (very low to low quality evidence) without significant difference in all-cause mortality (RR: 0.88; 95% CI 0.52 to 1.50; heterogeneity: I2=0%) (very low-quality evidence). A significant difference in the negative fluid balance, increase in GFR and decrease in urinary β2 microglobulin was seen in favour of theophylline.

 

Conclusion and relevance A single dose of prophylactic theophylline helps in prevention of AKI/severe renal dysfunction in term neonates with severe birth asphyxia (moderate quality evidence) without increasing the risk of complications and without affecting all-cause mortality (very low-quality evidence).

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Iodine supplementation for the prevention of mortality and adverse neurodevelopmental outcomes in preterm infants – Cochrane Review

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Background

Parenteral nutrition solutions, artificial formulas, and human breast milk contain insufficient iodine to meet recommended intakes for preterm infants. Iodine deficiency may exacerbate transient hypothyroxinaemia in preterm infants and this may be associated with adverse neonatal and longer‐term outcomes.

Objectives

To assess the evidence from randomised controlled trials that dietary supplementation with iodine reduces mortality andmorbidity in preterm infants.

Search methods

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials(CENTRAL 2018, Issue 1), Ovid MEDLINE, Ovid Embase, Ovid Maternity & Infant Care Database, and CINAHL to February 2018. Wesearched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlledtrials and quasi‐randomised trials.

Selection criteria

Randomised or quasi‐randomised controlled trials that compared supplementing enteral or parenteral feeds with iodine (asiodide salt) versus placebo or no supplementation in preterm infants.

Data collection and analysis

Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We analysed treatment effects asdescribed in the individual trials and reported risk ratios (RR) and risk differences for dichotomous data, and mean differences(MD) for continuous data, with 95% confidence intervals (CI). We used a fixed‐effect model in meta‐analyses and planned toexplore potential causes of heterogeneity in sensitivity analyses. We used the GRADE approach to assess the quality of evidence.

Main results

Two randomised controlled trials fulfilled the eligibility criteria. Both trials used methods to limit bias including allocation concealment and blinding of clinicians and investigators to the allocated intervention. The trials enrolled 1394 infants. One trial recruited 1273 participants. Most participants were born very preterm (less than 32 weeks’ gestation) and about one‐third were extremely preterm (less than 28 weeks’ gestation). Analyses found no effect of iodine supplementation on mortality before hospital discharge (typical RR 1.01, 95% CI 0.72 to 1.42; 2 studies, 1380 infants) or on neuro-developmental assessments at two years post‐term (Bayley Scales of Infant and Toddler Development, Third Edition main domain composite scores: cognitive: MD –0.30, 95% CI –2.44 to 1.84; motor: MD 0.20, 95% CI –2.15 to 2.55; language: MD –0.10, 95% CI –2.50 to 2.30; 1 study, 1259 infants). There were no differences in the proportion of infants who died or had a composite score less than 85 in any main Bayley domain(RR 1.05, 95% CI 0.94 to 1.17; 1 study, 1259 infants), or had visual impairment (RR 0.63, 95% CI 0.28 to 1.45; 1 study, 1092 infants) or auditory impairment (RR 1.05, 95% CI 0.51 to 2.16; 1 study, 1093 infants). Using GRADE methods, we assessed the evidence for the effects on mortality and neuro-development outcomes as high‐certainty.

Authors’ conclusions

The available trial data, predominantly from one large, high‐quality multi-centre study published in 2017, do not show any evidence of beneficial effects of iodine supplementation for preterm infants. Given the high certainty of these estimates of effect, further trials of this intervention in this population are unlikely to be considered research priorities.

 

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Child abuse and neglect – NICE Quality standard QS179

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Image: Pixabay

This quality standard covers recognising, assessing and responding to abuse and neglect of children and young people under 18. It covers physical, sexual and emotional abuse. This quality standard describes high-quality care in priority areas for improvement.

It does not cover areas of national policy, such as legislative changes and statutory requirements.

Link to NICE article here