Elliot Long

Endotracheal intubation in the pediatric emergency department

Prospective safety data on emergency department (ED) intubation in children are limited. We aimed to describe the practice and adverse events associated with endotracheal intubation in a large urban pediatric ED.

Does Respiratory Variation in Inferior Vena Cava Diameter Predict Fluid Responsiveness: A Systematic Review and Meta-analysis

Background: The aim of fluid resuscitation is to increase stroke volume, yet this effect is observed in only 50% of patients. Prediction of fluid responsiveness may allow fluid resuscitation to be administered to those most likely to benefit. The aim of this study was to systematically review the test characteristics of respiratory variation in inferior vena cava (IVC) diameter as a predictor of fluid responsiveness in patients with acute circulatory failure. Methods: Electronic searches combined with reference review of identified studies. Prospective observational studies of all patient groups and ages that used a recognized reference standard, stratified participants into fluid responders and fluid non-responders, and used summary statistics to describe their results were selected for inclusion. Study design, size, setting, patient population, use of mechanical ventilation and tidal volume, definition of fluid responsiveness, fluid challenge strategy, and summary statistics were abstracted. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) domains. Results: Seventeen studies involving 533 patients were included, in whom 253 (47%) were fluid responders. The pooled sensitivity and specificity for a positive IVC ultrasound as a predictor of fluid responsiveness were 0.63 (95% confidence interval [CI]: 0.56–0.69) and 0.73 (95% CI: 0.67–0.78), respectively, with a pooled area under the receiver operating characteristic curve of 0.79 (standard error 0.05). In subgroup analysis, respiratory variation in IVC diameter was a better predictor of fluid responsiveness in mechanically ventilated patients. Conclusions: Respiratory variation in IVC diameter has limited ability to predict fluid responsiveness, particularly in spontaneously ventilating patients. A negative test cannot be used to rule out fluid responsiveness. Clinical context should be taken into account when using IVC ultrasound to help make treatment decisions.

Is there a role for humidified heated high-flow nasal cannula therapy in paediatric emergency departments?

Background Humidified heated high-flow nasal cannula (HFNC) therapy is a potentially useful form of non-invasive respiratory support for children with moderate respiratory distress and/or hypoxaemia. No prospective data support its use in the paediatric emergency department (ED). We introduced HFNC therapy into a paediatric ED and evaluated its use and failure rates. Methods Prospective observational study of all patients presenting to the Royal Childrens Hospital, Australia, who received HFNC therapy between April 2013 and September 2013 (one southern hemisphere winter season). We assessed demographics, indications, failure rate, predictors of failure and adverse events. Results 71 patients commenced HFNC therapy in ED over the study period. The median age was 9 months. The most common indication was bronchiolitis (49/71; 69%). Five (7%) of the patients failed HFNC and were escalated to other forms of respiratory support in ED, four to nasal continuous positive airway pressure and one required intubation. A further 21 (32%) failed HFNC therapy after intensive care unit (ICU) admission, giving a total failure of 28 (39%). There were no serious adverse events in ED, and one child with asthma developed air leak syndrome after transfer to the ICU. Conclusions HFNC therapy may have a role in the paediatric ED as an easily administered and well tolerated form of non-invasive respiratory support, but about one-third of patients required escalation to a higher level of respiratory support. Further studies should assess the safety profile of HFNC in larger series, and define the role of HFNC in key respiratory conditions compared with other possible interventions.

A prospective quality improvement study in the emergency department targeting paediatric sepsis

Objective Quality improvement sepsis initiatives in the paediatric emergency department have been associated with improved processes, but an unclear effect on patient outcome. We aimed to evaluate and improve emergency department sepsis processes and track subsequent changes in patient outcome. Study design A prospective observational cohort study in the emergency department of The Royal Childrens Hospital, Melbourne. Participants were children aged 0–18 years of age meeting predefined criteria for the diagnosis of sepsis. The following shortcomings in management were identified and targeted in a sepsis intervention: administration of antibiotics and blood sampling for a venous gas at the time of intravenous cannulation, and rapid administration of all fluid resuscitation therapy. The primary outcome measure was hospital length of stay. Results 102 patients were enrolled pre-intervention, 113 post-intervention. Median time from intravenous cannula insertion to antibiotic administration decreased from 55 min (IQR 27–90 min) pre-intervention to 19 min (IQR 10–32 min) post-intervention (p≤0.01). Venous blood gas at time of first intravenous cannula insertion was performed in 60% of patients pre-intervention vs 79% post-intervention (p≤0.01). Fluids were administered using manual push-pull or pressure-bag methods in 31% of patients pre-intervention and 84% of patients post-intervention (p≤0.01). Median hospital length of stay decreased from 96 h (IQR 64–198 h) pre-intervention to 80 h (IQR 53–167 h) post-intervention (p=0.02). This effect persisted when corrected for unequally distributed confounders between pre-intervention and post-intervention groups (uncorrected HR: 1.36, 95% CI 1.04 to 1.80, p=0.02; corrected HR: 1.34, 95% CI 1.01 to 1.80, p=0.04). Conclusions Use of quality improvement methodologies to improve the management of paediatric sepsis in the emergency department was associated with a reduction in hospital length of stay.

Airway emergencies presenting to the paediatric emergency department requiring advanced management techniques

Background Airway emergencies presenting to the emergency department (ED) are usually managed with conventional equipment and techniques. The patient group managed urgently in the operating room (OR) has not been described. Aims This study aims to describe a case series of children presenting to the ED with airway emergencies managed urgently in the OR, particularly the anaesthetic equipment and techniques used and airway findings. Methods A retrospective cohort study undertaken at The Royal Children’s Hospital, Melbourne, Australia. All patients presenting to the ED between 1 January 2012 and 30 July 2015 (42 months) with an airway emergency who were subsequently managed in the OR were included. Patient characteristics, anaesthetic equipment and technique and airway findings were recorded. Results Twenty-two airway emergencies in 21 patients were included over the study period, on average one every 2 months. Median age was 18 months and 43% were male. Inhalational induction was used in 77.3%, combined inhalational and intravenous induction in 9.1%, and intravenous induction alone in 13.6%. The most commonly used inhalational induction agent was sevoflurane, and the most commonly used intravenous induction agents were ketamine and propofol. Ten airway emergencies did not require intubation, seven for removal of inhaled foreign body, two with progressive tracheal stenosis requiring emergent dilatation and one examination under anaesthesia to rule out inhaled foreign body. Of the 12 airway emergencies that required immediate intubation, direct laryngoscopy was used in 9 and fibre-optic intubating bronchoscopy in 3. For intubations performed by direct laryngoscopy, one was difficult (Cormack and Lehane grade 3). First pass success was 83.3%. Adverse events occurred in 3/22 (13.6%) cases. Conclusion Advanced airway techniques, including inhalational induction and intubation via fibre-optic intubating bronchoscope, are rarely but predictably required in the management of patients presenting to the ED. Institutions caring for children should prepare in advance where such patients should be managed, by whom, and provide equipment and training for their care.

Fluid resuscitation therapy for paediatric sepsis

Sepsis and septic shock are the final common pathway for many decompensated paediatric infections. Fluid resuscitation therapy has been the cornerstone of haemodynamic resuscitation in these children. Good evidence for equivalence between 0.9% saline and 4% albumin, with the relative expense of the latter, has meant that 0.9% saline is currently the most commonly used resuscitation fluid world‐wide. Evidence for harm from the chloride load in 0.9% saline has generated interest in balanced solutions as first line resuscitation fluids. Their safety has been well established in observational studies, and they may well be the most reasonable default fluid for resuscitation. Semi‐synthetic colloids have been associated with renal dysfunction and death and should be avoided. There is evidence for harm from excessive administration of any resuscitation fluid. Resuscitation fluid volumes should be treated in the same way as the dose of any other intravenously administered medication, and the potential benefits versus harms for the individual patient weighed prior to administration.

Fluid resuscitation for paediatric sepsis: A survey of senior emergency physicians in Australia and New Zealand

It is unclear whether emerging evidence for harm from aggressive fluid resuscitation for paediatric sepsis has altered clinical practice. We surveyed senior emergency physicians to see if their fluid resuscitation practices conformed to published clinical guidelines.

Implementation of NAP4 emergency airway management recommendations in a quaternary‐level pediatric hospital

Emergency airway management, particularly outside of the operating room, is associated with a high incidence of life‐threatening adverse events. Based on the recommendations of the 4th National Audit Project, we aimed to develop hospital‐wide systems changes to improve the safety of emergency airway management. We describe a framework for governance in the form of a hospital airway special interest group. We describe the development and implementation of the following systems changes: 1. A local intubation algorithm modified from the Difficult Airway Societys plan A‐B‐C‐D approach, including clear pathways for airway escalation, and emphasizing the concepts of resuscitation prior to intubation, planning for failure, and avoidance of fixation error. 2. Simplified and standardized airway equipment located in identical airway carts in all critical care areas. 3. A preintubation checklist and equipment template to standardize preparation for airway management. 4. Availability of continuous waveform endtidal capnography in all critical care areas for confirmation of correct endotracheal tube placement. 5. Multidisciplinary team training to address the technical and nontechnical aspects of nonoperating room intubation. In addition, we describe methodology for ongoing monitoring of performance through a quality assurance framework. In conclusion, changes in the process of emergency airway management at a hospital level are feasible through collaboration. Their impact on patient‐based outcomes requires further study.

Prospective observational study of point-of-care ultrasound for diagnosing pneumonia

Objectives The clinical diagnosis of pneumonia lacks specificity and may lead to antibiotic overuse, whereas radiological diagnoses can lack sensitivity. Point-of-care lung ultrasound is an emerging diagnostic tool. There are limited prospective data, however, on the accuracy of sonologists in the paediatric emergency department setting. We aimed to test the diagnostic accuracy of lung ultrasound for pneumonia using chest radiograph (CR) as the reference standard. Methods This prospective observational cohort study in a paediatric emergency department enrolled children aged 1 month to <18 years, who had a CR ordered for possible pneumonia. Lung ultrasounds were performed by two blinded sonologists with focused training. Sonographic pneumonia was defined as lung consolidation with air bronchograms. Radiograph and ultrasound results both required agreement between two readers, with final results determined by an arbiter in cases of disagreement. Patient management was decided by treating clinicians who were blinded to lung ultrasound results. Follow-up was performed by phone and medical record review to obtain final diagnosis and antibiotic use. Results Of 97 included patients, CR was positive for pneumonia in 44/97 (45%) and lung ultrasound was positive in 57/97 (59%). Ultrasound sensitivity was 91% (95% CI 78% to 98%) and specificity was 68% (95% CI 54% to 80%). Ultrasound results displayed greater consistency with CR and patient outcomes when sonographic consolidation exceeded 1 cm. Thirteen of 57 patients with sonographic consolidation improved without antibiotics. Conclusion Lung ultrasound may have a role as first-line imaging in patients with possible pneumonia, with higher specificity for consolidations exceeding 1 cm. Trial registration number ACTRN12616000361404, http://www.ANZCTR.org.au/ACTRN12616000361404.aspx

Prevalence of suicidality in asymptomatic adolescents in the paediatric emergency department and utility of a screening tool

Many authorities recommend screening adolescents for risk of suicide. The ED is a potential setting for such screening. The aim of this study is to explore the use of the Risk of Suicide Questionnaire (RSQ) as a screening tool for suicidality in patients who come to the ED without mental health concerns and without recent mental health history. The Suicide Ideation Questionnaire (SIQ) was the comparison standard.