Samiran Ray

The Predictive Value of the NICE "Red Traffic Lights" in Acutely Ill Children

Objective Early recognition and treatment of febrile children with serious infections (SI) improves prognosis, however, early detection can be difficult. We aimed to validate the predictive rule-in value of the National Institute for Health and Clinical Excellence (NICE) most severe alarming signs or symptoms to identify SI in children. Design, Setting and Participants The 16 most severe (“red”) features of the NICE traffic light system were validated in seven different primary care and emergency department settings, including 6,260 children presenting with acute illness. Main Outcome Measures We focussed on the individual predictive value of single red features for SI and their combinations. Results were presented as positive likelihood ratios, sensitivities and specificities. We categorised “general” and “disease-specific” red features. Changes in pre-test probability versus post-test probability for SI were visualised in Fagan nomograms. Results Almost all red features had rule-in value for SI, but only four individual red features substantially raised the probability of SI in more than one dataset: “does not wake/stay awake”, “reduced skin turgor”, “non-blanching rash”, and “focal neurological signs”. The presence of ≥3 red features improved prediction of SI but still lacked strong rule-in value as likelihood ratios were below 5. Conclusions The rule-in value of the most severe alarming signs or symptoms of the NICE traffic light system for identifying children with SI was limited, even when multiple red features were present. Our study highlights the importance of assessing the predictive value of alarming signs in clinical guidelines prior to widespread implementation in routine practice.

Risk score to stratify children with suspected serious bacterial infection: observational cohort study

Objectives To derive and validate a clinical score to risk stratify children presenting with acute infection. Study design and participants Observational cohort study of children presenting with suspected infection to an emergency department in England. Detailed data were collected prospectively on presenting clinical features, laboratory investigations and outcome. Clinical predictors of serious bacterial infection (SBI) were explored in multivariate logistic regression models using part of the dataset, each model was then validated in an independent part of the dataset, and the best model was chosen for derivation of a clinical risk score for SBI. The ability of this score to risk stratify children with SBI was then assessed in the entire dataset. Main outcome measure Final diagnosis of SBI according to criteria defined by the Royal College of Paediatrics and Child Health working group on Recognising Acute Illness in Children. Results Data from 1951 children were analysed. 74 (3.8%) had SBI. The sensitivity of individual clinical signs was poor, although some were highly specific for SBI. A score was derived with reasonable ability to discriminate SBI (area under the receiver operator characteristics curve 0.77, 95% CI 0.71 to 0.83) and risk stratify children with suspected SBI. Conclusions This study demonstrates the potential utility of a clinical score in risk stratifying children with suspected SBI. Further work should aim to validate the score and its impact on clinical decision making in different settings, and ideally incorporate it into a broader management algorithm including additional investigations to further stratify a childs risk.

Shock Index Values and Trends in Pediatric Sepsis: Predictors or Therapeutic Targets? A Retrospective Observational Study.

Background: Shock index (SI) (heart rate [HR]/systolic blood pressure [SBP]) has been used to predict outcome in both adult and pediatric sepsis within the intensive care unit (ICU). We aimed to evaluate the utility of SI before pediatric ICU (PICU) admission. Patients and Methods: We conducted a retrospective observational study of children referred to a pediatric intensive care transport service (PICTS) between 2005 and 2011. The predictive value of SI, HR, and blood pressure at three prespecified time points (at referral to PICTS, at PICTS arrival at the referring hospital, and at PICU admission) and changes in SI between the time points were evaluated. Death within the first 48 h of ICU admission (early death) was the primary outcome variable. Results: Over the 7-year period, 633 children with sepsis were referred to the PICTS. Thirty-nine children died before transport to a PICU, whereas 474 were transported alive. Adjusting for age, time points, and time duration in a multilevel regression analysis, SI was significantly higher in those who died early. There was a significant improvement in SI with the transport team in survivors but not in nonsurvivors. However, the predictive value of a change in SI for mortality was no better than either a change in HR or blood pressure. Conclusions: The absolute or change in SI does not predict early death any more than HR and SBP individually in children with sepsis.

The Score Matters: Wide Variations in Predictive Performance of 18 Paediatric Track and Trigger Systems

Objective To compare the predictive performance of 18 paediatric early warning systems (PEWS) in predicting critical deterioration. Design Retrospective case-controlled study. PEWS values were calculated from existing clinical data, and the area under the receiver operator characteristic curve (AUROC) compared. Setting UK tertiary referral childrens hospital. Patients Patients without a ‘do not attempt resuscitation’ order admitted between 1 January 2011 and 31 December 2012. All patients on paediatric wards who suffered a critical deterioration event were designated ‘cases’ and matched with a control closest in age who was present on the same ward at the same time. Main outcome measures Respiratory and/or cardiac arrest, unplanned transfer to paediatric intensive care and/or unexpected death. Results 12 ‘scoring’ and 6 ‘trigger’ systems were suitable for comparative analysis. 297 case events in 224 patients were available for analysis. 244 control patients were identified for the 311 events. Three PEWS demonstrated better overall predictive performance with an AUROC of 0.87 or greater. Comparing each system with the highest performing PEWS with Bonferronis correction for multiple comparisons resulted in statistically significant differences for 13 systems. Trigger systems performed worse than scoring systems, occupying the six lowest places in the AUROC rankings. Conclusions There is considerable variation in the performance of published PEWS, and as such the choice of PEWS has the potential to be clinically important. Trigger-based systems performed poorly overall, but it remains unclear what factors determine optimum performance. More complex systems did not necessarily demonstrate improved performance.

Valproate toxicity in a child: two novel observations.

Sodium valproate, at therapeutic levels (350 – 700 micromol/L; 50 – 100 mg/L), is largely protein bound (80% – 94%). However in overdose the protein binding is saturated and higher proportions of the drug are free. The elimination of half-life increases in overdose from 6 to 16 hours to over 30 hours. In neonates and infants the elimination of the drug is also low, although this increases in children to levels higher than in adults per kilogram body weight. 1,2

Survey of Oxygen Delivery Practices in UK Paediatric Intensive Care Units

Purpose. Administration of supplemental oxygen is common in paediatric intensive care. We explored the current practice of oxygen administration using a case vignette in paediatric intensive care units (PICU) in the united kingdom. Methods. We conducted an online survey of Paediatric Intensive Care Society members in the UK. The survey outlined a clinical scenario followed by questions on oxygenation targets for 5 common diagnoses seen in critically ill children. Results. Fifty-three paediatric intensive care unit members from 10 institutions completed the survey. In a child with moderate ventilatory requirements, 21 respondents (42%) did not follow arterial partial pressure of oxygen (PaO2) targets. In acute respiratory distress syndrome, cardiac arrest, and sepsis, there was a trend to aim for lower PaO2 as the fraction of inspired oxygen (FiO2) increased. Conversely, in traumatic brain injury and pulmonary hypertension, respondents aimed for normal PaO2 even as the FiO2 increased. Conclusions. In this sample of clinicians PaO2 targets were not commonly used. Clinicians target lower PaO2 as FiO2 increases in acute respiratory distress syndrome, cardiac arrest, and sepsis whilst targeting normal range irrespective of FiO2 in traumatic brain injury and pulmonary hypertension.

Pao2/fio2 Ratio Derived From the Spo2/fio2 Ratio to Improve Mortality Prediction Using the Pediatric Index of Mortality-3 Score in Transported Intensive Care Admissions*

Objectives: To derive a relationship between the SpO2/FIO2 ratio and PaO2/FIO2 ratio across the entire range of SpO2 values (0–100%) and to evaluate whether mortality prediction using the Pediatric Index of Mortality-3 can be improved by the use of PaO2/FIO2 values derived from SpO2/FIO2. Design: Retrospective analysis of prospectively collected data. Setting: A regional PICU transport service. Patients: Children transported to a PICU. Interventions: None. Measurements and Main Results: The relationship between SpO2/FIO2 and PaO2/FIO2 across the entire range of SpO2 values was first studied using several mathematical models in a derivation cohort (n = 1,235) and then validated in a separate cohort (n = 306). The best SpO2/FIO2-PaO2/FIO2 relationship was chosen according to the ability to detect respiratory failure (PaO2/FIO2 ⩽ 200). The discrimination of the original Pediatric Index of Mortality-3 score and a derived Pediatric Index of Mortality-3 score (where SpO2/FIO2-derived PaO2/FIO2 values were used in place of missing PaO2/FIO2 values) were compared in a different cohort (n = 1,205). The best SpO2/FIO2-PaO2/FIO2 relationship in 1,703 SpO2/FIO2-to-PaO2/FIO2 data pairs was a linear regression equation of ln[PF] regressed on ln[SF]. This equation identified children with a PaO2/FIO2 less than or equal to 200 with a specificity of 73% and sensitivity of 61% in children with SpO2 less than 97% (92% and 33%, respectively, when SpO2 ≥ 97%) in the validation cohort. PaO2/FIO2 derived from SpO2/FIO2 (derived PaO2/FIO2) was better at predicting PICU mortality (area under receiver operating characteristic curve, 0.64; 95% CI, 0.55–0.73) compared with the original PaO2/FIO2 (area under receiver operating characteristic curve, 0.54; 95% CI, 0.49–0.59; p = 0.02). However, there was no difference in the original and derived Pediatric Index of Mortality-3 scores and their discriminatory ability for mortality. Conclusions: SpO2-based metrics perform no worse than arterial blood gas–based metrics in mortality prediction models. Future Pediatric Index of Mortality score versions may be improved by the inclusion of risk factors based on oxygen saturation values, especially in settings where PaO2 values are missing in a significant proportion of cases.

Erratum to: Risk of over-diagnosis of hypotension in children: a comparative analysis of over 50,000 blood pressure measurements

Author details 1 Respiratory, Critical Care and Anaesthesia Section, UCL GOS Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK. 2 Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Trust, London, UK. 3 UCL Clinical Operations Research Unit, University College London, London, UK. 4 Philips Research North America, Cambridge, MA 02141, USA. 5 Paediatric Intensive Care Unit, St Mary’s Hospital, Imperial College Healthcare London NHS Trust, London, UK.

Child-protection medical assessments: the need for a uniform service model

Recent high-profile child-protection failings in Haringey, Birmingham and Doncaster, and the subsequent investigation from Lord Laming, have highlighted the need for close interagency collaboration in safeguarding of children.1–2 This is amply evident from the original article from Kirk et al .3 The authors showed that 67% of the medical assessments of children with alleged physical abuse revealed findings diagnostic or supportive of the allegations. Notably, however, all child-protection referrals were screened through the process of an interagency referral discussion. This resulted in only 19% of all referrals to proceed to a medical assessment. We conducted a similar service evaluation …

Protocol for a randomised pilot multiple centre trial of conservative versus liberal oxygenation targets in critically ill children (Oxy-PICU)

Introduction Optimal targets for systemic oxygenation in paediatric critical illness are unknown. Observational data indicate that high levels of arterial oxygenation are associated with poor outcomes in resuscitation of the newborn and in adult critical illness. Within paediatric intensive care units (PICUs), staff prevent severe hypoxia wherever possible, but beyond this there is no consensus. Practice varies widely with age, diagnosis, treating doctor and local or national guidelines followed, though peripheral blood oxygen saturations (SpO2) of >95% are often targeted. The overall aim of this pilot study is to determine the feasibility of performing a randomised trial in critically ill children comparing current practice of liberal SpO2 targets with a more conservative target. Methods and analysis Oxy-PICU is a pragmatic, open, pilot randomised controlled trial in infants and children requiring mechanical ventilation and receiving supplemental oxygen for abnormal gas exchange accepted for emergency admission to one of three participating UK PICUs. The study groups will be either a conservative SpO2 target of 88%–92% (inclusive) or a liberal SpO2 target of >94%. Infants and children who fulfil all inclusion criteria and none of the exclusion criteria will be randomised 1:1 by a secure web-based system to one of the two groups. Baseline demographics and clinical status will be recorded as well as daily measures of oxygenation and organ support. Discharge outcomes will also be recorded. In addition to observational data, blood and urine samples will be taken to identify biochemical markers of oxidative stress. Outcomes are targeted at assessing study feasibility with a primary outcome of adequate study recruitment (target: 120 participants). Ethics and dissemination The trial received Health Research Authority approval on 1 June 2017 (16/SC/0617). Study findings will be disseminated in national and international conferences and peer-reviewed journals. Trial registration number NCT03040570.