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The 24th Bubble Wrap


With millions upon millions of journal articles being published every year, it is impossible to keep up.  Every month, we ask some of our friends from PERUKI (Paediatric Emergency Research in the UK and Ireland) to point out something that has caught their eye.

Article 1: Paediatric Traumatic Cardiac Arrest

Vassalo J, et al. Paediatric traumatic cardiac arrest: the development of an algorithm to guide recognition, management and decisions to terminate resuscitation. 2018. 

What’s it all about?

The PERUKI team have formed an expert consensus opinion to define the optimum management of paediatric TCA to construct an algorithm to guide clinical practice. The group previously published a 3-round Delphi process with an expert panel of 73 participants to form 14 consensus statements around recognition, management and cessation of paediatric TCA.

To develop the algorithm, a modified consensus development conference was held where 41 participants (mainly consultants from multiple relevant disciplines) presented existing evidence in the form of topic-specific systematic reviews. 

The second part of the meeting explored statements that did not meet consensus during the previous Delphi process. 19 questions relating to definition, diagnosis, management and termination resuscitation in paediatric TCA were given to the participants to discuss in small groups of 5-7. After 5 minutes of discussion the key points were presented from each small group to all the other participants.

Following this, each individual participant was asked to vote on their agreement with the statement in question using electronic voting devices by voting ‘yes’, ‘no’ or ‘don’t know’.

Consensus was set at a priori at 70% of the total number of participants responding to a question. There was only a single round of voting per question. Those who didn’t record a vote to a question were included in the ‘don’t know’ category. Of the 19 statements, 13 reached a positive consensus, 5 did not reach a consensus, and 1 had a negative consensus. Three of the statements not reaching consensus related to the use of vasopressors. The question that had negative consensus related to giving rescue breaths in paediatric TCA at the entry to the algorithm. Here is the final algorithm:

Why does it matter?

Paediatric traumatic cardiac arrest (TCA) is a high-acuity, low-frequency event. There are less than 15 cases/per year in the UK. Survival is low, but with standardised approaches and the development of TCA-specific algorithms, improvement in survival rates has been seen in the adult population.

Currently, there is no standardised approach to paediatric TCA, and most clinicians have limited experience. A consensus-based guide for paediatric TCA management could provide a framework for further research.

The algorithm is similar to that used in adults (see Algorithm on page 14 of ERC2015 guidelines and comments on chest compressions below). The focus is on the rapid management of reversible causes.

In this paediatric algorithm, this bundle of life-saving interventions should be prioritised ahead of chest compressions.

The Bottom Line

Paediatric TCA is rare.  Having an algorithm formulated through expert opinion may help guide decision-making and mitigate stress, especially in environments not used to dealing with major trauma.

Reviewed by: Vikram Baicher

Article 2: What is the benefit of a prolonged PICU stay?

Matsumoto N, et al. Long-term mortality and functional outcome after prolonged paediatric intensive care unit stay. Eur J Pediatr. 2018 Oct 27

What’s it about?

The retrospective cohort study of PICU stays between 2011-13 was conducted in a paediatric intensive care unit (PICU) with six beds in a large tertiary (non-surgical) centre in Japan (Osaka). The authors looked at the impact of prolonged PICU stay (>14 days) on mortality and functional outcomes after three years.

Whereas most children (>50%) stay in the PICU for just a night or two, 14% stay more than 14 days and occupy around 50% of the beds.

Favourable outcomes were defined as a Pediatric Overall Performance Category (POPC) score of 1-2 and unfavourable outcomes as a POPC score of 3-6 or death. 

The survival rate was 75% at three years, with an overall favourable outcome rate of 43% (57% among survivors). Nine patients were lost to follow-up and excluded. These patients had a higher proportion of neuromuscular disease, which may have further reduced the proportion of favourable outcomes had they been included. 

Although prolonged PICU-stay patients needed many PICU resources, most survived at least three years. More than half of the survivors had favourable functional outcomes.

The author’s statistic of >50% favourable outcomes is based on a subset of 58 patients who were >1 month with POPC scores, where 12 out of 19 patients with good POPC pre-admission maintained this at three years follow-up. Conversely, 39 of the 58 patients > one month had unfavourable POPC scores prior to admission, with ten improving and 29 remaining in the unfavourable outcome group at 3-year follow-up. The study also found that extremely prolonged stays (≥ 28 days, 43 patients) had mortality rates of 33% and fewer favourable functional outcomes (30%).

Why does it matter?

Prolonged PICU stays represent a small but growing proportion of patients with significant costs. This study provides additional information about what outcomes might be expected for patients with prolonged PICU stays.

The numbers were small. 43% of patients were less than one month old.

Clinical Relevant Bottom Line

This study found that 112 children with prolonged PICU stay over 14 days had an overall 3-year survival rate of 75% . Although we need larger studies to confirm these findings, prolonged PICU stay seems justified.

Reviewed by: Anke Raaijmakers

Article 3: Do we need appendicectomies?

Salminen P, et al. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018. 20 (12), pp1259-65

Why does it matter?

This RCT compares the use of broad-spectrum antibiotics to appendicectomy in managing uncomplicated appendicitis.

Patients were followed up for five years to determine the recurrence rate of appendicitis. If antibiotics alone are an effective treatment option, we could see a reduction in the need for appendicectomies, avoiding associated surgical and anaesthetic complications.

What’s it about? 

Between 2009- 2012, 530 patients aged 18 – 60 were enrolled from six hospitals across Finland. Patients with CT-confirmed uncomplicated appendicitis were randomized in a 1:1 ratio to receive antibiotics (IV ertapenem 3 days, PO metronidazole and levofloxacin seven days) or undergo open appendicectomy (gold standard surgical method in Finland).

Of the 257 patients who received antibiotics, 70 patients had a recurrence of appendicitis (no set criteria or protocol, diagnosed at the surgeon’s discretion). They required appendectomy within the first year, with 30 more patients requiring appendectomy over the next four years. This makes the likelihood of late recurrence within five years 39.1%.

The secondary outcome of post-treatment complications included surgical site infections, incisional hernias, abdominal pain, and obstructive symptoms. At five years, the overall complication rate was higher in the appendectomy group (24.4%) than the antibiotic group (6.5%).

Clinically Relevant Bottom Line:

Whilst the use of antibiotics to manage uncomplicated appendicitis seems promising in adults, the APPAC study protocol makes it difficult to replicate in a paediatric age group.

The difficulty for us lies in clinically diagnosing appendicitis in children. Ultrasounds, though commonly used, are not always helpful. At this stage, we would still be picking up the phones to talk to the surgeons for their expertise!

Reviewed by: Tina Abi Abdallah

Article 4: Where is the threshold for resuscitation in Extremely Preterm Infants?

Wilkinson D, Verhagen E, Johansson S. Extremely Preterm Infants in the UK, Sweden, and Netherlands. Pediatrics. 2018. 142 (s1)

What’s it about?

A survey of 162 neonatologist registrars, fellows and consultants across the UK, Sweden and the Netherlands looked at the different thresholds for resuscitation of extremely preterm infants (<28 weeks).

Four scenarios were posited to assess the lowest gestational age respondents might provide active resuscitation. These were:- if parents were supportive of or reluctant for resuscitation for both a good or poor condition at birth. Doctors also reported their thresholds for resuscitation using the probability of survival without severe disability.

There was a spectrum of responses between the countries, with more doctors in Sweden being proactive (a threshold of 22-23 weeks) compared to the UK (23-24 weeks) and Netherlands (24-26 weeks) gestation. This reflects differences in national guidelines being 22, 23, and 24 weeks gestation, respectively. As one might expect, the threshold rose if infants were born in poor conditions.

Half the doctors were prepared to resuscitate at parental request if an infant had <5% to 10% chance of survival without severe morbidity. Half would not be prepared to withhold resuscitation 
if an infant had a >20% to 30% chance of survival without severe morbidity.

Why does it matter?

Resuscitation and care of extremely preterm infants (<28 weeks) continues to push the abilities and limits of medical care. There have been some gains in the survival of extremely preterm babies, but also concern regarding the high prevalence of neurodevelopment disability.

Babies born below 24 weeks continue to have relatively poor survival outcomes, with a 2016 American retrospective cohort study finding survival at one year of life for 22-week and 23-week infants to be 6% and 27%, respectively.

Parents should be involved in decision-making about the resuscitation of extremely preterm infants on the edges of viability. It is our duty to support and counsel parents and deliver care appropriately. Comparing and contrasting collective opinions of neonatologists across countries inform our awareness of global practices.

The Bottom Line

Across Sweden, the UK and the Netherlands, there is a range of thresholds for the resuscitation of extremely preterm infants. This is also reflected in the differences in national guidelines being 22, 23 and 24 weeks gestation, respectively.

If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments! That’s it for this month. Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to.


  • Grace is a Registrar at Sydney Children's Hospital. She loves innovative medical education and paediatrics. She is on the organising committee for the DFTB18 and SMACC conference. Grace is a former internal director of the AMSJ. She enjoys board games, cooking and graphic design.


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