Ben Gelbart

Fluid Bolus Therapy-Based Resuscitation for Severe Sepsis in Hospitalized Children: A Systematic Review.

Objectives: To review systematically data from randomized and nonrandomized studies of fluid bolus therapy in hospitalized children with septic shock. Data Sources: Medline, EMBASE, and Cochrane Central Register of Controlled Trials. Study Selection: We searched for randomized controlled studies of fluid bolus therapy in children with severe sepsis. We identified retrospective, prospective, and observational studies. We excluded studies of severe sepsis/septic shock due to a specific microbiological etiology, neonatal studies, and studies where advanced supportive therapies were unavailable. Data Extraction: Two authors screened articles for inclusion. Data Synthesis: We identified and analyzed three randomized controlled trials and eight nonrandomized studies. Heterogeneity precluded meta-analysis. Two single-center Indian studies and one Brazilian study assessed three different fluid bolus therapy regimens in small cohorts with different populations, physiological triggers, and physiological and clinical outcomes. No randomized controlled trials compared fluid bolus therapy with alternative interventions, such as vasopressors. The nonrandomized studies were heterogeneous in populations, methodology, and outcome measures. No observed physiological differences were identified based on volume of fluid bolus therapy. Conclusions: There are only limited data to support the use of fluid bolus therapy in hospitalized children. Prospective observational data and randomized controlled trials are urgently needed to evaluate this therapy in resource rich settings.

Burden of disease and change in practice in critically ill infants with bronchiolitis.

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. Changing thresholds to admit bronchiolitis patients to PICU have had a major impact on cost and resource utilisation http://ow.ly/AVA630a08rx

The Melbourne epidemic thunderstorm asthma event 2016: an investigation of environmental triggers, effect on health services, and patient risk factors

BACKGROUND A multidisciplinary collaboration investigated the worlds 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.

Rhabdomyolysis in a Tertiary PICU: A 10-Year Study.

Objectives: Rhabdomyolysis is a disorder of muscle breakdown. The aim of this study was to describe the epidemiology of rhabdomyolysis in children admitted to a PICU and to assess the relationship between peak creatinine kinase and mortality. Design: Retrospective cohort study in children admitted to the PICU with rhabdomyolysis between January 1, 2005, and December 31, 2014. Demographic, clinical, and outcome data were recorded. Outcomes were analyzed by level of peak creatinine kinase value (0–10,000, 10,001–50,000, > 50,000IU/L). Long-term renal outcomes were reported for PICU survivors. Setting: A single-centre academic tertiary PICU. Patients: Children admitted to the PICU with serum creatinine kinase level greater than 1,000 IU/L. Interventions: None. Measurements and Main Results: There were 182 children with rhabdomyolysis. The median peak creatinine kinase value was 3,583 IU/L (1,554–9,608). The primary diagnostic categories included sepsis, trauma, and cardiac arrest. Mortality for peak creatinine kinase values 0–10,000, 10,001–50,000, and > 50,000 IU/L were 24/138 (17%), 6/28 (21%), and 3/16 (19%), respectively (p = 0.87). Children with a peak creatinine kinase greater than 10,000 IU/L had a longer duration of mechanical ventilation and ICU length of stay than children with peak creatinine kinase less than 10,000. Renal replacement therapy was administered in 29/182 (16%). There was longer duration of mechanical ventilation (273 [141–548] vs. 73 [17–206] hr [p < 0.001]) and ICU length of stay (334 [147–618] vs. 100 [37–232] hr (p < 0.001)] in children receiving renal replacement therapy. Continuous veno-venous hemofiltration was the most common modality 23/29 (79%). Only one child required renal replacement therapy postintensive care stay, and adverse long-term renal outcomes were uncommon. Conclusions: In children with rhabdomyolysis requiring intensive care, peak creatinine kinase was not associated with mortality but is associated with greater use of intensive care resources. Chronic kidney disease is an uncommon sequelae of rhabdomyolysis in children requiring intensive care.

Chronic use of teething gel causing salicylate toxicity

Teething gels are commonly used for symptoms attributed to primary tooth eruption in infancy despite a lack of benefit and potential harm from chronic salicylate poisoning. We describe a case of metabolic derangement with significant encephalopathy and liver impairment secondary to chronic use of Bonjela teething gel (Reckitt Benckiser (8.7% choline salicylate)) in a 17– month-old boy. We summarise relevant pharmacological considerations and highlight the need for greater warnings on the packaging of teething gels for awareness of this risk. This case acts as a useful clinical vignette with which to highlight the importance of taking a detailed medication history, including use of over-the-counter medications, and of considering adverse effects of medications as a cause of presentation in the initial assessment of a sick child with metabolic derangement of unclear aetiology.

Challenges of paediatric organ donation

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.