Vicarious Trauma : It’s ok to not be ok

Cite this article as:
Jasmine Antoine. Vicarious Trauma : It’s ok to not be ok, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19256

One afternoon my team broke the news to three different families that their children had a non survivable condition. That same week I was involved with a patient transitioning to a palliative pathway focused on comfort. I returned home to utter the words, “She is so sweet, I hope she dies soon.

For many of us, days like these, occur commonly.

Being a doctor is a privilege, an honour, a calling. Our jobs are stressful, diagnostically challenging, involve managing team members, and effectively communicating and engaging with different families whom have different needs. We are reliant on our knowledge and skills. What sets our job apart from other high stress environments is that any given day can involve death and dying. We see distressing conditions. Our day includes the uncommon, the unlucky and the unfortunate events of life. To the public these events occur few and far between, but for us it may be a daily occurrence -a relentless barrage of traumatic events, poor outcomes and sad stories.

The intensive care environment is difficult to navigate. The rates of burnout, mental health issues and self medication are high amongst our peers. 70% of junior doctors feel burnt out following a neonatal rotation. Strikingly, their (our) rates of suicide are twice that of the general population. Most of us have heard the words compassion fatigue. Some of us may even be familiar with vicarious trauma – the negative experience of working directly with traumatised populations. Compassion fatigue and vicarious trauma are on a spectrum. We initially may feel overwhelmed by our interaction but this can develop into symptoms of post traumatic stress.

At DFTB18, I spoke about some of the things we can do to reduce this happening to us, and the events above reinforced that message;

  • Seek the support of those around you.
  • Reflect with your supervisor.
  • Get together with your team to debrief.
  • Seek professional psychological support.
  • Foster a culture in your workplace that is supportive and open, whilst also taking time for yourself.
  • Make a regular appointment to see you GP.

And remember, it’s ok not to be ok

For more on this topic of the difficulties of dealing with death and burn out hit up DFTB at:

Burning out by Mark Garcia

A short story about death by Andy Tagg

Selected References

Boss RD, Geller G, Donohue PK. Conflicts in Learning to Care for Critically Ill Newborns: “It makes me question my own morals”, Bioethical Inquiry. 2015;12:437-448

Hauser N, Natalucci G, Ulrich H, Sabine K, Fauchere JC. Work related burden on physicians and nurses working in neonatal intensive care units: a survey, Journal of Neonatology and Clinical Pediatrics. 2015;2:2:0013.

Nimmo A, Huggard, P. A systematic review of the measurement of compassion fatigue, vicarious trauma and secondary traumatic stress in physicians. Australian Journal of Disaster and Trauma Studies. 2013;1:37-44.

Stress, burnout and vicarious trauma: looking after yourself. RACGP Webinar Series.

The Collapsed Cardiac Child: Kath Browning Carmo at DFTB18

Cite this article as:
Team DFTB. The Collapsed Cardiac Child: Kath Browning Carmo at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18978

There is nothing like the thought of dealing with a shocked neonate to strike the fear of the almighty into the most experienced doctor. If you are lucky enough to have Kath Browning Carmo on speed dial then you may be a little more relaxed but if you don’t here she is to offer some words of comfort.

(Kath has chosen Moonlight Sonata as her ringtone so she gets woken gently rather than in a fluster – what a great idea: Ed)

Here’s a sketch note from the talk by @char_durand

If you want to get a better idea of some of the congenital abnormalities that can occur then take a look at these animations from Cincinatti Children’s.

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story‘ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

DFTB19 has already sold out but there are still spots for some of the pre-conference workshops.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Selected References

Evans NJ, Archer LN. Postnatal circulatory adaptation in healthy term and preterm neonates. Archives of disease in childhood. 1990 Jan 1;65(1 Spec No):24-6.

Fever under 60 days of age

Cite this article as:
Alasdair Munro & Damian Roland. Fever under 60 days of age, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18571

Prompted by Tessa’s Top 5.5 Papers in PEM presentation at RCEM, Alasdair Munro kicked off an exciting twitter debate with the question…Would you do a full septic screen on a baby under 60 days with a fever?

Many of us will be familiar with the mantra that all children under 3 months get a full septic screen and antibiotics. It feels like we are over-treating, but this is a high risk group so is there any other way?

Top 5 Papers in PEM

Cite this article as:
Tessa Davis. Top 5 Papers in PEM, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18476

This post is based on a talk I presented at the RCEM Spring Conference in April 2019 – Top 5 papers in PEM.

Kylie and Jason are enjoying their time at home with their first baby. The highs of being new parents is at its peak and true sleep deprivation is yet to set in. Jayden is two weeks old and is simply perfect. They spend hours staring at him each day marvelling at the perfect human they have created. 

As we follow Jayden through his journey to adulthood, we’ll encounter some common paediatric problems. The 5.5 papers I have chosen were selected because: they cover common presentations; they use large patients groups; and they were conducted by well-respected and highly regarded research groups. But back to our story…

 One night Jayden seems a bit more unsettled than normal. When they check his temperature it’s 38.4. They get in the car and bring Jayden to ED

 Febrile neonates are a huge source of concern – we know that they can deteriorate quickly and we usually err on the side of caution by doing a full septic screen, IV antibiotics, and admission. Actually many of these babies don’t have a serious bacterial infection. Is there a way to tell which ones do?

When you see Jayden in your ED, you ask yourself is…should I do a full septic screen?

Paper 1 - Kupperman et al, 2019, A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections, JAMA Pediatrics


This paper aimed to derive and validate a highly accurate prediction rule to identify infant at low risk of SBI. The patients were febrile infants 60 days and younger (who had a rectal temp of >38 in the ED or a fever at home within the preceding 24 hours)

They excluded those who were critically ill, who had antibiotics in the preceding 48 hours, those born premature, and those with other medical conditions.

There were 1821 febrile infants included.

The authors considered clinical suspicion of SBI. They then look at various markers: blood culture; urine culture and urinalysis; CSF; FBC; and procalcitonin levels. The outcomes  considered were serious bacterial infection – that is bacterial meningitis, bacteraemia, or urinary tract infection.

Overall, the rates of SBI in this group was 9%. The authors formulated a rule with a very high sensitivity (97.7%) for identifying those at low risk of serious bacterial infection. They were low risk if they fulfilled three criteria:

  • negative urinalysis
  • neutrophil count of less than 4/mm3 
  • procalcitonin of less than 0.5ng/ml

61.3% of their patient group were low risk.

Interestingly their low risk rule does not include use of  lumbar puncture67.4% of the low risk group had a lumbar puncture that would not have been necessary.

Key take away: There may be some febrile neonates that are low risk, and therefore we could avoid a lumbar puncture and full work up. In practical terms, this is unlikely to change our practice at the moment. Many of us cannot send a procalcitonin in the ED, and we might have to wait several hours to get a neutrophil count back. However this does bode well for the future in identifying which of these well febrile neonates are low risk.

Jayden does get a full septic screen. He has IV antibiotics for 48 hours and remains well. His blood cultures are negative so his antibiotics are stopped and he is discharged.

FLASH FORWARD…

 

 

Jayden is growing well. At 7 months of age, he is looking great and developmentally normal. Dad, Jason, smokes, but reassures you that he never does so in the house. Jayden develops a cough and two days later starts breathing very quickly and noisily. They head to the emergency department.

Jayden has bronchiolitis. This is very common and your departments and wards have no doubt been filled with these children over the winter. We know that little works with these children. So you force yourself to hold back the ‘trial of salbutamol’ because it won’t make any difference.. But high flow does seem to be the one thing (along with oxygen) that might make a difference.

You ask yourself the question...should I start high flow?

Paper 2 - Franklin et al, A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. NEJM. 2018. 378(12):1121-1131

This study looks at infants under 12 months old with a clinical diagnosis of bronchiolitis and a need for supplemental oxygen. 1472 were included (after exclusions). Patients were excluded if: they had an alternative diagnosis; they had cyanotic heart disease; or they were on home oxygen.

Patients were randomised to either high flow or low flow. The high flow group were given heated humidified high flow oxygen – 2L/kg/min via Optiflow. The oxygen was then weaned to achieve target saturations, and they were taken off high flow once they had been on air for four hours. The low flow group were given wall oxygen via nasal cannulae at 2L/min max.

The outcome  was escalation of care. This meant who in the low flow group was escalated to high flow, and who in the high flow group was escalated to BiPAP or was intubated. Treatment failure was based on: an increase in heart rate; if the respiratory rate increased or didn’t drop; if they were needing oxygen in >2L/min of flow or >0.4 FiO2 to maintain their saturations; or if they achieve a high early warning score. Clinicians could also escalate care themselves (34% were escalated in this way).

Escalation of care occurred much more commonly in the low flow group – with 12% being escalated in the high flow group and 23% in the low flow group.

 

Interestingly there was no difference in the length of stay between the two groups.

Key take away: High flow does reduce the need for escalation. Escalation itself is significant – it requires increased nursing attention for low flow patients while they are transferred onto Optiflow.  There may be less medical staffing on the wards if the child deteriorates on high flow overnight. Although they aren’t comparing like with like, escalation itself is an important clinical event. They also demonstrated that high flow does not increase the number of adverse events (for example there was no difference in the number of pneumothoraces between the groups). High flow is safe to use and we should consider starting it early in ED.

You start Jayden on high flow in ED and he stabilises. 12 hours later he is weaned off on the ward and is discharged the following day.

FLASH FORWARD…

Jayden is now a healthy 3 year old boy. He loves Paw Patrol.  He hates vegetables and won’t eat any food that is the colour green or yellow. Kylie and Jason are expecting their next child, and Jason has finally quit smoking. Unfortunately Jayden is prone to wheezy episodes and now has his very own inhaler which he hates using. The change in weather in London, from quite cold to…colder, seems to have triggered something and he’s now pretty wheezy and short of breath. They head into their favourite emergency department.

 Jayden is now firmly in the realm of viral-induced wheeze. Yes, it’s all on a spectrum, but he’s now 3 years old with an inhaler. You asses him and think he should have a salbutamol burst.

As you are writing the salbutamol up, your SHO asks  you – should I give him steroids?

Paper 3 - Foster SJ, Cooper MN, Oosterhof S, Borland ML. Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial. The Lancet Respiratory Medicine. 2018 Jan 17.

 This paper aimed to assess the efficacy of oral prednisolone in children presenting to an ED with viral wheeze.

The patients included were 2-6 years old. They were excluded if: saturations were less than 92% in air; they had a silent chest; they had sepsis; there was a previous PICU admission for wheeze; they had prematurity; or they had recently had steroids.

605 patients were included and they were randomised to receive either prednisolone or placebo. The prednisolone group received 1mg/kg prednisolone once a day for three days. The placebo group received a placebo medication (matched for volume and taste to prednisolone) once a day for three days.

Patients were assessed for their wheeze severity using a validated pulmonary score.

The outcome measures were length of stay (until clinically fit for discharge). They also considered re-attendance, readmission, salbutamol usage, and residual symptoms.

The results are tricky to interpret. Those who were discharged from ED within four hours did not benefit from prednisolone. However there may be some benefit in the mild to moderate wheeze group, and some in those who used salbutamol at home prior to presenting to ED. Interestingly this paper did not support our previously held belief that those children with atopy respond better to prednisolone.

 Key take homes: Some pre-schoolers are steroid responsive, but identifying which ones is a challenge. As Damian Roland discusses here, it is likely that we are seeing lots of children presenting with the same symptoms (wheeze) but with different pathology behind it. Once we can identify the pathology we can start to target specific groups of patients with management that works.

You decided not to give Jayden prednisolone and after his salbutamol burst he stretches to 4 hours and is discharged home.

FLASH FORWARD…

Jayden is 5 years old and in his excitement of building the new Hogwarts Lego castle he accidentally swallows a Lego head. Kylie and Jason aren’t sure whether to worry or not? So they take him into ED.

Children ingesting random objects is a common presentation to ED.

When you see Jayden in the department, his parents ask you…should I search through his poo?

Paper 3.5 - Tagg, A. , Roland, D. , Leo, G. S.Y., Knight, K. , Goldstein, H. , Davis, T. , DFTB, (2018), Everything is awesome: Don’t forget the Lego. J Paediatr Child Health. doi:10.1111/jpc.14309

Myself and 5 of my fearless, and brave, paediatric colleagues swallowed a Lego head each to see how quickly it passed. The paper was generously published in the Journal of Paediatrics and Child Health.

To ensure serious scientific rigour, we put together some scoring systems.

The Stool Hardness and Transit time (the SHAT score) took into account how hard our stools were, and whether that impacted (no pun intended) on the time to retrieve the Lego head.

And out main outcome was the Found And Retrieved Time (the FART score). This was the time to get our Lego heads back, and the average FART score was 1.71 days.

Unfortunately one of the six of us didn’t find his Lego head. After valiantly searching through his own faeces for two weeks, he gave up. And it may still be up there.

Key take home: Don’t search through poo, it’s gross.

Jayden heads home happily to finish building his Lego Castle.

FLASH FORWARD.

Jayden is 6 years old. He thinks Paw Patrol is for losers. Fortunately he still loves Lego and Harry Potter. He also enjoys climbing. Unfortunately, two days ago he fell off the ladder coming down from his bunk bed. He seemed okay at the time, and Kylie and Jason had other plans that evening, so they decided to keep him at home. Now, two days later, he has a massive egg on his head and has been complaining of a headache. He also vomited yesterday. They bring him to ED.

 

We have fabulous head injury guidance for kids thanks to PECARN, CHALICE, and CATCH. But actually PECARN and CATCH specifically exclude injuries more than 24 hours old, and CHALICE doesn’t publish data on this group. So, for Jayden you need to put the NICE guideline away because it doesn’t apply. This is a common grey area.

The question you ask is….should I scan his head?

Paper 4 - Borland M, Dalziel SR, Phillips N, Lyttle M, Bressan S, Oakley E, Hearps SJC, Kochar A, Furyk J, Cheek J, Neutze J, Gilhotra Y, Dalton S, Babl F. Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study, Annals of Emergency Medicine, DOI: https://doi.org/10.1016/j.annemergmed.2018.11.035

This paper aimed to establish the prevalence of traumatic brain injuries in children presenting more than 24 hours after the head injury.

Traumatic brain injury (TBI) was defined as: intracranial haemorrhage; contusion; cerebral oedema; diffuse axonal injury; traumatic infarction; shearing injury; or a sigmoid sinus thrombosis.

The also looked a clinically significant traumatic brain injury (cTBI) – this included death, intubation for more than 24 hours, neurosurgery, or admission for 2 or more nights to hospital.

The patients were from the Australian Paediatric Head Injury Study Cohort which was 20,137 patients. 5% of these presented over 24 hours after the injury. 981 children were included in this study.

The authors considered the injury characteristics and demographics, trying to find an association between mechanism and delay in presentation. Those presenting were more likely to have: a non-frontal scalp haematoma; headache; vomiting; and assault with NAI concern. Those with loss of consciousness and amnesia were more likely to have presented within the first 24 hours.

The CT rates were much higher in the late presentation group – 20.6% being scanned in the delayed group and only 7.9% in the early group. This probably reflects the lack of evidence in this area, and therefore we feel safer doing more scans.

But the rates of TBI also varied. 3.8% in the delayed presentation group had a TBI, whereas only 1.2% in the early presentation group did.

The rates cTBI were the same between the groups at 0.8%

Key take homes: There is an increased risk of TBI when presenting more than 24 hours after a head injury injury. The authors found that risk is increased if the patient has a non-frontal scalp haematoma or a suspicion of a depressed skull fracture.

You decide to scan Jayden’s head, but it turns out to be normal and he is discharged home.

FLASH FORWARD… 

Jayden is 8. He’s been drinking a LOT of water over the last few weeks and seems to be weeing constantly. His clothes seem a bit big for him too. He looks so bad one day (and has vomiting and abdominal pain) that Jason finally reneges and takes him into ED.

Jayden has DKA. The debate about over-zealous fluid administrations and its relationship to the dreaded cerebral oedema is long-standing. Previous research suggested a link but only by association, not causality.

You ask yourself…how fast should I give IV fluids?

Paper 5 - Kupperman et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis NEJM 2018 vol 378 (24) pp 2275-2287

The study examines the causal effect between fluid resuscitation and cerebral oedema.

They included 1389 episodes of DKA. Exclusions were mainly due to too much management prior to contact with the study team, as well as children with a GCS<12. The median age was 11. It should be noted that the very young and the very sick are probably lost in this cohort.

Patients were randomised to received either fast or slow rehydration, and then were split again into received either 0.9% NaCl or 0.45% NaCl.

The fast rehydration group received 20ml/kg bolus and then replacement of 10% deficit, half over 12 hours and rest over next 24 hours. The slow rehydration group received a 10ml/kg bolus and then replacement of 5% deficit over 48 hours. Maintenance fluids and insulin were given in addition.

The outcomes looked at were deterioration of neurological status within first 24 hours of treatment. They also assessed short term memory during treatment, and IQ 2-6 months after the episode of DKA.

In short, they found no difference between the groups. There was a 0.9% rate of brain injury overall and it didn’t matter which type of fluids or how fast. Patients were more likely to get hyperchloraemic acidosis in the 0.9% NaCl group but this is of debatable clinical significance.

Key take homes: The evidence does not support our traditionally cautious approach to DKA. The speed of IV fluids does not seem to be the cause of brain injury in DKA.

You resuscitate Jayden and send him off to the ward. He is discharged a few days later with good support from the Endocrine team for management of his diabetes.

FLASH FORWARD…

Jayden is now 16 years old and next time he comes to ED, he’ll be in the harsh world of Adult ED. We have navigated him through his common childhood presentations to ED and answered the key questions we ask ourselves every day in the Paeds ED.

 

Should I do a full septic screen on this hot baby?

Should I start high flow on this infant with bronchiolitis?

Should I give prednisolone to this 2 year old with wheeze?

Should I scan this child with a head injury?

How fast should I give fluids to my DKA?

And most importantly, do I ever need to sift through my child’s poo, or my own ever again?

Antenatal Counselling: Trish Woods at DFTB18

Cite this article as:
Team DFTB. Antenatal Counselling: Trish Woods at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18153

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFTB19, which will be held in London, UK, are now on sale from www.dftb19.com.

Being a NICU parent: Joanne and Scott Beedie at DFTB18

Cite this article as:
Team DFTB. Being a NICU parent: Joanne and Scott Beedie at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18131

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFTB19, which will be held in London, UK, are now on sale from www.dftb19.com.

Cuffed or uncuffed tubes?

Cite this article as:
Tessa Davis. Cuffed or uncuffed tubes?, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17511

The debate over uncuffed versus cuffed endotracheal tubes (ETTs) is a long-standing one. In a paper published in Pediatric Anesthesia this week, one paediatric critical care unit has published the results of their experience of introducing cuffed ETTs.

Greaney D, Russell J, Dawkins I, Healy M, A retrospective observational study of acquired subglottic stenosis using low-pressure, high-volume cuffed endotracheal tubes. Pediatric Anesthesia, 2018, DOI: 10.1111/pan.13519

 

What’s the background?

Many intensive care units use uncuffed ETTs in neonates due to concerns of cuff-related trauma and subglottic stenosis. The estimated incidence of ETT-related subglottic stenosis (SGS) ranges from 0.3-11%.

The benefits of a cuffed tube are thought to be: accurate ETCO2 monitoring, protection from aspiration, fewer tube changes due to air leaks, and continuous lung recruitment.

The concerns about cuffed tubes are that they cause increased trauma and that this trauma can lead to erosion, infection, cricoid perichondritis, and ultimately sub-glottic stenosis.

The author introduced the use of Microcuff ETTs into their unit hypothesizing that it may lead to less ulceration, chondritis, and fibrosis in the subglottic space. Microcuffs are a specific type of ETT (low-pressure, high-volume), but the smallest type is 3.0mm internal diameter which is not recommended for neonates less than 3kg.

 

Who were the patients?

This was a retrospective analysis of all patients admitted to the Paediatric Critical Care Unit in Australia over a five year period.

Patients were included if they also had a microlaryngobronchoscopy (MLB) procedure.

Patients were excluded if they were >18 years old; had congenital SGS; had previous airway surgery, or had a previous SGS diagnosis.

 

What were the outcomes?

MLB reports were reviewed to look for findings consistent with clinically significant acquired endotracheal tube-related pathology (within six months of intubation).

Demographics were analyzed including age, sex, prematurity, comorbidities, duration of ventilation, number of intubations, duration of admission.

 

What did they find?

There were 5309 PCCU admissions over the five year period, and 61% required intubation.

297 patients had an MLB.

23 children (0.68% of all intubations) had a clinically significant ETT-related pathology: 8 had acquiredsub-glottic stenosis; the other 15 had other ETT-related pathology (granulomas, ulcers, or cysts).

5 of the 8 children with sub-glottic stenosis required tracheostomies.

All those who required surgical correction of the SGS were ex-prem neonates who had received invasive ventilation in a NICU with an uncuffed tube prior to admission to PCCU.

 

What conclusions did they draw?

They demonstrated a low incidence (but high morbidity) of acquired SGS.

There were a few issues around the conclusions drawn:

  • The authors state ‘there was no single case of de novo clinically significant acquired SGS with the use of cuffed ETTs‘. I’m not sure that this is a fair conclusion, as there were 8 cases of acquired SGS. Yes, these cases all had an uncuffed tube initially in NICU, but they also had a cuffed tube in PCCU.
  • It would be good to be able to compare the rates of SGS before the introduction of Microcuff ETTs with these rates after its introduction – this would help to see whether rates have increased. It would also be helpful to look at the neonatal group in particular as this study reports the overall percentage of SGS in all patients, and then draws conclusions about its safety in neonates.

 

However, in spite of concerns around the use of cuffed tubes that exist, no study has previously shown that cuffed ETTs lead to a higher incidence of SGS than uncuffed ETTs. This is an interesting paper to open the discussion around the use of cuffed ETTs in neonates.

If you want to learn more about tiny tubes then catch this talk from Shabs Rajapaksa from DFTB18.

 

Expert Opinion – Eric Levi, Consultant Paediatric Otolaryngologist

I would love to see other data to enhance this paper: comparison with rates of SGS prior to cuffed tubes and comparison of rates of SGS in other patients who did have an uncuffed tube but did not develop SGS. Surely in the 3000 or so intubations, there would have been others who were also tubed with uncuffed tube and yet not develop any tube related pathology.

Although this is not a perfect paper, I do think the authors are onto something, and that they are adding to the body of knowledge suggesting that in their cohort, cuffed tubes are not associated with SGS.

Neonatal intubation: Shabs Rajapaksa at DFTB18

Cite this article as:
Team DFTB. Neonatal intubation: Shabs Rajapaksa at DFTB18, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17490

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFT19, which will be held in London, UK, are now on sale from www.dftb19.com.

Neonatal jaundice – the basics

Cite this article as:
Shalome Kanagaratnam. Neonatal jaundice – the basics, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17047

Most newborns are jaundiced. Indeed, 60% of term infants, 80% of premies and 33% of breastfed babies are jaundiced in early life. Fortunately, the majority of these self-resolve and have no sinister underlying cause. But how do we identify those who require urgent management? How can we effectively and confidently reassure anxious patients whilst ensuring we don’t miss a significant diagnosis?

Bronchiolitis guidelines

Cite this article as:
Tessa Davis. Bronchiolitis guidelines, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17023

Up to 48% of infants admitted to Australian hospitals with bronchiolitis receive treatment that has no evidence of benefit. Bronchiolitis remains the most common reason for admission to hospitals in Australia and New Zealand for infants, and yet our practice in treating these patients remains variable.  The PREDICT network have conducted a systematic review to produce Australia’s first bronchiolitis guideline based on a robust systematic review. These guidelines broadly agree with the American Academy of Pediatrics and NICE guidelines.

 

O’Brien S, Wilson S, Gill FJ, Cotterell E, Borland ML, Oakley E, Dalziel SR, Paediatric Research in Emergency Departments
International Collaborative (PREDICT) network, Australasia. The management of children with bronchiolitis in the Australasian hospital setting: development of a clinical practice guideline. J Paediatric Child Health, 2018. doi:10.1111/jpc.14104

 

The authors have produced 22 recommendations based on their robust evidence review. Let’s take a look at their key recommendations.

 

What investigations should we do?

  • Routine blood and urine testing is not recommended.
  • Viral swabs are not recommended (although the authors mention that further study needs to be done to determine the benefit of cohorting in wards i.e. when all babies with the same virus are put in the same bay together to avoid spread).
  • The authors note that in infants under 2 months old with bronchiolitis there is an increased risk of a concurrent UTI.

Therefore in babies under 2 months old with pyrexia, likely bronchiolitis but some clinical uncertainty – send a urine for m, c, & s

 

What treatments are effective?

  • Salbutamol – there is no benefit in using salbutamol in infants with bronchiolitis (and some evidence of adverse effects)
  • Nebulised adrenaline – no benefit
  • Nebulised hypertonic saline – there is weak evidence of a reduction in length of stay of 0.45 days. However when two studies were removed, both of which used a different discharge criteria than most hospitals, there was no benefit. This is not recommended routinely, although the authors suggest that it should be used only as part of an RCT
  • Glucocorticoids – no benefit
  • Antibiotics – not recommended

The risk of a secondary bacterial infection is very low, and there is potential harm from giving antibiotics

  • Oxygen – no evidence of benefit in infants with no hypoxia, and low level evidence that maintaining the sats over 91% with oxygen actually prolongs the length of stay. There are no reports of long-term adverse neurodevelopmental outcomes in infants with bronchiolitis, however there is also no data on the safety of targeting sats <92%

Commence oxygen therapy to maintain sats over 91%

  • Sats monitoring – there is moderate evidence suggesting that continuous sats monitoring increases the length of stay in stable infants
  • High flow – there is low to very-low level evidence of benefit with high flow
  • Chest physiotherapy – not recommended
  • Saline drops – routine saline drops are not recommended but a trial with feeds may help
  • Feeds – both NG and IV are acceptable routes for hydration

 

This is the first robust Australasian acute paediatric guideline on bronchiolitis. It provides clear guidance for the management of patients seen in Australasian EDs and general paediatric wards with bronchiolitis and is in line with US and UK recommendations. Our current practice often deviates from this evidence-based, and hopefully these guidelines will start the shift towards unifying evidence-based practice in managing infants with bronchiolitis.

 

 

References

American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics 2006; 118: 1774–93.

Ricci V, Delgado Nunes V, Murphy MS, Cunningham S; on behalf of the Guideline Development Group and Technical Team. Bronchiolitis in children: Summary of NICE guidance. BMJ 2015; 350: h2305.

A short story about death…

Cite this article as:
Andrew Tagg. A short story about death…, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16636

This is the first of a two-part post based on my talk for FIX18 entitled A short story about death and life… We’ll publish the second part tomorrow.

 

“Someone will be along in a minute to explain what is going on”

Then a minute became two, three, five, until fifteen silent minutes had passed, each one seemingly longer than the last. Then footsteps…

It must have taken her an hour to cross the floor, or maybe just 30 seconds, I don’t know. I was no longer there.

I’m sorry, Mr. Tagg, I’ve got some bad news for you….Despite our best efforts, we were unable….

Her words disappeared and floated away with our dreams and I was lost.

That was how I had found out that my daughter had died. It was a tragic accident, the result of an unexpected antepartum haemorrhage and  an unsuccessful neonatal resuscitation. Something happened that day that fundamentally changed me, not just as a person, but as a doctor.

Flashbulb memories

Memory is imprecise – even in times of extreme emotion when it feels like every frame is burnt into your retina like the after image of photograph. These flashbulb memories have been heavily studied by psychologists and Malcolm Gladwell gives an easy to understand rundown in this episode of Revisionist History. What is most fascinating to me is that they are not always correct. So what does that mean of my recollection of the events that August?

The rarity of neonatal resuscitation

According to the Australian Bureau of Statistics a baby is born every 1 minute 42 seconds. That equates to around 8000 babies a day. Unfortunately, 7.2 per 1000 babies are stillborn and there are 2.4 neonatal deaths per 1000 live births. So in the whole of Australia, there are up to 19 neonatal deaths every single day.*

Most of us attend a delivery and never expect to resuscitate an infant. When we do a waft of oxygen is often all that is required. A Dutch study showed that around 2.6% of all births via elective caesarean required supplemental oxygen, around 1% require bag-valve-mask ventilation of some sort and only 0.1% require any more intensive resuscitation. The rates are much higher in lower/middle income countries.

Because they are such a rare event most doctors never expect to have to deal with a fatal outcome. Just as most emergency physicians obsess over the rarest of events, the surgical airway, perhaps those of us that may potentially be present at birth should be prepared to do what is necessary?

*A neonatal death is one that occurs within 28 days of birth

 

Absence does not make the heart grow fonder

A lot has already been written about the benefits and challenges of parental presence during the management of a critically ill child. To get you up to speed then read this post from Natalie May over on St Emlyns. The Resuscitation Council (UK) seems to think it is a good idea and most literature focuses on parental presence in either the ICU or ED setting and in an older cohort.

An exploratory interview study by Harvey and Pattison identified four key concerns surrounding the presence of the father during neonatal resuscitation in the delivery suite.

  • Whose job is it to support them?
  • What should they say or do?
  • The importance of teamwork
  • Impact on the healthcare practitioner

Think about the last time you did any neonatal life support training? No doubt you focussed on the core clinical skills – airway, breathing, circulation – with very little if no mention of dealing with the parents.

Medicine has moved on from beneficient paternalism to a more patient/parent-centred approach. It can be a hard decision to make – stay or go – but it doesn’t have to be the clinician’s choice.

Being present at a neonatal resuscitation can also be distressing for the staff involved and so one can understand how medical teams might want to shield parents from the hurt. There is concern that caregivers might interfere or get in the way with treatment. A skilled guide, such as a social worker or trained nurse, can help explain what is going on and translate the complex medical into plain English.

 

‘They’ll always remember how you made them feel”

In a time when infant death was a common occurrence, the prevailing thought was that grief could be avoided by preventing mothers from seeing their stillborn children. Psychologists would later theorize that an attachment bond had not been formed and so whisking the baby away without ceremony would cause no harm. By the 1970s this theory had been thrown out the window and grieving parents were offered the opportunity to see their children. Perhaps now the attachment bond is formed even earlier, through the use of antenatal screening, regular ultrasound scans and midwife visits making grief even more palpable.

 

The traditional (if flawed) Kubler-Ross model of grief

There will always be questions after an unexpected death – some can be answered and some can never be. But is important for parents to have the opportunity to ask. A qualitative study by Bakhbahki and colleagues in the South West of England identified a number of parental concerns centred around the framework of transparency, flexibility, inclusivity, and positivity.

We want to know that there is a perinatal mortality review process and how it works. As one of the interviewed stated, they wanted to know “this is how your child died and this is how we investigate it“. Parents wanted to know that this process was multidisciplinary involving not just neonatologists or paediatricians but also the obstetricians in order to identify any factors that may future tragic events.

We want our children to be treated like any child should be treated – with respect – regardless of whether they are alive or dead.

“The most distressing thing for me was knowing that she had been stripped of her blanket and photographed before I even had the chance to hold her.”

E.T. – a bereaved mother

There is a stigma attached to the death of a child. Society, whether it means to or not, sees the death of a child as a failure on the part of the mother. She must have done something wrong in pregnancy, she must have broken the rules. Then, these women are isolated from other newborns and their parents to the extent that they may even receive sub-optimal care.

An alternate view

It has been 8 years now and I have progressed far enough in my career to be the one bearing bad news. As an emergency physician who deals with a lot of sick and critically unwell adults, I have gone out of my way to seek formal training on breaking bad news. Specialties, such as obstetrics and paediatrics, are not exposed to death and dying on such a routine basis and very few have received formal training.

So what could be done better?

Whilst being an emotionally distant automaton may afford some protection for the clinician it is important that those breaking bad news are humans first, doctors second. I’ve written before about the power of kindness and this is one of those moments when we need to stop, look, listen and think. The death of a child, any child, is a devastating event and should be acknowledged as such.

 

With thanks to Tess (for letting me share our story) and my big-hearted cheer squad (Tessa, Ben, Henry, Tanya, Genevieve, Ian, and Ross)

Selected References

The rarity of neonatal resuscitation

*De Luca R, Boulvain M, Irion O, Berner M, Pfister RE. Incidence of early neonatal mortality and morbidity after late-preterm and term cesarean delivery. Pediatrics. 2009 Jun 1;123(6):e1064-71.

Kerber KJ, Mathai M, Lewis G, Flenady V, Erwich JJ, Segun T, Aliganyira P, Abdelmegeid A, Allanson E, Roos N, Rhoda N. Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby. BMC pregnancy and childbirth. 2015 Dec;15(2):S9.

Knight M, Draper ES, Kurinczuk JJ. Key messages from the UK Perinatal Confidential Enquiry into term, singleton, intrapartum stillbirth and intrapartum-related neonatal death 2017.

Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, Pattinson R, Darmstadt GL. Two million intrapartum‐related stillbirths and neonatal deaths: where, why, and what can be done?. International Journal of Gynecology & Obstetrics. 2009 Oct 1;107(Supplement):S5-19.

Lee AC, Cousens S, Wall SN, Niermeyer S, Darmstadt GL, Carlo WA, Keenan WJ, Bhutta ZA, Gill C, Lawn JE. Neonatal resuscitation and immediate newborn assessment and stimulation for the prevention of neonatal deaths: a systematic review, meta-analysis and Delphi estimation of mortality effect. BMC public health. 2011 Dec;11(3):S12.

Richmond S, Wyllie J. European resuscitation council guidelines for resuscitation 2010 section 7. Resuscitation of babies at birth. Resuscitation. 2010 Oct 1;81(10):1389-99.

Wilmink FA, Hukkelhoven CW, Lunshof S, Mol BW, van der Post JA, Papatsonis DN. Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry. American journal of obstetrics and gynecology. 2010 Mar 1;202(3):250-e1.

Wyllie J, Bruinenberg J, Roehr CC, Rüdiger M, Trevisanuto D, Urlesberger B. European Resuscitation Council Guidelines for Resuscitation 2015: Section 7. Resuscitation and support of transition of babies at birth. Resuscitation. 2015 Oct 1;95:249-63.

 

Absence does not make the heart grow fonder

Boie ET, Moore GP, Brummett C, Nelson DR. Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents. Annals of emergency medicine. 1999 Jul 1;34(1):70-4.

Cacciatore J, Rådestad I, Frederik Frøen J. Effects of contact with stillborn babies on maternal anxiety and depression. Birth. 2008 Dec;35(4):313-20.

Fulbrook P, Latour JM, Albarran JW. Paediatric critical care nurses’ attitudes and experiences of parental presence during cardiopulmonary resuscitation: a European survey. International journal of nursing studies. 2007 Sep 1;44(7):1238-49.

Harvey ME, Pattison HM. The impact of a father’s presence during newborn resuscitation: a qualitative interview study with healthcare professionals. BMJ open. 2013 Jan 1;3(3):e002547.

Nederstigt I, Van Tol D. Parental presence during resuscitation. Resuscitation. 2008 May 1;77:S61.

Offord RJ. Should relatives of patients with cardiac arrest be invited to be present during cardiopulmonary resuscitation?. Intensive and Critical Care Nursing. 1998 Dec 1;14(6):288-93.

Sawyer A, Ayers S, Bertullies S, Thomas M, Weeks AD, Yoxall CW, Duley L. Providing immediate neonatal care and resuscitation at birth beside the mother: parents’ views, a qualitative study. BMJ open. 2015 Sep 1;5(9):e008495.

Tripon C, Defossez G, Ragot S, Ghazali A, Boureau-Voultoury A, Scépi M, Oriot D. Parental presence during cardiopulmonary resuscitation of children: the experience, opinions and moral positions of emergency teams in France. Archives of disease in childhood. 2014 Jan 6:archdischild-2013.

 

‘They’ll always remember how you made them feel”

Badenhorst W, Riches S, Turton P, Hughes P. The psychological effects of stillbirth and neonatal death on fathers: Systematic review. Journal of Psychosomatic Obstetrics & Gynecology. 2006 Jan 1;27(4):245-56.

Bakhbakhi D, Siassakos D, Burden C, Jones F, Yoward F, Redshaw M, Murphy S, Storey C. Learning from deaths: Parents’ Active Role and ENgagement in The review of their Stillbirth/perinatal death (the PARENTS 1 study). BMC pregnancy and childbirth. 2017 Dec;17(1):333.

Bonanno GA, Kaltman S. The varieties of grief experience. Clinical psychology review. 2001 Jul 1;21(5):705-34.

Boyle FM, Vance JC, Najman JM, Thearle MJ. The mental health impact of stillbirth, neonatal death or SIDS: prevalence and patterns of distress among mothers. Social science & medicine. 1996 Oct 1;43(8):1273-82.

Flenady V, Boyle F, Koopmans L, Wilson T, Stones W, Cacciatore J. Meeting the needs of parents after a stillbirth or neonatal death. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Sep;121:137-40.

Flenady V, King J, Charles A, Gardener G, Ellwood D, Day K, et al.PSANZ Clinical practice guideline for perinatal mortality. Perinatal Mortality Group https:// www.psanzpnmsig.org.au. Perinatal Society of Australia and New Zealand, April 2009; Vol. Version 2.2.

Koopmans L, Wilson T, Cacciatore J, Flenady V. Support for mothers, fathers and families after perinatal death. Cochrane database of systematic reviews. 2013(6).

Mills TA, Ricklesford C, Cooke A, Heazell AE, Whitworth M, Lavender T. Parents’ experiences and expectations of care in pregnancy after stillbirth or neonatal death: a metasynthesis. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Jul 1;121(8):943-50.

Nuzum D, Meaney S, O’donoghue K. The impact of stillbirth on consultant obstetrician gynaecologists: a qualitative study. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Jul 1;121(8):1020-8.