The 24th Bubble Wrap

Cite this article as:
Leo, G. The 24th Bubble Wrap, Don't Forget the Bubbles, 2018. Available at:

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 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) were 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 positive consensus, 5 did not reach 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 with less than 15 cases/year in the UK. Survival has traditionally thought to be low but with standardised approaches and 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 the majority of clinicians have a limited experiences of paediatric TCA management. Gaining consensus to provide a guide for paediatric TCA management provides a framework on which further research can build. The published algorithm is similar to those used in the adult  population (see Algorithm on page 14 of ERC2015 guidelines and comments on chest compressions below) and there is a focus on the rapid management of reversible causes. In this paediatric algorithm this ‘bundle of life saving interventions’ are clearly prioritised ahead of chest compressions.

The Bottom Line?

Paediatric TCA is rare, thankfully.  Having an algorithm that has been formulated through expert opinion may help guide decision making and mitigate human stress factors especially in environments not well accustomed to dealing with major trauma.

Reviewed by: Vikram Baicher


Article 2: Prolonged PICU stay and morbidity/mortality rates; where lays the benefit?

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 as conducted in a ‘large’ paediatric intensive care unit (PICU) with 6 beds in a large tertiary (non surgical) centre in Japan (Osaka). The authors investigated the impact of prolonged PICU stay (>14 days) on mortality and functional outcome after three years. Whereas most children (>50%) stay in PICU for a night or two, only 14% of patients in PICU stay >14 days but occupied around 50% of the beds at a time. 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. At the 3-year follow-up, the survival rate was 75% and the overall favourable outcome rate was 43% (57% among survivors). Nine patients were lost to follow up due to patient transfer and were excluded however they had higher proportion of neuromuscular disease which may have further reduced the proportion of favourable outcomes, had they been able to be included. The authors concluded that although prolonged PICU-stay patients utilized many PICU resources, most survived at least 3 years and more than half of the survivors had favourable functional outcomes as defined by POPC scores.

It should be noted  that the authors statistic of >50% favourable outcomes is actually 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 3 year follow up. Conversely, 39 of the 58 patients >1 mo, had unfavourable POPC scores prior to admission, with 10 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 as well as significant costs. This study provides additional information about what outcomes might be expected patients with prolonged PICU stays. However this should be weighed with the fact that the numbers in this study were small and 43% of patients were less than one month old with no prior POPC scores able to be determined for comparision at the 3 year follow up.

Clinical Relevant Bottom Line

This study found that 112 children with prolonged PICU stay > 14 days had an overall 3 year survival rate of 75% and a favourable outcome rate of 43% (or 57% amongst survivors). Although we need larger studies to confirm these findings, prolonged PICU stay seems to be justified.

Reviewed by: Anke Raaijmakers


Article 3: Can we cut out the need for 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 for the management of uncomplicated appendicitis. The cohort of patients was followed up for 5 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 years were enrolled via 6 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 7 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) and required appendectomy within the first year, with 30 more patients requiring appendectomy over the next 4 years. This makes the likelihood of late recurrence within 5 years 39.1%.

The secondary outcome of post treatment complications included surgical site infections, incisional hernias, abdominal pain, and obstructive symptoms. As predicted, at 5 years the overall complication rate was statistically significantly higher in the appendectomy group (24.4%) compared to the antibiotic group (6.5%).

Clinically Relevant Bottom Line:

Whilst the use of antibiotics to manage uncomplicated appendicitis seems promising for the adult age group, 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, and 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 of Extremely Preterm Infants in the UK, Sweden and Netherlands?

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 Netherlands assessed the different thresholds for resuscitation of extreme preterm infants (<28 weeks). Four  scenarios were used to assess the lowest gestational age at which respondents would provide active resuscitation. These were if  parents were supportive of vs reluctant for resuscitation for both a good or poor condition at birth. Doctors also reported their thresholds for resuscitation using probability of survival without severe disability.

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

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 survival of extremely preterm babies but also concern regarding the high prevalence of neurodevelopment disability. Babies born below 24 weeks continue to have relatively survival poor outcomes with a 2016 American retrospective cohort study found survival at 1 year of life for 22 week and 23 week infants to be 6% and 27% respectively.

Parents should be involved in decision making about resuscitation of extreme preterm infants on the edges of viability. It is our duty as health care professionals to be able to support and counsel parents and deliver care appropriately. Being able to compare and contrast collective opinions of neonatologists across countries is useful to help inform our awareness of global practices.

The Bottom Line
Across the Sweden, the UK and Netherlands there is a range of threshold for the resuscitation of extreme 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.

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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.

Author: Grace Leo 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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