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The 63rd Bubble Wrap

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

Article 1: How much fluid should I give to patients in DKA?

Hamud A et al Diabetic ketoacidosis fluid management in children: a systematic review and meta-analysis Arch Dis Child 2022 Published Online June 23

What’s it about? 

This was a systematic review and meta-analysis comparing liberal versus conservative fluid strategies in the management of paediatric DKA. There were 3 RCTs involving children (aged under 18), for an n=1457. The outcomes measured were the time to recovery, need for PICU admission, the development of cerebral oedema, a reduced GCS, kidney injury and all-cause mortality. There was no significant difference between the groups when looking at a drop in GCS (RR=0.77 95% CI 0.44-1.36) or the development of cerebral oedema (RR= 0.5 95% CI 0.15-1.68). The time to recovery was longer in the conservative group (MD=2.49, 95% CI -2,86-7.84). As only three studies were included the sample size is relatively small.

Why does it matter?

DKA is the leading cause of mortality and morbidity for children with IDDM. There has been debate over whether conservative or liberal use of resuscitation fluid is better. One particular concern is the development of cerebral oedema. The association between fluid regime and risk of cerebral oedema remains controversial. 

Clinically Relevant Bottom Line :

There appears to be no difference in the development of cerebral oedema and a drop in consciousness level between liberal and conservative fluids. A conservative fluid regime may prolong recovery time.

Reviewed by: Sarah Reynolds

Article 2: POCUS for intussception?

Lin-Martore, M, Firnberg, M.T., Kohn, M.A.,Kornblith, A.E., Gottlieb, M. Diagnostic accuracy of point-of-care ultrasonography for intussusception in children: A systematic review and meta-analysis. American Journal of Emergency Medicine 2022; 58: 255-264. DOI: https://doi.org/10.1016/j.ajem.2022.06.025.

What’s it about? 

The diagnostic gold standard for intussusception is radiology-performed ultrasound. However, point of care ultrasonography (POCUS) for intussusception can be taught to emergency trainees and provides a more readily available diagnostic option in many emergency departments. 

This was a systematic review and meta-analysis using PRISMA guidelines and best practice recommendations. Several major medical databases with global contributors were searched to include prospective and retrospective studies assessing the diagnostic validity of POCUS for intussusception in children under the age of 18 years. All studies included a reference-standard confirmatory test and no language or date restrictions were applied to the literature search. Case reports, case series and adult studies were excluded. Two investigators independently assessed studies for inclusion and discrepancies were resolved using a blinded third party.

Eleven studies were included (1165 identified, 794 abstracts reviewed, 43 full texts considered), two of which were conference abstracts. These studies comprised 345 (14.4%) cases of intussusception from 2400 participating children (38 to 775 per study). 6 were prospective and the majority took place in North America. Participants were mostly male and the average age ranged from 12 months to 6 years. The outcomes included radiology-performed ultrasonography as well as clinical course and follow-up in some studies. A low risk of bias was identified, though a higher risk of patient selection bias was acknowledged as all studies used convenience sampling.

A bivariate mixed-effects model was used from the pooled results of the included studies. These demonstrated POCUS was 95.1% (95% CI: 90.3% to 97.2%) sensitive and 98.1% (95% CI: 95.8% to 99.2%) specific with a positive likelihood ratio of 50 (95% CI: 23 to 113) and a negative likelihood ratio of 0.05 (95% CI: 0.03 to 0.09). Two sensitivity analyses including only prospective studies or excluding inconclusive index tests, respectively, yielded similar results. This was done because the rate of intussusception was found to be lower in the prospective studies compared to the retrospective studies. This suggests that partial verification bias may have been present in the retrospective studies- hence the further analyses performed.

Why does it matter? 

Intussusception is a common abdominal emergency in children from 6 months to 3 years for which early diagnosis is essential. There is potential morbidity and mortality associated with impaired blood flow to the bowel that results. POCUS is efficient, may reduce time to diagnosis, reduce resource utilization, and thus hospital admissions. This has implications for health cost savings and may improve patient care and satisfaction. This study provided an update on the diagnostic accuracy of POCUS in children with possible intussusception.  

Clinically Relevant Bottom Line:

POCUS can play a role as part of a diagnostic workup protocol for children presenting to the ED with concerns for intussusception. The heterogeneity of POCUS education in the included studies suggest that it may be easily taught.

Future research directions include paediatric intussusception evaluation protocol designs including POCUS and the evaluation and optimization of physician POCUS for intussusception training.

Reviewed by: Georgie Jacko

Article 3: Does brief training in paediatric sedation improve our management of adverse events?

Schinasi, Dana Aronson; Colgan, Jennifer; Nadel, Frances M.; Hales, Roberta L.; Lorenz, Douglas; Donoghue, Aaron J. Less. A Brief, Just-in-Time Sedation Training in the Paediatric Emergency Department Improves Performance During Adverse Events Encountered in Simulated Procedural Sedations Pediatric Emergency Care. March 2022 38(3):e1030-e1035 PMID 35226626

What’s it about?

This was a prospective cohort study that took place in a tertiary children’s hospital in Philadelphia. Post-graduate year 1 (PGY1) and year 2 (PGY2) doctors who were undertaking their paediatric placement filled in a questionnaire assessing their confidence in paediatric sedation. Then their performance during a simulated sedation was assessed. This identified a need for further training and education.

A ‘Just in Time” training session was developed and delivered by senior clinicians. They took place just before a PGY1 or PGY2 was about to perform the procedure. The sessions gave clinicians a thorough overview of possible adverse events and how to manage them. The doctors then completed the questionnaire again and their performance re-assessed. A significantly significant difference was found in the doctors who had completed the training in providing positive end-expiratory pressure to manage an apnoeic event. They were also more confident than those who had not completed the training.

Why does it matter?

We frequently perform procedural sedation in the emergency department. Clinicians must have the skills to recognise and respond appropriately to any adverse events in a timely manner.

Clinically Relevant Bottom Line:

Whilst this study is limited by the small number of participants (40 trainee doctors, it did succeed in demonstrating the positive impact of increased clinician confidence and better management of adverse events during simulated paediatric sedation after “Just in Time” training. Departments should look at ways in which training can be delivered to clinicians.

Reviewed by: Cristina Hearnshaw

Article 4: Can you tell when an inhaler is empty?

Fullwood I et al. Do you know when the inhaler is empty? Arch Dis Child May 2022

What’s it about?

Asthma is a condition with high mortality and morbidity. Good inhaler technique can go a long way to prevent the need for admission. Metered dose inhalers (MDI) are commonly used to treat asthma. This paper evaluated if patients are able to assess when their MDI inhaler is empty and by how they dispose of them. Because metered dose inhalers contain propellant as well as the active drug it can be hard to tell when the inhaler is empty, some inhalers have a dose counter however salbutamol does not. The only accurate way to identify when a salbutamol inhaler is empty is to count the doses. This was a prospective multicentre QI project between October 2020 and September 2021 including 157 patients drawn from hospitals which are part of the West Midlands Severe Asthma Network. Children/carers attending hospital were shown an empty salbutamol inhaler and asked how they would identify if it was empty and how they would dispose of it. 54.8% thought they could identify if an inhaler was empty but 73.5% of patients thought an empty inhaler was full / partially full. 18.2% of MDI with dose counters were empty at review. 83% of patients threw away their inhalers along with general waste.

Why does it matter?

Three-quarters of the patients were unable to identify when an inhaler was empty so were potentially treating acute exacerbations with empty inhalers.  Salbutamol inhalers should be taken back to local pharmacies and recycled- not in placed in household waste.

Clinically Relevant Bottom Line:

We should be checking whether children/carers can identify an empty inhaler when reviewing inhaler technique.

Reviewed by: Sarah Reynolds

Article 5: Should we rethink febrile children with comorbities?

Borensztajn, D.M., Hagedoorn, N.N., Carrol, E.D. et al. Febrile children with comorbidities at the emergency department — a multicentre observational study. Eur J Pediatr (2022).

What’s it about?

Patients with comorbidities represent a vulnerable population that often presents to the ED. Unfortunately, they are commonly excluded from studies.

The aim of this study was to assess presenting signs and symptoms, clinical management, and the cause of infection of febrile children with comorbidities attending the emergency department in a large European cohort. Comorbidity was defined as a chronic underlying condition that was expected to last > 1 year.

This was part of the MOFICHE study – a prospective observational multicentre study that assessed the clinical management and outcome of febrile children in 12 European EDs (from 8 participating countries) using routinely collected data. ED-Paediatric Early Warning Score (ED-PEWS), clinical alarming signs based on the National Institute for Health and Care Excellence, clinical management, disposition, and final diagnosis were recorded.

A total of 38,110 patients were included in the analysis. In total, 5906 patients had comorbidities (16%, range between EDs 5.3 and 62%). The most common co-morbidities were pulmonary, neurologic/psychomotor delay, prematurity (gestational age < 37 weeks), neurology/nephrology, cardiac, and malignancy/immunodeficiency. Patients with co-morbidities tended to be older (3.7 years vs 2.6 years), male and presented with a fever duration <24 hours (44% vs 35%).

Patients with comorbidities presented appearing more unwell , with higher ED-PEWS, and higher inflammatory markers. There was a higher use of life-saving interventions, increased rate of admission (including both ward and PICU) and antibiotic use. Additionally, there was a higher rate of serious bacterial infections, including sepsis/meningitis in children with comorbidities presenting with fever in the ED (especially in children with malignancy/immunodeficiency) compared to children without comorbidities.

Regarding limitations, the study included paediatric patients presenting to an emergency department with fever and excluded patients who presented to primary care or those admitted to specialized wards (haematology/oncology). The cohort may not be representative of the total patients with comorbidity that present in paediatric EDs.

Why does it matter?

This is one of the first studies that compare clinical manifestations, clinical management, and cause of infection between paediatric patients with comorbidity vs patients without comorbidity, presenting with fever in the ED.

Clinically Relevant Bottom Line:

This study showed that paediatric patients with comorbidities represent an important and heterogeneous cohort, that present in the ED more ill-appearing, with higher rates of invasive bacterial infections compared to children without comorbidities. Results of these studies highlight the importance of including paediatric patients with comorbidities in future paediatric ED studies.

More work needs to be done to look at why this is the case.

Reviewed by: Spyridon Karageorgos

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.

All articles reviewed and edited by Vicki Currie

About the authors

  • Vicki is a Paediatric Registrar in the West Midlands in the UK , starting PEM in September 2021. Vicki is passionate about good communication in teams and with patients along with teaching at undergraduate and postgraduate level. When not editing Bubble wrap Vicki can be found running with her cocker spaniel Scramble or endlessly chatting with friends.

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