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The 70th Bubble Wrap – DFTB x MSc in PEM


With millions of journal articles published yearly, 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. This time the PEM MSc team from QML, in association with DFTB, are taking over…..

Article 1: Insulin infusion in paediatric DKA – high or low? Which way should we go?

Forestell B, Battaglia F, Sharif S, et al. Insulin Infusion Dosing in Pediatric Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Explor. 2023;5(2):e0857. Published 2023 Feb 17. doi:10.1097/CCE.0000000000000857

What’s it about? 

Insulin is one of the mainstays of paediatric diabetic ketoacidosis (DKA) management. Insulin works by reducing blood glucose levels while also halting lipolysis and ketogenesis. This way, it leads to the resolution of ketoacidosis. However, high insulin infusion doses may also result in hypoglycaemia and hypokalaemia. The optimal dose of insulin infusion in paediatric DKA is yet to be determined.

This study compared the efficacy and safety of different insulin infusions in patients presenting with DKA.

Four randomized controlled trials, comprising 190 paediatric patients (mean age 6-10 years old) were included in the analysis. Low-dose (0.05 units/Kg/hr) insulin infusion was compared to standard-dose (0.1 units/Kg/hr). 

There was no difference between the low-dose and high-dose insulin infusion groups regarding the time to resolution of hyperglycaemia, time to resolution of acidosis as well as the rate of blood glucose change. On the other hand, low-dose insulin infusion was associated with a lower incidence of hypoglycaemia and hypokalaemia episodes.

This study had a number of limitations that make it less generalizable – all studies were performed in a single country, there were a small number of patients included (n=190), and adolescents were excluded.

Why does it matter?

Results of this study showed that the use of low-dose insulin infusion led to similar clinical outcomes and fewer adverse events compared to the standard-dose insulin infusion.

Clinically Relevant Bottom Line

In paediatric patients with DKA, a low-dose insulin infusion (0.05 units/kg/hr) is as efficacious as standard-dose, with fewer adverse events. More studies are needed to define the optimal insulin infusion dose in paediatric DKA.

Reviewed by: Spyridon Karageorgos and Katie Finn

Article 2: Do bougies help when intubating critically ill children?

Prekker ME, Bjorklund AR, Myers C, et al. The Pediatric Bougie for the First Tracheal Intubation Attempt in Critically Ill Children [published online ahead of print, 2023 Feb 23]. Ann Emerg Med. 2023;S0196-0644(23)00030-6. doi:10.1016/j.annemergmed.2023.01.016

What’s it about? 

This single-centre academic urban institution in the United States (US) undertook a 10-year retrospective observational study of paediatric intubation and bougie use in their emergency department (ED). They compared first-attempt intubation success and procedural complications between paediatric patients with or without bogie use during tracheal intubation.

During a 6-month period, paediatric patients (< 18 years old) who underwent tracheal intubation in their ED were included in the study. 468 paediatric patients were intubated in this timeframe. However, 273 were excluded, as 173 were intubated outside of ED, and 95 had missing datasets. Of the remaining 195 patients who met the inclusion criteria, 126 (65%) had a bougie used on the first intubation attempt, and 69 (35%) did not. The median patient age was 5 years in the bougie group and 1.7 years in the non-bougie group.

First-attempt intubation occurred in 91/126 (72%) of patients in the bougie group and 54/69 (78%) in the non-bougie group (absolute difference with a bougie -6.6%, 95% CI -19% to 6%). In the multivariable analysis, bougie use was not associated with increased first-attempt success. Procedural complications occurred in 48/126 (38%) patients intubated with a bougie and in 35/69 (51%) without a bougie. Common complications included hypoxia or mainstem bronchus intubation. Two neonates, one in each group, experienced a potential injury to the airway of the lower respiratory tract.

There were limitations to this study in that only a single academic institution was observed, and retrospective data could create data bias. The intubating clinicians were residents with modest paediatric intubation experience. Age, gender and pathology variability between the two groups made it difficult to reliably compare data. First-pass success rate was reported by the intubator, leading to potential bias.

Why does it matter? 

Although bougie use is recommended for managing difficult airways in children, there is little evidence supporting its use. Even more, case reports have described complications in neonates. In this single-centre retrospective observational study, there was no significant difference between first-attempt intubation when compared to a non-bougie technique. Likewise, there was no difference in complications between groups. Compared to an adult trial in the same centre, the first-attempt success rate was much lower (98% vs 72%) in the bougie group. This could be explained by less experienced personnel dealing with the paediatric airway. Because of the retrospective nature of the study, the decision to use the bougie was operator-dependent. Consequently, the success rate could be biased. Also, the study was conducted in a centre where clinicians commonly use a bougie for airway management. This limits the external validity of the results to other centres with less practice.

Clinically Relevant Bottom Line:

Using a bougie as a safe alternative for airway management in children when clinicians have experience. Higher quality evidence is needed to recommend for or against using the bougie as a first-line technique in paediatric airway management.

Reviewed by: Roberto Segura and Mel Ranaweera

Article 3: Does hand position affect CPR quality in young children?

O’Connell KJ, Sandler A, Dutta A, et al. The effect of hand position on chest compression quality during CPR in young children: Findings from the Videography in Pediatric Resuscitation (VIPER) collaborative. Resuscitation. 2023;185:109741. doi:10.1016/j.resuscitation.2023.109741

What’s it about?

We don’t know the ideal depth for chest compressions in infants and young children. O’Connell et al. tried to determine the effect of hand position on chest compression quality during cardiopulmonary resuscitation (CPR) in a prospective observational exploratory study.

O’Connell et al.used video recording and chest compression monitoring devices in all children under eight years of age who suffered a cardiac arrest to try and answer this question. The risk of bias was reduced by recording and monitoring all events, with parents and carers being given the option to withdraw consent later. Video also allowed any abnormal chest morphology to be identified (which may have affected compression depth and choice of technique). Researchers analysed the data in segments, and the average chest compression depth was reported as a percentage of the recommended minimum depth (AHA guidelines) for three different age groups (<1yr (n=26), 1-<5yrs (n=15), 5-8yrs (n=6)).

Amongst the 47 infants and children, 270 chest compression were analysed. Four hand positions were looked at. They were:-

1) two thumbs with hands encircling the chest,
2) two fingers (2nd and 3rd digit) pressing anteriorly on the child’s sternum,
3) one hand (heel of the palm on child’s sternum), and
4) two hands (heel of one palm on child’s sternum with another hand on top).

Hand position was not randomised, and as such, provider choice introduced an element of bias.

O’Connell et al. demonstrated hand position and chest compression quality varied amongst age groups and techniques. Across all ages, compressions were often too shallow. For infants using one or two hands, whilst for children using two hands, resulting in a better depth of compressions without exceeding a depth of 6cm (which is thought to cause harm).

Some limitations include the enrolment of the patients at different centres over differing time spans. For providers using the two-thumb technique for infants, they couldn’t determine if this was appropriate for the provider and patient as the thoracic measurement of the patient was not undertaken.

Overall survival was poor, and as such, the effect of chest compressions on clinical outcomes, could not be analysed. Similarly, CPR-related injuries couldn’t be assessed for.

Why does it matter?

Providing high-quality chest compressions remains the cornerstone of treatment for children in cardiac arrest. Current AHA recommendations allow rescuers to choose between different techniques; for infants, this choice is often between two thumbs and two fingers.

We should consider a one-handed technique for infants and two hands for children to better comply with recommended compression depth and to provide high-quality CPR.

Clinically Relevant Bottom Line:

The use of a one-handed compression technique in infants and a two-handed compression technique in children was observed to result in better quality CPR.

Reviewed by: Owen Hibberd

Article 4: Intraosseous access success rates for pre-hospital paediatric resuscitations.

Garabon JJW, Gunz AC, Ali A, Lim R. EMS Use and Success Rates of Intraosseous Infusion for Pediatric Resuscitations: A Large Regional Health System Experience. Prehosp Emerg Care. 2023;27(2):221-226. doi:10.1080/10903127.2022.2072553

What’s it about?

Garabon et al. undertook a retrospective review of 49 patients aged 0-17 years who had ≥1 EZ-IO insertion attempt by EMS responders in Canada in the context of cardiac arrest or a peri-arrest state if IV access was unobtainable. This explorative review described insertion success rates, time to first insertion, and duration of IO function (time from insertion to IO failure, IV access insertion, transfer to ICU, or death).

Garabon et al. demonstrated a first-attempt success rate of 71% in all ages and an overall success rate in 83% of cases. The median time to the first insertion was 4 minutes (IQR 3-7). The median duration of IO function was 27.6 minutes, or 89% of total resuscitation time, and the most common reason for loss of function was extravasation (occurring in 17.5% of functional IOs).

There was a significant drop in performance on sub-group analysis of patients under one year of age. This cohort required more insertion attempts (median two attempts, vs 1 for > 1-year-olds), had fewer functional IOs (26% versus 75%), and had a shorter duration of IO function (19 minutes versus 32 minutes).

This was a retrospective, single-centre design with a small sample size. Additionally, the pre-hospital setting may lack external validity to the emergency department. Moreover, the choice of outcome measures may not accurately reflect the true performance. For example, the time from EMS arrival to IO insertion may overestimate actual insertion times, whilst the use of transfer to ICU as an endpoint for IO functionality may underestimate the duration of use.

Why does it matter?

A paediatric cardiac arrest is a rare event, and early intravascular access can drastically improve outcomes. This is the first study to evaluate time to IO insertion and duration of function in a prehospital context. Their results support the use of IO insertion for rapid and reliable intravascular access in prehospital paediatric cardiac arrest.

Based on this study, further prospective research with more stringent outcome definitions may help to expand and clarify (e.g. whether factors such as fluid boluses increase the risk of IO extravasation injuries; subgroups < 1-year-old at highest risk of insertion failure; and more specific data around IO duration times).  

Clinically Relevant Bottom Line:

Paediatric IO insertion is a potentially life-saving prehospital intervention that merits bespoke training for EMS personnel. Particular emphasis should be placed on upskilling in IO insertion amongst < 1-year-olds, as this cohort is technically more challenging.

Reviewed by: Seán Casey & Holly Wakefield

Article 5: The painful truth, are we adhering to sickle cell guidance?

Rees CA, Brousseau DC, Ahmad FA, et al. Adherence to NHLBI guidelines for the emergent management of vaso-occlusive episodes in children with sickle cell disease: A multicenter perspective. Am J Hematol. 2022;97(11):E412-E415. doi:10.1002/ajh.26696

What’s it about?

Rees et al. examined how closely clinicians followed the National Heart, Lung and Blood Institute (NHLBI) 2014 guidelines for treating vaso-occlusive pain episodes (VOE) in sickle cell disease (SCD). This large multi-centre cross-sectional study had the advantage of including 400 young people with VOE and SCD, aged 3-21 years (median 14.6), from twenty tertiary paediatric emergency departments in North America.

The guidelines’ five main recommendations were assessed using descriptive statistics. 92% were triaged as high priority; 48% received parenteral opioid analgesia within 60 minutes of emergency department (ED) arrival; for mild-moderate pain, 66% received NSAIDs; 6% received a second dose of opioids within 30 minutes of the first dose; 91% had their pain score reassessed after each dose; 34% received appropriate fluid therapy.

Interestingly, 65/75 (87%) patients who got intranasal fentanyl (IF) as their first opioid (IF was included as a parenteral opioid) received it within < 60 min, compared to 125/314 (40%) of IV-delivered opioids (P < 0.001) IF increased the likelihood of children getting adequate pain-relief within 60 minutes of arrival (OR 9.83, 95% CI 4.87–19.85).

The external validity of this study may be limited by only including tertiary paediatric emergency departments. Additionally, implicit provider bias was not accounted for in terms of attitudes towards giving analgesia in this patient group. The study did not account for NSAIDs or opioids prior to arrival.

Why does it matter?

Patients with SCD frequently have vaso-occlusive crises. These account for 78% of their emergency department attendances. There has been concern regarding the under-treatment and inconsistent management of VOE in these patients, creating disparity and unnecessary morbidity.

These patients should be managed in a timely manner. The study showed that care continues to be suboptimal – particularly when re-evaluating pain and administering a second opioid.

Clinically Relevant Bottom Line

Intranasal fentanyl is a fast and effective method of controlling pain in children with sickle cell disease children. Targeted initiatives are needed to be used to improve adherence to the NHLSBI guidelines.

Reviewed by: Helena Wilcox and Petra Valk-Zwickl

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


  • Vicki is a consultant in the West Midlands in the UK. She 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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