Neonate resus update 2021

2021 Resuscitation Council UK Guidance: What’s new in neonates?

Cite this article as:
Anandi Singh, Jilly Boden and Vicki Currie. 2021 Resuscitation Council UK Guidance: What’s new in neonates?, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33461

We’ve looked at the changes in the paediatric resuscitation guidelines, here we take a closer look at neonatal guidelines.

Supporting transition at birth

There are no major changes for the newborns (just yet), but there is clarification on certain practices since the last 2015 update.

The umbilical cord: Leave it hanging?

We should delay clamping the cord for sixty seconds after the first cry. Researchers are looking at the benefit of beginning resuscitation whilst the cord still remains intact. Immediate cord clamping (ICC) has been shown to significantly reduce ventricular pre-load while simultaneously adding to left ventricular afterload.

If delayed cord clamping (DCC) is not possible, ‘milking of the cord’ can result in some transient benefits. There may be less need for inotropic support and fewer transfusions but no overall reduction in morbidity or mortality in the premature. There is insufficient data to suggest any benefit in babies 34 weeks to term. Milking of the cord is not recommended below 28 weeks as one large study was terminated early after babies were found to have higher risk of intraventricular haemorrhage.

Inflation and ventilation breaths: Increased pressure

When delivering inflation breaths, the resuscitation guidelines recommend slightly increased pressures than before

<32 weeks gestation, 25cm H2O for peak inspiratory pressure
>32 weeks, we should be using 30cm H2O initially slowly titrating up to achieve good chest wall movement.

Set the PEEP at at 5cm H2O for all babies that need assisted ventilation.

Laryngeal Mask Airways

LMAs are better than (in systematic review of 7 studies, N=794) bag-mask ventilation. Using them reduces the need for intubation and the duration of ventilation, though the evidence was low/moderate quality. The updated guidelines suggest more proactive use of an LMA in babies >34weeks and >2kgs.

Oxygen: Start low

  • For babies >32/40, the guidelines remains unchanged, start in air, monitor SpO2 and increase as needed. It can take several minutes to reach normal saturation levels.
  • For babies born between 28-32 weeks gestation, a small amount of supplemental oxygen (21-30% FiO2) may help with the effort of breathing and reduce mask ventilation time.
  • Start babies born before 28 weeks gestation on 30% FiO2.
  • Turn the FiO2 immediately up to 100% if you have to start chest compressions.

Thick Meconium: Don’t rush to suction

In the past, if a ‘non-vigorous’ baby (i.e. hasn’t cried yet), was delivered through thick meconium, you were supposed to visualise the cords with a laryngoscope and suction before providing inflation breaths. There wasn’t great evidence for this and the thought was that it simply delayed ventilation in an otherwise apnoeic baby.

What about adrenaline dosing?

There are still a few studies looking at the dosing of adrenaline in neonates but now the recommended dose is 20 micrograms/kg (0.2 mL/kg of 1:10,000 adrenaline (1000 micrograms in 10 mL)).  This should be repeated every 3-5 minutes as needed.

Focus on temperature: Aim for 36.5-37.5°C

The admission temperature of all (non-asphyxiated) babies across all settings and gestational ages, is a strong predictive factor for morbidity and mortality.

  • Use heated and humidified gases from the outset if you can, for babies born <32 weeks. A meta-analysis of 2 RCTs (N=476) suggested that this reduced the rate of hypothermia on admission by 36%.
  • Skin-to-skin care may be enough to keep >32 week babies warm, though a study focusing on 28-32+6 gestation babes suggested that this may be sub-optimal compared to conventional means of warming (a mix of radiant heaters, plastic bags, heated mattresses etc).

For each 1 degree Celsius decrease in admission temperature below the recommended range, an increase in the baseline mortality by 28% has been reported.

Emergency access: You know the drill

Umbilical catheterisation remains the prime means of vascular access.   If this is not an option, then use intraosseous access to give emergency drugs and volume.  Simulation studies suggest that the IO route may be quicker, though not without risk. Adverse events such as osteomyelitis, compartment syndrome and fractures have occurred.

Neonatal resuscitation updates

Stopping resuscitation should be considered by the team if there is no response after 20 minutes and reversible (e.g. tension pneumothorax, hypovolaemia, equipment failure) have been discounted.

Selected references

Resuscitation Council UK Guidelines 2021 https://www.resus.org.uk/library/2021-resuscitation-guidelines

Madar J et al European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth (2021). https://doi.org/10.1016/j.resuscitation.2021.02.014

ERC Guidelines 2021: https://cprguidelines.eu/

Wyckoff MH, ET AL. Neonatal Life Support Collaborators. Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020 Nov;156:A156-A187.  https://doi.org/10.1016/j.resuscitation.2020.09.015 Epub 2020 Oct 21. PMID: 3309891

Paediatric resus update 2021

2021 Resuscitation Council UK Guidance: What’s new in paediatrics?

Cite this article as:
Anandi Singh, Jilly Boden and Vicki Currie. 2021 Resuscitation Council UK Guidance: What’s new in paediatrics?, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.33450

You are working in Paeds ED. The alert phone rings for a 2-year-old boy coming in a cardiac arrest. You hear some colleagues talking about Plasmalyte, capnography, and reduced respiration rates. Don’t panic! You had heard somebody mention that there were new resuscitation guidelines out though you’ve not read them yet. How much could have really changed?

Let’s take a step back. Where do these resus guidelines come from?

The Resuscitation Council UK recently issued their 2021 guidelines. They are tailored to UK clinical practice and derived from the European Resuscitation Council (ERC) 2021 Guidelines. The International Liaison Committee on Resuscitation (ILCOR) is responsible for the International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR). This consensus document is then used by international member organisations to develop guidelines. They are updated roughly every five years. CoSTR 2020 formed the ERC 2021 guidance.

The guideline development process utilised systematic reviews, scoping reviews, evidence updates and engagement from worldwide stakeholders (including members of the public and cardiac arrest survivors).

The 2021 Resuscitation Council UK Guidance covers both adult and paediatric basic and advanced life support. We have reviewed the corpus of generic guidance, some key additions and the main changes to both paediatric and neonatal life support algorithms.

The new guidelines do not specifically include the management of arrest secondary to COVID-19. You can be find them at https://www.resus.org.uk/covid-19-resources.

Epidemiology of Paediatric Cardiac Arrest

Epidemiology of paediatric cardiac arrest

Changes in paediatric resuscitation

Paediatric Basic Life Support

There are a few minor changes in 2021 to the paediatric BLS guidelines. They all apply to children up to 18 years of age (except for newborns).

Initial Assessment

Assess for signs of life simultaneously with the delivery of rescue breaths. If there are no signs of life, start chest compressions immediately after initial rescue breaths (you do not need to pause here).

Deliver five rescue breaths followed by ventilation breaths with compressions at a ratio of 15:2.

Emphasis on achieving high quality CPR

We should use mobile phones on loudspeaker for dispatcher guidance on how to deliver CPR or to summon emergency medical services (EMS) without leaving the victim.

Whilst the majority of paediatric cardiac arrests are respiratory in nature, effective chest compressions still play their part. Do these on a firm surface( so not a bed) and to a depth of at least one third the anterior-posterior diameter of the chest (or by 4cm in an infant and 5cm in a child). The rate remains at a rate of 100-120/min. The chest needs to fully recoil after each compression and around 80% of the CPR cycle should be composed of compressions.

Airway

The Resus Council recommend cuffed endotracheal tubes in children, if intubation is needed, and uncuffed tubes in neonates (Ed. note-we’ll look at this another day). Monitor this cuff pressures and try to keep it below 20mmHg.

Breathing

Target oxygen saturations (SpO2) of 94-98% with as little supplemental oxygen as possible. Avoid giving pre-emptive oxygen therapy without signs of hypoxemia or shock and try to avoid readings of up to 100% – unless in situations such as carbon monoxide poisoning. Hyperoxia appears to be almost as harmful as hypoxia.

High-flow nasal cannula oxygen (HFNC) or continuous positive airway pressure (CPAP)/non-invasive ventilation (NIV) support should be considered in children that have adeqaute respiratory drive but are not responding to low-flow oxygen. Bag-mask ventilation (BMV) is recommended in children with inadequate respiratory drive. If oxygenation/ventilation doesn’t improve, or ventilation may be ongoing, it is time for more advanced airway techniques – supraglottic airway devices (SGA) or endotracheal intubation.

Changes to paediatric resuscitation guidelines

Monitor capnography

End-Tidal CO2 monitoring is the gold standard, whether using an SGA or bag-valve-mask ventilation. Waveform capnography can reliably confirm tracheal tube placement when has a perfusing rhythm, as long as they are over two kilos in weight. There is a reasonable correlation between ETCO2 and PaCO2 but the guidelines do not go so far as suggesting a threshold ETCO2 or PaCO2 for stopping the resuscitation attempt.

What can the ETCO2 waveform tell us in resuscitation?

Use of end-tidal in paediatric resus

Circulation

No single finding can reliably identify the severity of circulatory failure. We still need to reassess frequently and after every intervention. This can be done by monitoring mean arterial blood pressure, trends in lactate, urine output and, if competent, ultrasound findings.

Vascular Access

Peripheral intravenous (IV) lines are the first choice for vascular access but it’s just two attempts and you are out. Then it is time to move on.

Intraosseous (IO) access is the primary rescue alternative. Remember it can be painful so give proper intraosseous analgesia before giving the first fluid bolus in every (awake) child.

A balanced approach to fluids

In children with shock, use a 10 mL/kg fluid bolus repeated up to 40-60 mls/kg.

How much should we give? There is an emphasis on smaller volumes with careful reassessment after each bolus to enable early identification of signs and symptoms of fluid overload. These include hepatomegaly, bilateral basal lung crackles, and jugular venous distention. Current evidence shows that a restrictive approach to fluid therapy is at least as effective as larger volumes.

In children with shock secondary to haemorrhage, we need to keep crystalloid boluses to a minimum (max 20mls/kg). Early use of blood products is the way to go in children who present with severe trauma.

Having decided to give fluid, what should we give? Balanced isotonic crystalloids (e.g. Plasmalyte) are the first choice with 0.9% sodium chloride being an acceptable alternative. Saline can induce hyperchloremic acidosis and may be associated with a worse outcome. The evidence for Hartmanns/Ringer’s lactate is still limited and shows ‘no more than a trend’ (?) towards a better outcome – so this is still left a bit unclear… Don’t use dextrose-based solutions for volume replacement – these will be redistributed rapidly away from the intravascular space and will cause hyponatremia and hyperglycaemia which may worsen neurological outcome.

Consider using permissive hypotension (mean arterial blood pressure (MAP) at 5th percentile for age) in traumatic injury. Be mindful that It is contraindicated in children with traumatic brain injury. You need to maintain a reasonable cerebral perfusion pressure. The Resus Council UK guidelines recommend giving tranexamic acid (TXA) to all children requiring transfusion after severe trauma and/or significant haemorrhage, as long as it is within three hours of injury

Vasoactive drugs need to be started early In children with persistent decompensated circulatory failure. Noradrenaline or adrenaline are recommended as first-line agents. Vasoactive drug choice may be directed by individual patient circumstances once more detailed information about the pathophysiology is available..

Dopamine is no longer recommended but can be used if adrenaline and noradrenaline are not available.

Cardiac Arrest in Special Circumstances

Specific approach to CPR needed during specific conditions such as cardiac surgery, neurosurgery, trauma, drowning, sepsis, and pulmonary hypertension. However, there are no major changes to any of these guidelines.

When managing traumatic cardiac arrest we need to fix the reversible causes.

Traumatic cardiac arrest guidelines

We need to start simultaneous chest compressions whilst treating these causes. This trumps adrenaline use. Though exceedingly rare we should think about thoracotomy in paediatric TCA patients with penetrating trauma with or without signs of life on ED arrival.

Extracorporeal Life Support (ECLS)

Extracorporeal cardiopulmonary resuscitation (E-CPR) is the implementation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in a patient with refractory cardiac arrest. E-CPR should only be considered if it is readily available and there is a (presumed) reversible cause.

For specific subgroups of children with decompensated cardiorespiratory failure (e.g. severe refractory septic shock or cardiomyopathy or myocarditis and refractory low cardiac output), the pre-arrest use of ECLS can be lifesaving and provide end-organ support, preventing cardiac arrest.

Post-cardiac arrest care

Avoid hypoxia, hypotension and fever in children and infants who have a return of spontaneous circulation (ROSC) following cardiac arrest. Targeted temperature management of children post-ROSC should comprise active treatment with either normothermia or mild hypothermia and continuous invasive temperature monitoring.

Changes in adult resuscitation guidance

Are you curious about the big people?

For the adults, there are no major changes in ADULT BLS/ ALS 2021 guidelines. The guide states that a child is any person up to 18 years – in terms of when we switch from paediatric to adult algorithm. If the child looks like a child, we use the paediatric algorithm. If it turns out that your patient looks more youthful than they actually are then little harm will ensue. They also recommend a stepwise approach to airway management. The expert consensus is that: providers with a high first-pass success rate should perform tracheal intubation.

The use of adrenaline is controversial. We don’t have great evidence for either the dosing or the timing of doses. A large trial in the UK (PARAMEDIC 3, expected Autumn 2021) will look in more detail at the timing of adrenaline and the potential benefits of an IO first approach.

There is a greater emphasis on POCUS and ECMO. This reflects the increasing evidence as a rescue therapy in certain adult patients in cardiac arrest. There is an increasing role of point-of-care ultrasound (POCUS) in peri-arrest care for diagnosis, but it requires a skilled operator, and the need to minimise interruptions during chest compression.

As with the paediatric population: there is a greater recognition that patients with both in- and out-of-hospital cardiac arrest have premonitory signs, and that many of these arrests may be preventable.

What else is in the guidance?

Health inequality (HI) and it’s impact on cardiac arrest outcome

There is vast inequality in the incidence of cardiac arrest, use of bystander CPR and the distribution of public access defibrillators. Deprived areas, and areas with a greater proportion of residents from minority ethnic backgrounds, have a higher incidence of cardiac arrest, lower incidence of bystander CPR and lower access to public access defibrillators. This needs further discussion and research. Teaching CPR to children in all schools would be a way of improving some of these inequalities.

Improving education and systems can save (more) lives

50% of out-of-hospital cardiac arrests (OHCAs) are witnessed. Bystanders perform CPR in 70% of these. Public education is crucial in saving lives. In 2018, 59% of members of the public in the UK reported having received training in CPR and 19% in how to use an automated external defibrillator (AED).

In 2019, over 291,000 people in the UK were trained in CPR as part of World Restart a Heart Day. Teaching the essential core skills in resuscitation will improve patient survival.

How to get better at paediatric resus

Technology-enhanced education, as well as simulation, can be used to improve teaching and engage learners. Social media and smartphone apps can be used to engage the community. A new section has been added to the guidance named ’Systems Saving Lives’ with the intended audience being governments, managers in health and education systems, health care professionals, teachers, students and members of the public. By emphasising the importance of the connections along the Chain of Survival, we can improve the performance of resuscitation systems.

4 Key areas that have been highlighted are:

What's new in paediatric resus guidelines

Ethics

Another key area in the new guidelines is around integrating decisions about CPR in advanced treatment plans (e.g. Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process). The guideline highlights the need for communication strategies and interventions to support discussions with patients and their family around resuscitation.

What might we see in the next revision…

  • Could IO become the first choice route of adrenaline?
  • Will we still be using adrenaline in all arrest situations?
  • Will (ab)normal saline be removed entirely?
  • Will we have more concrete evidence on using Hartmann’s/ Ringer’s Lactate in resuscitation fluids?
  • Will we have more information on the barriers and motivators to bystander CPR and AED use in respect of ethnic, socio-economic, cultural and educational background?

Selected references for the updated Resuscitation Council UK guidelines

Resuscitation Council UK Guidelines 2021 https://www.resus.org.uk/library/2021-resuscitation-guidelines

Madar Jet al European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth (2021). https://doi.org/10.1016/j.resuscitation.2021.02.014 ERC Guidelines 2021: https://cprguidelines.eu/

Wyckoff MH, ET AL. Neonatal Life Support Collaborators. Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. 2020 Nov;156:A156-A187.  https://doi.org/10.1016/j.resuscitation.2020.09.015 Epub 2020 Oct 21. PMID: 3309891

Ethical considerations and decision-making about the resuscitation of very sick children

Cite this article as:
Karen Horridge. Ethical considerations and decision-making about the resuscitation of very sick children, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.30898

You wouldn’t judge a book by its cover, would you?

When thinking about the knotty matter of decision-making about resuscitation of sick children, we need to remember:

Every child’s life matters.

To always listen to the child, their parents and those who know the child best and include them in best-interests decision-making.

To always make decisions within an ethical framework and record the process of decision-making and who was involved.

To ensure pathways are in place to record and make visible best-interests’ decisions about levels of intervention.

So, what can help us with an ethical framework? Our friends at the General Medical Council have laid this out for us, in ‘Treatment and care towards the end of life: good practice in decision-making’.

Covers of GMC guidelines

This helpful document reminds us that:

  • Equalities, capacity and human rights laws reinforce our ethical duty to treat all children, neonates and young people fairly. 
  • We must always listen to child, parents and others close to them. We must take account of their views. Where there are different views, our primary duty of care is to the child.
  • Decisions must always be in a child’s best interests. 
    • We should weigh benefits, burdens and risks of treatment. 
    • We should consider all relevant factors in the decision-making process.
  • Decisions must start from a presumption in favour of prolonging life.

When making decisions, even in a dire emergency, we are reminded to:

  • Take account of up-to-date, authoritative clinical guidance.
  • In case of uncertainty, seek further expert opinions early.
  • Explain, justify and document all factors considered in decision-making.
  • Not rely on personal values when making best interests’ decisions.
    We must be careful not to make judgements based on poorly informed or unfounded assumptions about the impact of disability on the child or young person’s quality of life. 

So, you wouldn’t judge a book by its cover, would you?

Disabled children and young people come in all shapes and sizes. We can’t all be experts in each child, which is why it is so important for us to listen to parents and those who know the child best.

Please do beware of falling down the rabbit hole of preconceived ideas about what a child’s quality of life is like – always ask parents and familiar carers what the child is like when well. They may have photos and videos they can show you of their child having fun and taking part in everyday activities.

Disabled children may appear, sound and behave differently when unwell. This may be because they cannot tell you where it hurts or how they feel. They may present with behaviours that others may see as challenging. They may not tick the expected boxes on the usual screening tools, for example, for sepsis. Their temperatures may be low when you might expect them to be high, they might have high or low heart rates and may not be able to mount the expected increased work of breathing, because their respiratory muscles may be too weak for them to do so. Their control centres may not work as expected.

Hasty decisions based on preconceived ideas can lead to poor outcomes, including premature death. None of us want that.

So, what’s all this about premature death in people with learning disabilities?

If you are ready for a shocking read, then take a look at Death by Indifference, written by Mencap in 2006, but just as relevant today.

If you prefer some e-learning on the subject, take time to work through the Disability Matters session: Equal Access to the Best Health Outcomes Matters. This was co-produced with disabled children, young people, parent carers and other experts.

Then there’s the Confidential Inquiry into Premature Deaths of People with Learning Disabilities report. This report showed that women and men with learning disabilities die 29 and 23 years, respectively, sooner than women and men without learning disabilities.

So what about children? The series of reports on Why Children Die show that more than half of all children who die in England have a pre-existing, life-limiting condition. So, we all need to pay great attention and ensure we achieve the very best outcomes for these children and all children.

The team at Bristol University have built on the work they did for the CIPOLD report and now lead on the Learning Disabilities Mortality Review (LeDeR) programme. This links to the Child Death Review programme and considers the circumstances of every death of anyone with a learning disability at any age. The latest annual report can be found here.

Between 01/07/2016 and 31/12/2019, 516 children aged 4-17 years were notified to the LeDeR programme. Of these children and young people who died, 43% were from Black and Minority Ethnic groups. 46% had profound and multiple disabilities.

Whilst 7% of the deaths reported to the LeDeR programme were of children and young people aged 4-17 years, the death rate overall in the 5-19 years age group in England was 0.3%.

The LeDeR programme 2019 report highlights good and problematic practices that the multidisciplinary team, including people with learning disabilities, identified.

Good practices included:

  • Good care coordination across agencies and specialities
  • Excellent end-of-life care
  • Person-centred care, adjusted as the child or young person’s needs changed

Problematic areas of practice to reflect and learn from included:

  • Delays in responding to signs of illness or investigating illness.
    • This is known as ‘diagnostic overshadowing’, where clinicians may see the disabilities and think all presenting signs and symptoms can be explained by those, rather than undertaking a careful and structured clinical assessment to identify the underlying cause, such as pain from appendicitis, constipation, sepsis etc.
  • Poor quality multidisciplinary team working.
    • The needs of disabled children and young people are usually multifaceted and require a range of expertise to adequately assess and address them all.
  • Poor advanced care planning. 
    • Clinicians can be reluctant to have those difficult conversations with families about the risk of both sudden and unexpected death and also the risk of deterioration and death. We all need to do better on this.
  • Problems with the direct provision of care.

Recommendations from the LeDeR report included:

  • Identification of a key worker to coordinate care and communication for disabled children and young people.
  • Timely advanced care planning embedded in care pathways and clinical practice, responsive to changing needs.
  • Better discharge planning and better community support.
  • Consistent support and communication throughout each child’s life.

So where is the evidence about what parents think about end-of-life decision making? Dr Sarah Mitchell is a GP who is really interested in this and has written a useful paper in BMJ Open on the subject.

Sarah and her team interviewed parents and reported that:

  • Parents have significant knowledge and experiences that influence decision-making process
  • Trusted relationships with healthcare professionals are key to supporting parents making end of life decisions
  • Verbal and non-verbal communication with healthcare professionals impacts on the family experience.
  • Engaging with end of life care decision-making can be emotionally overwhelming, but becomes possible if parents reach a
    ‘place of acceptance’
  • Families perceive benefits to receiving end of life care for their child in a PICU 

With regard to the last statement, preferred place of death is, in my experience, different for each family. Some choose home, others need to know that no stone has been left unturned right to the end, so choose intensive care. Whilst this may not always sit comfortably with paediatric intensive care teams, for some families it is what is needed to bring them peace in their journeys of grief. I have been witness to what I would consider to be ‘good deaths’ in a wide range of settings, including homes, hospices, children’s wards and intensive care units over many years. What matters most and what families remember, are how the child’s needs were identified and addressed at every step and how they are families were kept in the loop about what was happening, including being fully involved in all decision-making.

Smiling boy with disability
Matthew

It’s all well and good listening to my views as an experienced disability paediatrician on the subject, but much better to hear directly from a mother who has been on the advance care planning journey. Here are Kay’s words, describing her and her family’s journey with her son Matthew. If you prefer to hear her speaking directly, please check out the Disability Matters e-learning session Advance Care Planning Matters.

Kay says:

“Matthew had quite severe learning and physical disabilities. He was a very complex child and we used the Emergency Health Care Plan to help plan for the future and to enable us to communicate fully with other health professionals in the healthcare setting. 

Matthew didn’t have the capacity to actually make decisions for himself although he was a very wilful little boy who had very clear likes and dislikes, so he could make decisions for himself that were relevant to his day to day needs like what he wanted to eat, where he wanted to go. He had no formal communication, but as parents and the people who were involved with him we learned to read what he was trying to tell us, and as I say, he was very clear on what he liked and disliked doing but wouldn’t have been able to make the kind of big decisions that as parents we were responsible for making for him.

We did have a very large team involved in Matthew’s care and we discussed the Plan with his consultant paediatrician but she also took into account the views of people like the occupational therapists, physiotherapists, the surgeons who were dealing with him as well as the parents, myself and Matthew’s dad. We were all involved in the discussions around the development of the Plan and what was in his best interests.

Matthew’s Health Care Plan went everywhere with him and it lived in his communication bag on the back of his wheelchair. So it went with him to school, to his respite and to his dad’s house when he was there and also it was with him whenever he needed to go into hospital.

The Emergency Health Care Plan actually protected Matthew’s rights should he ever become seriously unwell. It clearly stated that he needed full resuscitation and any treatment that was available to him and clinicians then could use the plan to make judgments on what treatment would be necessary but he was able then to access a full range of treatment that would be available to any other child in a similar circumstance.

Matthew was very well for the early part of his life but when he turned 11 he had an accident, a quite serious accident and we were able to use the Emergency Healthcare Plan to access full range of medical interventions for him, as a result of that he did end up in intensive care for the first time. After that we did go through a period when he was 12 he had a twisted bowel, so he was literally in and out of intensive care and needed to be resuscitated on quite a few occasions, unfortunately, but his plan enabled us to access all of this medical intervention for him and saved his life in that instance.

Over a period of about a year, Matthew became more and more unwell. He needed regular trips to Intensive Care and regular trips to the hospital. The Plan actually went with him to hospital in Newcastle. It gave us the assurance that during these periods of Matthew being very, very poorly that the doctors in the hospital that weren’t used to dealing with Matthew, the Plan gave them all the information so we didn’t have to go through it every time that he was admitted. They trusted what we were saying because it was backed up by the Plan”.

Matthew’s paediatrician says:
“Matthew developed a lot of new symptoms that were unexplained; his seizures were becoming less controlled and we needed discussions around how we were going to treat these new symptoms as and when they appeared and what needed to be done for them.

So at this point in time, having taken account of the views of both of Matthew’s parents and the whole of the multidisciplinary team, we made a decision in his best interests that, at that time, further intrusive procedures or further intensive care was not going to be helpful or appropriate for him and might cause him further distress. So, together, we changed the wording on Matthew’s Advanced Care Plan at that time to reflect the possibility of him being allowed a natural death when his time came, recognising that we would always be there to manage his symptoms and always be there to support his family”. 

Kay continues:
“Matthew had had a chest infection and was having great difficulty breathing and his dad brought him up to hospital. We called all the family, it was obvious that Matthew was dying at this point. We had all the family called from all corners of the UK to come and say goodbye to him. We sat for hours and hours with him in the hospital ward and he was almost pronounced dead when all of a sudden, he decided it wasn’t quite his time and he took a great big breath and started breathing normally and all his colour came back. His dad described it as, like, “re-booting” his system as he wasn’t on any treatment. He was having no medication or anything and he just decided “No, it’s not my time. I’m going to come back” and we had him for another five weeks after that.

Then one day, approximately five weeks after the “re-booting” incident, Matthew wasn’t very well at all. He was due to see his paediatrician in clinic that day, but I phoned and said that “I don’t think he’s up to actually travelling to hospital,” so the paediatrician agreed to visit at home, so we waited. He’d had a massive seizure. I’d had to give him medication to bring him back from the seizure. When his paediatrician arrived, it became obvious that he was deteriorating very, very quickly and we decided that we were just going to keep him at home and see what the outcome would be, whether he would “re-boot” again or how it would play out this time”.

Matthew’s paediatrician continues:
“So Matthew was really very frail on clinical assessment at this point, so I needed to put in place the right procedures to make sure that his needs were met and the family’s needs were met. He was very peaceful and he was essentially drifting off to sleep. He didn’t have any difficult symptoms at that point that needed any changes in medication or changes in his Plan. What we did at that point is I made arrangements for if Matthew was to slip away in the night, a colleague to be able to come out and support the family and to confirm his death at that point. I also contacted the Coroner, because our Coroner liked to know in advance about any child’s death and if there is a death that is likely to be expected as defined under the Child Death Review Procedures, then our Coroner liked to know in advance. So, we made all of those arrangements and let the family have their special private time together”. 

Kay reflects:
“We spent quite a few hours with Matthew – we called close family this time around. We didn’t get everybody coming from the far end of the country to be with Matthew. So, the time when Matthew did die, it was very, very peaceful. We had some quality time with him. We had a wonderful five weeks planning memories, planting memories for the other children and we spent those few hours reflecting on that and talking and supporting each other through the inevitable outcome of Matthew dying in the early hours of the morning.

We found that, when dealing with the professionals around Matthew’s death, that being able to change the wording of the Emergency Health Care Plan it kind of validated for us that what we wanted … we wanted Matthew to be peaceful and at home when he died, surrounded by his toys and his family. We felt that the Plan, when we read the wording of it, was quite a shock to see that he should be allowed to ‘die with dignity’ but it validated what we were feeling, that it gave us permission to ask that he could die at home where we wanted him to be. It made us feel that we weren’t asking for anything that was out of the ordinary or not possible and felt that we were actually more in control of the situation when the time actually came for Matthew to pass away”. 

Achieving a supporting a child or young person through a good death is an important part of our job, when death is inevitable. We need to ensure we always steer the best possible course through the tricky waters of decision-making, protecting the rights of all children and young people to the best possible outcomes.

So, back to the key messages

  • Every child’s life matters.
  • Always listen to the child, their parents and those who know the child best and include them in best-interests decision-making.
  • Always make decisions within an ethical framework and record the process of decision-making and who was involved.
  • Ensure that pathways are in place to record and make visible best-interests’ decisions about levels of intervention.

If you want to read more about advance care planning, look at:

Horridge KA. Advance Care Planning: practicalities, legalities, complexities and controversies. Arch Dis Child. 2015;100:380-385

If you want to see and hear examples of the conversations that underpin advance care planning, more free e-learning can be found here:

https://councilfordisabledchildren.org.uk/our-work/health-and-wellbeing/practice/emergency-healthcare-plans

To listen to discussions between paediatricians and a parent about signs of sepsis in disabled children, tune in to Episode 4 of the RCPCH sepsis podcast series here.

Thank you for your time and all the best for your advance planning and decision-making.

Top 5 papers in neonatology: James Tooley at DFTB19

Cite this article as:
Team DFTB. Top 5 papers in neonatology: James Tooley at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22344

James Tooley is consultant neonatologist in Bristol. We gave him the task of bringing us a little more up-to-date with the neonatal literature.

 

 

Here are the papers he chose:-

Battaloglu E, Porter K. Management of pregnancy and obstetric complications in prehospital trauma care: prehospital resuscitative hysterotomy/perimortem caesarean section. Emerg Med J. 2017 May 1;34(5):318-25.

Foy KE, Mew E, Cook TM, Bower J, Knight P, Dean S, Herneman K, Marden B, Kelly FE. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC‐NIC survey. Anaesthesia. 2018 Nov;73(11):1337-44.

Qureshi MJ, Kumar M. Laryngeal mask airway versus bag‐mask ventilation or endotracheal intubation for neonatal resuscitation. Cochrane Database of Systematic Reviews. 2018(3).

Sproat T, Hearn R, Harigopal S. Outcome of babies with no detectable heart rate before 10 minutes of age, and the effect of gestation. Archives of Disease in Childhood-Fetal and Neonatal Edition. 2017 May 1;102(3):F262-5.

Wilkinson, A.R., Ahluwalia, J., Cole, A., Crawford, D., Fyle, J., Gordon, A., Moorcraft, J., Pollard, T. and Roberts, T., 2009. Management of babies born extremely preterm at less than 26 weeks of gestation: a framework for clinical practice at the time of birth. Archives of Disease in Childhood-Fetal and Neonatal Edition94(1), pp.2-5.

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. 

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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Practice made perfect?

Cite this article as:
Sonia Twigg. Practice made perfect?, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20694

Okay, perhaps  not perfect but we think these bite sized chunks of simulation from Children’s Health Queensland are pretty good! They are free to download and play with. You can find access to all current OPTIMUS resources here. Enjoy!

 

Introducing BONUS – A Bank of Independently Useful Sims

 

 

 

What are they?

OPTIMUS BONUS is an ongoing project driven by Children’s Health Queensland involving the creation of simulation education packages on topics in paediatric resuscitation.  Each package contains;

  • An introduction by an expert explaining why the topic is important.
  • A simulation with clear learning objectives, instructions and hints for debriefing.
  • Pre-reading resources for participants. These are fun and easy to read resources including podcasts, videos, guidelines and apps.
  • An infographic summarising the topic. QR codes on the posters link to Just In Time Training resources including videos and guidelines.  Just point the camera on your smart phone at the poster and a link will appear to the website to see the video.

 

Who writes them?

The STORK team (Simulation Training Optimising Resuscitation in Kids) from Children’s Health Queensland provides simulation based education throughout Queensland.  We provide two courses as part of our OPTIMUS curriculum; Optimus CORE (for first responders) and Optimus PRIME (for mid phase care while awaiting retrieval).

 

 Why did we make them?

 

What we love about them

  • They’re free to download, expert reviewed, repeatedly tested and assessed by a statewide advisory group to ensure we’re providing a quality product.
  • Our infographics look awesome, summarise the key messages, are easy to share on social media and easy to store on your phone.
  • Some packages contain Just in Time Training JITT resources and videos via QR codes to give you the info you need when you need it :
    • Just scan the QR codes on your phone to see refresher videos before you go and perform that skill
  • We’ve curated great open access #FOAMed resources on paediatric topics for each Simulation, so you can deep dive into more learning before or after the Sim!

 

Love the simulations and want to help out?

Thanks!  We need your help to share these simulations and infographics online any way you can. Shout out to @childhealthqld @LankyTwig @Caroelearning @paedsem and @symon_ben on twitter if you’re using them!

The other thing that REALLY helps is getting good feedback.  So, if you have thoughts on them to share fill out the surveys via the QR codes in the package so we can keep making better simulations to share with the world.

If you’d like to know more, email us at stork@health.qld.gov.au

Other than that, retweet them, share them widely, and help us improve paediatric care everywhere in the world.

 

Enjoy!

Sonia and the BONUS team

Dr Sonia Twigg (@LankyTwig), Dr Benjamin Symon (@symon_ben), Dr Carolina Ardino Sarmiento (@caroelearning), Dr Ben Lawton (@paedsem) Ms Louise Dodson and Mrs Tricia Pilotto.

 

Selected references

Case, Nicky, “How to remember anything forever-ish.:  Oct 2018.  Available at: https://ncase.me/remember/

Cheng et al, “Resuscitation Education Science: Educational Strategies to Improve Outcomes from Cardiac Arrest; A Scientific Statement from the American Heart Association.”Circulation 2018; 138: e82-e122. Available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000583

Cheng et al, “Highlights from the 2018 AHA Statement on Resuscitation.” June 2018.  Available at: https://canadiem.org/aha-scientific-statement-on-resuscitation-education/

Dubner S.“Freakonomics Radio.  How to become great at just about anything (Ep 244).” Apr 2016.  Available at: https://freakonomics.com/podcast/peak/

Ericsson A,“Peak” Vintage 2017.

Tim Horeczko: Towards A Calmer Resus at DFTB17

Cite this article as:
Team DFTB. Tim Horeczko: Towards A Calmer Resus at DFTB17, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16235

This talk was recorded live during the final plenary session of DFTB17 in Brisbane. If you missed out in 2017 then you can check out our YouTube channel to watch any of the talks.