Frank Shann

A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension.

Abstract Object: The object of our study was to determine, in children with traumatic brain injury and sustained intracranial hypertension, whether very early decompressive craniectomy improves control of intracranial hypertension and long-term function and quality of life. Methods: All children were managed from admission onward according to a standardized protocol for head injury management. Children with raised intracranial pressure (ICP) were randomized to standardized management alone or standardized management plus cerebral decompression. A decompressive bitemporal craniectomy was performed at a median of 19.2 h (range 7.3–29.3 h) from the time of injury. ICP was recorded hourly via an intraventricular catheter. Compared with the ICP before randomization, the mean ICP was 3.69 mmHg lower in the 48 h after randomization in the control group, and 8.98 mmHg lower in the 48 hours after craniectomy in the decompression group (P=0.057). Outcome was assessed 6 months after injury using a modification of the Glasgow Outcome Score (GOS) and the Health State Utility Index (Mark 1). Two (14%) of the 14 children in the control group were normal or had a mild disability after 6 months, compared with 7 (54%) of the 13 children in the decompression group. Our conclusion was that when children with traumatic brain injury and sustained intracranial hypertension are treated with a combination of very early decompressive craniectomy and conventional medical management, it is more likely that ICP will be reduced, fewer episodes of intracranial hypertension will occur, and functional outcome and quality of life may be better than in children treated with medical management alone (P=0.046; owing to multiple significance testing P <0.0221 is required for statistical significance). This pilot study suggests that very early decompressive craniectomy may be indicated in the treatment of traumatic brain injury.

Paediatric index of mortality (PIM): a mortality prediction model for children in intensive care

AbstractObjective: To develop a logistic regression model that predicts the risk of death for children less than 16 years of age in intensive care, using information collected at the time of admission to the unit. Design: Three prospective cohort studies, from 1988 to 1995, were used to determine the variables for the final model. A fourth cohort study, from 1994 to 1996, collected information from consecutive admissions to all seven dedicated paediatric intensive care units in Australia and one in Britain. Results: 2904 patients were included in the first three parts of the study, which identified ten variables for further evaluation. 5695 children were in the fourth part of the study (including 1412 from the third part); a model that used eight variables was developed on data from four of the units and tested on data from the other four units. The model fitted the test data well (deciles of risk goodness-of-fit test p=0.40) and discriminated well between death and survival (area under the receiver operating characteristic plot 0.90). The final PIM model used the data from all 5695 children and also fitted well (p=0.37) and discriminated well (area 0.90). Conclusions: Scores that use the worst value of their predictor variables in the first 12–24 h should not be used to compare different units: patients mismanaged in a bad unit will have higher scores than similar patients managed in a good unit, and the bad unit‘s high mortality rate will be incorrectly attributed to its having sicker patients. PIM is a simple model that is based on only eight explanatory variables collected at the time of admission to intensive care. It is accurate enough to be used to describe the risk of mortality in groups of children.

AETIOLOGY OF PNEUMONIA IN CHILDREN IN GOROKA HOSPITAL, PAPUA NEW GUINEA

To determine the aetiology of pneumonia in 83 children admitted to Goroka Hospital, Papua New Guinea, lung aspirates and blood were cultured for bacteria. Haemophilus infuenzae, Streptococcus pneumoniae, or both, were isolated from 43 (52%) of the children, other bacteria from 8 (10%), and no bacteria from 32 (39%). Of the 32 strains of H influenzae tested, 18 (56%) were non-serotypable, 8 (25%) were serotypes other than type b, and only 6 (19%) were type b. Viruses were isolated from lung or nasopharyngeal aspirates from 18 (29%) of the 62 children for whom viral cultures were done. It seems that, although viruses may initiate infection, death from pneumonia in children in developing countries is often due to H influenzae, S pneumoniae, or both. Antibiotic therapy would prevent many of these deaths. There is an urgent need for vaccines, effective in children less than 6 months old, that protect against all strains of H influenzae, and S pneumoniae.

Should paediatric intensive care be centralised? Trent versus Victoria

BACKGROUND The mortality rate is lower among children admitted to specialist paediatric intensive care units (ICUs) than among those admitted to mixed adult and paediatric units in non-tertiary hospitals. In the UK, however, few children receive intensive care in specialist paediatric units. We compared the ICU mortality rate in children from the area the Trent Health Authority, UK, with the rate in children from Victoria, Australia, where paediatric intensive care is highly centralised. METHODS We studied all children under 16 years of age from Trent and Victoria who received intensive care between April 1, 1994, and March 31, 1995. Children younger than 1 month were excluded unless they had cardiac disorders. We developed a logistic regression model that used information gathered at the time of admission to ICU to adjust for risk of mortality. FINDINGS The rates of admission of children to intensive care were similar for Trent and Victoria (1.22 and 1.18 per 1000 children per year), but the mean duration of an ICU stay was 3.93 days for Trent children compared with 2.14 days for children from Victoria. 74 (7.3%) of the 1014 children from Trent died, compared with 60 (5.0%) of the 1194 children from Victoria. With adjustment for severity of illness at the time of admission to ICU, the odds ratio for the risk of death for Trent versus Victoria was 2.09 (95% CI 1.37-3.19, p < 0.0005). There were 31.7 (14.0-50.4) excess deaths in Trent children, which is equivalent to 42.8% of the deaths in ICU, and 11.1% of all deaths in children between the ages of 1 month and 16 years in Trent. INTERPRETATION If Trent is representative of the whole country, there are 453 (200-720) excess deaths a year in the UK that are probably due to suboptimal results from paediatric intensive care. If the ratio of paediatric ICUs to children were the same in the UK as in Victoria, there would be only 12 paediatric ICUs in the country. Our findings suggest that substantial reductions in mortality could be achieved if every UK child who needed endotracheal intubation for more than 12-24 h were admitted to one of 12 large specialist paediatric ICUs.

Continuous plasmafiltration in sepsis syndrome

Objective:To assess the effect of plasmafiltration (PF) on biochemical markers of inflammation, cytokines, organ dysfunction, and 14-day mortality in human sepsis.Design:Multicenter, prospective, randomized, controlled clinical trial.Setting:Seven university-affiliated intensive care units.Patients:

Clinical signs of dehydration in children.

102 children with acute gastroenteritis were thought by the admitting junior doctors to be 5% or more dehydrated. As judged by subsequent weight recovery in hospital, the main indicators of mild to moderate dehydration were decreased peripheral perfusion, deep breathing, decreased skin turgor, high urea, low pH, and a large base deficit; a history of increased thirst was just short of statistical significance. Dehydration was not indicated by a history of oliguria, by the presence of restlessness or lethargy, sunken eyes, dry mouth, or a sunken fontanelle or by the absence of tears. Clinical signs of dehydration became apparent at 3-4% rather than 5% dehydration. The degree of dehydration was overestimated by a mean of 3.2%; this caused unnecessary hospital admissions and overtreatment with intravenous fluid.

Three decades of pediatric intensive care: Who was admitted, what happened in intensive care, and what happened afterward

Objective: To describe the characteristics of children admitted to intensive care in 1982, 1995, and 2005–2006, and their long-term outcome. Setting: Pediatric intensive care unit in a university-affiliated childrens hospital. Design/Methods: Information for 2005–2006 admissions was obtained from pediatric intensive care unit database, and long-term outcome was ascertained through telephone interviews. Results were compared to previous cohorts from 1982 and 1995. Results: A total of 4010 children were admitted on 5250 occasions. Readmissions increased from 11% for 1982 to 31% in 2005 to 2006 (p < .001). In 2005–2006, fewer children were admitted after accidents (p < .001), or with croup (p < .001), or epiglottitis (p = .01), and 8% were treated with noninvasive ventilation compared to none in 1982 (p < .0001). Among children aged ≥1 month, pediatric intensive care unit length of stay remained constant. The risk of death predicted by the Pediatric Index of Mortality (PIM) remained constant (approximately 6%) between 1995 and 2005–2006.The proportion that died in the pediatric intensive care unit fell from 11.0% in 1982 to 4.8% in 2005–2006 (p < .001). Among children aged ≥1 month, proportion admitted with a preexisting moderate or severe disability was similar: 12.0% in 1982 and 14.6% in 2005–2006 (p = .11), but the proportion with a moderate or severe disability at follow-up increased from 8.4% in 1982 to 17.9% in 2005–2006 (p < .001). The proportion of children aged ≥1 month who either died in the pediatric intensive care unit or survived with disability did not improve: it was 19.4% in 1982 and 22.7% in 2005–2006. Conclusion: Over the last three decades, the length of stay in the pediatric intensive care unit and the severity of illness have not changed, but there has been a substantial reduction in pediatric intensive care unit mortality. However, the proportion of survivors with moderate or severe disability increased significantly. Some children who would have been allowed to die in 1982 and 1995 were kept alive in 2005–2006, but survived with disability. This trend has important implications for our patients and their families, and for the community as a whole.

Acute lower respiratory tract infections in children: possible criteria for selection of patients for antibiotic therapy and hospital admission

Acute lower respiratory tract infections are a common cause of morbidity and mortality in children in the less developed countries. Considering the urgent need for rational protocols for the management of these infections in children and how little is known about the clinical signs that might predict the need for antibiotic therapy in a primary health care setting, a prospective study of the clinical signs in 200 paediatric outpatients presenting with a cough, 100 age-matched controls without cough, and 50 children admitted to hospital with pneumonia was carried out.In children with cough, a respiratory rate greater than 40 or 50 per minute (or a qualitative impression of tachypnoea) is probably the best indicator of the need for starting antibiotic treatment by primary health workers. The presence of fever appeared to be a poor guide to the need for antibiotic therapy. The presence of chest indrawing is, however, a reliable indication that a child with cough should be admitted to a health centre or a hospital. Further prospective studies are needed to determine the ability of these clinical signs to predict the course of these infections.

Systematic review of rheumatic heart disease prevalence in children in developing countries: The role of environmental factors

Objectives:  To consider the worldwide prevalence of rheumatic heart disease in children in developing countries using surveys with uniform methodologies, and to consider the effect of environmental factors including socio‐economic status, overcrowding, urbanization, nutrition and access to medical services on the distribution of rheumatic heart disease in developing countries.

The suitability of the Pediatric Index of Mortality (PIM), PIM2, the Pediatric Risk of Mortality (PRISM), and PRISM III for monitoring the quality of pediatric intensive care in Australia and New Zealand.

Objective: To compare the performance of the Pediatric Index of Mortality (PIM), PIM2, the Pediatric Risk of Mortality (PRISM), and PRISM III in Australia and New Zealand. Design: A two-phase prospective observational study. Phase 1 assessed the performance of PIM, PRISM, and PRISM III between 1997 and 1999. Phase 2 assessed PIM2 in 2000 and 2001. Setting: Ten intensive care units in Australia and New Zealand. Patients: Included in the study were 26,966 patients aged <16 yrs; 1,147 patients died in the intensive care unit. Interventions: None. Measurements and Main Results: Discrimination between death and survival was assessed by calculating the area under the receiver operating characteristic plot for each model. The areas (95% confidence interval) for PIM, PIM2, PRISM, and PRISM III were 0.89 (0.88–0.90), 0.90 (0.88–0.91), 0.90 (0.89–0.91), and 0.93 (0.92–0.94). The calibration of the models was assessed by comparing the number of observed to predicted deaths in different diagnostic and risk groups. Prediction was best using PIM2 with no difference between observed and expected mortality (standardized mortality ratio [95% confidence interval] 0.97 [0.86–1.05]). PIM, PRISM III, and PRISM all overpredicted death, predicting 116%, 130%, and 189% of observed deaths, respectively. The performance of individual units was compared during phase 1, using PIM, PRISM, and PRISM III. There was agreement between the models in the identification of outlying units; two units performed better than expected and one unit worse than expected for each model. Conclusions: Of the models tested, PIM2 was the most accurate and had the best fit in different diagnostic and risk groups; therefore, it is the most suitable mortality prediction model to use for monitoring the quality of pediatric intensive care in Australia and New Zealand. More information about the performance of the models in other regions is required before these results can be generalized.