OBJECTIVES:Delayed antimicrobials are associated with poor outcomes in adult sepsis, but data relating antimicrobial timing to mortality and organ dysfunction in pediatric sepsis are limited. We ...sought to determine the impact of antimicrobial timing on mortality and organ dysfunction in pediatric patients with severe sepsis or septic shock.
DESIGN:Retrospective observational study.
SETTING:PICU at an academic medical center.
PATIENTS:One hundred thirty patients treated for severe sepsis or septic shock.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:We determined if hourly delays from sepsis recognition to initial and first appropriate antimicrobial administration were associated with PICU mortality (primary outcome); ventilator-free, vasoactive-free, and organ failure–free days; and length of stay. Median time from sepsis recognition to initial antimicrobial administration was 140 minutes (interquartile range, 74–277 min) and to first appropriate antimicrobial was 177 minutes (90–550 min). An escalating risk of mortality was observed with each hour delay from sepsis recognition to antimicrobial administration, although this did not achieve significance until 3 hours. For patients with more than 3-hour delay to initial and first appropriate antimicrobials, the odds ratio for PICU mortality was 3.92 (95% CI, 1.27–12.06) and 3.59 (95% CI, 1.09–11.76), respectively. These associations persisted after adjustment for individual confounders and a propensity score analysis. After controlling for severity of illness, the odds ratio for PICU mortality increased to 4.84 (95% CI, 1.45–16.2) and 4.92 (95% CI, 1.30–18.58) for more than 3-hour delay to initial and first appropriate antimicrobials, respectively. Initial antimicrobial administration more than 3 hours was also associated with fewer organ failure–free days (16 interquartile range, 1–23 vs 20 interquartile range, 6–26; p = 0.04).
CONCLUSIONS:Delayed antimicrobial therapy was an independent risk factor for mortality and prolonged organ dysfunction in pediatric sepsis.
Limited data exist about the international burden of severe sepsis in critically ill children.
To characterize the global prevalence, therapies, and outcomes of severe sepsis in pediatric intensive ...care units to better inform interventional trials.
A point prevalence study was conducted on 5 days throughout 2013-2014 at 128 sites in 26 countries. Patients younger than 18 years of age with severe sepsis as defined by consensus criteria were included. Outcomes were severe sepsis point prevalence, therapies used, new or progressive multiorgan dysfunction, ventilator- and vasoactive-free days at Day 28, functional status, and mortality.
Of 6,925 patients screened, 569 had severe sepsis (prevalence, 8.2%; 95% confidence interval, 7.6-8.9%). The patients' median age was 3.0 (interquartile range IQR, 0.7-11.0) years. The most frequent sites of infection were respiratory (40%) and bloodstream (19%). Common therapies included mechanical ventilation (74% of patients), vasoactive infusions (55%), and corticosteroids (45%). Hospital mortality was 25% and did not differ by age or between developed and resource-limited countries. Median ventilator-free days were 16 (IQR, 0-25), and vasoactive-free days were 23 (IQR, 12-28). Sixty-seven percent of patients had multiorgan dysfunction at sepsis recognition, with 30% subsequently developing new or progressive multiorgan dysfunction. Among survivors, 17% developed at least moderate disability. Sample sizes needed to detect a 5-10% absolute risk reduction in outcomes within interventional trials are estimated between 165 and 1,471 corrected patients per group.
Pediatric severe sepsis remains a burdensome public health problem, with prevalence, morbidity, and mortality rates similar to those reported in critically ill adult populations. International clinical trials targeting children with severe sepsis are warranted.
Summary Background The American Heart Association recommends cardiopulmonary resuscitation (CPR) by bystanders with chest compression only for adults who have cardiac arrests, but not for children. ...We assessed the effect of CPR (conventional with rescue breathing or chest compression only) by bystanders on outcomes after out-of-hospital cardiac arrests in children. Methods In a nationwide, prospective, population-based, observational study, we enrolled 5170 children aged 17 years and younger who had an out-of-hospital cardiac arrest from Jan 1, 2005, to Dec 31, 2007. Data collected included age, cause, and presence and type of CPR by bystander. The primary endpoint was favourable neurological outcome 1 month after an out-of-hospital cardiac arrest, defined as Glasgow-Pittsburgh cerebral performance category 1 or 2. Findings 3675 (71%) children had arrests of non-cardiac causes and 1495 (29%) cardiac causes. 1551 (30%) received conventional CPR and 888 (17%) compression-only CPR. Data for type of CPR by bystander were not available for 12 children. Children who were given CPR by a bystander had a significantly higher rate of favourable neurological outcome than did those not given CPR (4·5% 110/2439 vs 1·9% 53/2719; adjusted odds ratio OR 2·59, 95% CI 1·81–3·71). In children aged 1–17 years who had arrests of non-cardiac causes, favourable neurological outcome was more common after bystander CPR than no CPR (5·1% 51/1004 vs 1·5% 20/1293; OR 4·17, 2·37–7·32). However, conventional CPR produced more favourable neurological outcome than did compression-only CPR (7·2% 45/624 vs 1·6% six of 380; OR 5·54, 2·52–16·99). In children aged 1–17 years who had arrests of cardiac causes, favourable neurological outcome was more common after bystander CPR than no CPR (9·5% 42/440 vs 4·1% 14/339; OR 2·21, 1·08–4·54), and did not differ between conventional and compression-only CPR (9·9% 28/282 vs 8·9% 14/158; OR 1·20, 0·55–2·66). In infants (aged <1 year), outcomes were uniformly poor (1·7% 36/2082 with favourable neurological outcome). Interpretation For children who have out-of-hospital cardiac arrests from non-cardiac causes, conventional CPR (with rescue breathing) by bystander is the preferable approach to resuscitation. For arrests of cardiac causes, either conventional or compression-only CPR is similarly effective. Funding Fire and Disaster Management Agency and the Ministry of Education, Culture, Sports, Science and Technology (Japan).
The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of ...standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.
Utstein-style reporting templates provide a structured framework with which to compare systems of care for cardiac arrest. The 2004 Utstein reporting template encompassed both out-of-hospital and ...in-hospital cardiac arrest. A 2015 update of the Utstein template focused on out-of-hospital cardiac arrest, which makes this update of the in-hospital template timely. Representatives of the International Liaison Committee on Resuscitation developed an updated in-hospital Utstein reporting template iteratively by meeting face-to-face, by teleconference, and by online surveys between 2013 and 2018. Data elements were grouped by hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. Elements were classified as core or supplemental by use of a modified Delphi process. Variables were described as core if they were considered essential. Core variables should enable reasonable comparisons between systems and are considered essential for quality improvement programs. Together with core variables, supplementary variables are considered useful for research.
Purpose
To evaluate the incidence and associated risk factors of difficult tracheal intubations (TI) in pediatric intensive care units (PICUs).
Methods
Using the National Emergency Airway Registry ...for Children (NEAR4KIDS), TI quality improvement data were prospectively collected for initial TIs in 15 PICUs from July 2010 to December 2011. Difficult pediatric TI was defined as TIs by direct laryngoscopy which failed or required more than two laryngoscopy attempts by fellow/attending-level physician providers.
Results
A total of 1,516 oral TIs were reported with a median age of 2 years. A total of 97 % of patients were intubated with direct laryngoscopy. The incidence of difficult TI was 9 %. In univariate analysis, patients with difficult TI were younger median 1 year (0–4) vs. 2 (0–8) years,
p
= 0.046, and had a reported history of difficult TI (22 vs. 8 %,
p
< 0.001). Multivariate analysis showed that history of difficult airway and signs of upper airway obstruction are significantly associated with difficult TI. The advanced airway provider was more involved as a first provider in difficult TI (81 vs. 58 %,
p
< 0.001). The presence of difficult TI was associated with higher incidence of oxygen desaturation below 80 % (48 vs. 15 %,
p
< 0.001), adverse TI associated events (53 vs. 20 %,
p
< 0.001), and severe TI associated events (13 vs. 6 %,
p
= 0.003).
Conclusions
Difficult TI was reported in 9 % of all TIs and was associated with increased adverse TI events. History of difficult airway and sign of upper airway obstruction were associated with difficult TIs.
Despite the established vulnerability of children during airway management, remarkably little is known about complications in children with difficult tracheal intubation. To address this concern, we ...developed a multicentre registry (Pediatric Difficult Intubation PeDI) to characterise risk factors for difficult tracheal intubation, establish the success rates of various tracheal intubation techniques, catalogue the complications of children with difficult tracheal intubation, and establish the effect of more than two tracheal intubation attempts on complications.
The PeDI registry consists of prospectively collected tracheal intubation data from 13 children's hospitals in the USA. We established standard data collection methods before implementing the secure web-based registry. After establishing standard definitions, we collected and analysed patient, clinician, and practice data and tracheal intubation outcomes. We categorised complications as severe or non-severe.
Between August, 2012, and January, 2015, 1018 difficult paediatric tracheal intubation encounters were done. The most frequently attempted first tracheal intubation techniques were direct laryngoscopy (n=461, 46%), fibre-optic bronchoscopy (n=284 28%), and indirect video laryngoscopy (n=183 18%) with first attempt success rates of 16 (3%) of 461 with direct laryngoscopy, 153 (54%) of 284 with fibre-optic bronchoscopy, and 101 (55%) of 183 with indirect video laryngoscopy. Tracheal intubation failed in 19 (2%) of cases. 204 (20%) children had at least one complication; 30 (3%) of these were severe and 192 (19%) were non-severe. The most common severe complication was cardiac arrest, which occurred in 15 (2%) patients. The occurrence of complications was associated with more than two tracheal intubation attempts, a weight of less than 10 kg, short thyromental distance, and three direct laryngoscopy attempts before an indirect technique. Temporary hypoxaemia was the most frequent non-severe complication.
More than two direct laryngoscopy attempts in children with difficult tracheal intubation are associated with a high failure rate and an increased incidence of severe complications. These results suggest that limiting the number of direct laryngoscopy attempts and quickly transitioning to an indirect technique when direct laryngoscopy fails would enhance patient safety.
None.
Trauma is a global challenge and India has one of the highest trauma deaths in the world. Despite the United Nations’ target to halve the global number of deaths and injuries from road traffic ...crashes by 2030, death tolls from road traffic injuries (RTI) are rising in India. In the pediatric age group, falls from height add to the burden of trauma. Uncontrolled bleeding from exsanguination on scene is estimated to account for nearly 40% of RTI trauma related mortality. Stopping the bleeding in the first few minutes is crucial for meaningful survival and hence the role of training lay public who can reach the scene in minutes. Active bleeding control (ABC) pilot research project to simulation train the bystanders to stop the bleed showed promising outcomes in Hyderabad, India. This paper describes the ABC project and discusses the role of pediatricians in training the public to reduce morbidity and mortality from uncontrolled bleeding at the trauma scene.
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