With millions of journal articles published yearly, it is impossible to keep up.
Each year, Hari and the team at PICUJournalWatch publish a ‘Best of the Year’ summary of key articles in paediatric intensive care medicine (PICUJournalWatch – Best of the Year). In this Bubble Wrap, the PICSTAR team give you a high-impact summary of our favourites.
Happy Reading 🙂
If you or your team want to submit a review, please get in touch with Dr Vicki Currie at @DrVickiCurrie1 or vickijanecurrie@gmail.com.
Article 1: Lung-Protective Ventilation for Paediatric Acute Respiratory Distress Syndrome
Wong JJM, Dang H, Gan CS, et al. Lung-Protective Ventilation for Pediatric Acute Respiratory Distress Syndrome: A Nonrandomized Controlled Trial. Crit Care Med. 2024;52(10):1602-1611. doi:10.1097/CCM.0000000000006357
What’s it about?
This multicentre, prospective, before-and-after comparison design study examined the impact of implementing and adhering to a lung-protective mechanical ventilation (LPMV) protocol versus general lung-protective ventilation strategies in children with a diagnosis of PARDS. (See here for a summary of PARDS – Paediatric acute respiratory distress syndrome (PARDS) – Don’t Forget the Bubbles)
The study found that the implementation of the protocol did not show a difference; however, adherence to the protocol after implementation appeared to be associated with reduced mortality (after adjustment for confounders). They proposed that this may be the case since lung-protective ventilation measures are already accepted as best practice and are therefore likely to be practised routinely.
Why does it matter?
Careful ventilation strategies are necessary to manage PARDS, as suboptimal parameters can exacerbate further damage to already injured lungs. While a strong evidence base exists for the management of adult ARDS, the data within paediatrics is lacking. When individual components of LPMV were analysed, the study found that adherence to pressure-related components (PIP, driving pressure, PEEP) of LPMV was associated with a reduction in mortality.Â
While various strategies, such as limiting PIP and tidal volumes, have become increasingly popular methods to limit lung injury, no unifying approach for PARDS treatment exists.
Clinically Relevant Bottom Line
This study indirectly supports promoting adherence to an LPMV strategy, as recommended by PALICC-2 guidelines for children with severe PARDS.
However, we must be cognisant that this is based largely on data extrapolated from adult studies. There is much more work to be done in paediatrics (as ever)!
Reviewed by the PICSTAR team
Article 2: Prediction of good neurological outcome after return of circulation following paediatric cardiac arrest
Scholefield BR, Tijssen J, Ganesan SL, et al. Prediction of good neurological outcome after return of circulation following paediatric cardiac arrest: A systematic review and meta-analysis. Resuscitation. 2025;207:110483. doi:10.1016/j.resuscitation.2024.110483
What’s it about?
This systematic review evaluated various prognostic markers available within 14 days after return of circulation following cardiac arrest as predictors of good neurological recovery. Thirty-five studies involving ~3,000 children post-cardiac arrest were analysed. Tests, including clinical examination, biomarkers, electrophysiology, and imaging, were analysed against a benchmark of predicting a good neurological outcome with false positive rates under 30% and moderate-to-high sensitivity. The tests that met the benchmark criteria included a bilateral reactive pupil response within 12 hours, a GCS motor score of≥4 at 6 hours, continuous background, sleep spindles on EEG within 24 hours, and a normal brain MRI at 4-6 days. Early normal lactate and neuronal biomarkers also had low false-positive rates but lacked sensitivity.Â
All studies had a moderate to high risk of bias and too much outcome variability to perform a meta-analysis. The authors caution against over-interpreting these findings, as confounding factors such as sedation can impact individual results.
Why does it matter?
Paediatric cardiac arrest is a critical event with high mortality and adverse neurocognitive outcomes. Accurate prediction of neurological prognosis is essential for guiding management and facilitating shared decision-making processes. Synthesis of all available evidence around neuroprognostication in children provides clinicians with information needed at the bedside.
Clinically Relevant Bottom Line
A comprehensive assessment with multiple modalities, including clinical examination, blood-based biomarkers, EEG, and neuroimaging, may be useful for neuroprognostication.Â
Ultimately, while individual tests provide useful insights, future research integrating multimodal approaches is necessary to enhance prognostic accuracy and support informed care decisions.
Reviewed by PICSTAR team
Article 3: International Consensus Criteria for Paediatric Sepsis and Septic Shock
Schlapbach LJ, Watson RS, Sorce LR, et al. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA. 2024;331(8):665-674. doi:10.1001/jama.2024.0179
What’s it about?
This expert panel looked to revise global criteria for the diagnosis of sepsis and septic shock in children. Using answers from an international survey, alongside a systematic review, meta-analysis, and analysis of data from a global database, a modified Delphi process was undertaken, and the new Phoenix sepsis criteria were developed.Â
This scoring system is based on the presence and extent of dysfunction across 4 different organ systems. A Phoenix Sepsis Score ≥ 2 is used to define sepsis. Among patients who meet sepsis definition, the presence of a cardiovascular score of ≥ 1 is used to define septic shock.
Why does it matter?
Sepsis remains a major cause of morbidity and mortality in children worldwide. However, previous systemic inflammatory response-based scores were not necessarily directly transferrable across different resource settings. Standardised definitions for sepsis in children are also updated less frequently than their adult equivalents, and the Phoenix criteria can improve the prompt recognition of sepsis, improve individual patient outcomes, epidemiology and facilitate research. These new sepsis criteria had a higher positive predictive value and at least comparable sensitivity for in-hospital mortality when compared to the previous IPSCC paediatric sepsis definition from 2005.
For more on sepsis check out SIRS, Sepsis and Shock Module – Don’t Forget the Bubbles.
Clinically Relevant Bottom Line
The Phoenix criteria have redefined sepsis and septic shock in children with suspected or confirmed infection. Confusing terms such as SIRS and ‘severe sepsis’ are now obsolete! Remember, while the new criteria can help identify life-threatening organ dysfunction secondary to infection in children, they cannot be used as a screening tool for those at risk of sepsis.
Reviewed by PICSTAR team
Article 4: Visualization of the Intracranial Pressure and Time Burden in Childhood Brain Trauma
Kempen B, Depreitere B, Piper I, et al. Visualization of the Intracranial Pressure and Time Burden in Childhood Brain Trauma: What We Have Learned One Decade on With KidsBrainIT. J Neurotrauma. 2024;41(13-14):e1651-e1659. doi:10.1089/neu.2023.0254
What’s it about?
This study examines how intracranial pressure (ICP) dynamics influence outcomes in paediatric traumatic brain injury (TBI). (See here for a summary of the importance of ICP in TBI Managing raised intracranial pressure in severe traumatic brain injury – the basics – Don’t Forget the Bubbles)
Using 1.6 million minutes of high-resolution data from around 100 children with severe TBI, researchers from the KidsBrainIT consortium – an international collaborative of 16 PICUs from seven countries – analysed ICP patterns and association with outcomes. Their goal was to validate an ICP dose-response model, initially developed in 2015, which suggested that both the magnitude and duration of ICP elevation contribute to adverse neurological outcomes. This KidsBrainIT study successfully validated the dose-response plot. The dose-response plot generated from this dataset shows that 6-month neurological outcomes are influenced by both the magnitude and duration of the ICP. While ICP rises > 20 mmHg were poorly tolerated even for a short duration, ICP intensity levels lower than the 20 mmHg threshold may also be associated with adverse outcomes if sustained for a longer duration of time. Furthermore, CPP <50mmHg was also associated with adverse prognoses, independent of the ICP severity or duration.
Why does it matter?
Effective ICP management is the bedrock of treating paediatric severe TBI, but the precise threshold to target remains debated (the most definitive guidance at present being by that of the Brain Trauma Foundation, 2019 – Guidelines for the Management of Pediatric Severe TBI, 3rd Edition — Brain Trauma Foundation). These insights suggest that the current ICP management strategies may need refinement, particularly in defining tolerable pressure thresholds over time. By visualising ICP burden more precisely, the study provides a valuable tool for optimising treatment strategies, reducing secondary brain injury and improving patient outcomes.
Clinically Relevant Bottom Line
For paediatric severe TBI management, we should continue to target ICP <20mmHg and CPP >50mmHg, avoiding even brief periods of threshold breaches. Further research is needed to refine management based on more complex, yet precise, thresholds that incorporate combinations of pressure-time burdens in the future.
Reviewed by PICSTAR team
Article 5: Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants
Geraghty LE, Dunne EA, NÃ Chathasaigh CM, et al. Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants. N Engl J Med. 2024;390(20):1885-1894. doi:10.1056/NEJMoa2402785
What’s it about?
This single-centre randomised controlled trial (VODE trial) compared video laryngoscopy (VL) and direct laryngoscopy (DL) for intubation in 214 neonates. The neonates were preterm (most <32 weeks post-menstrual age) and small (almost half <1kg). The vast majority of intubations occurred in the early minutes of life. Most were performed by inexperienced practitioners (general paediatric doctors in training), with anaesthetic drugs, and in the NICU (rather than the delivery room).
The primary outcome was first-attempt success rate, and VL was significantly better than DL. First-attempt success rate was 74% (95% CI 66-82%) using VL vs. 45% (95% CI 35-54%) using DL. This was particularly true in babies of lower gestation and weight, where DL appeared to perform worse, but the VL success rate was maintained. Among the analysed secondary outcomes, no significant differences were found in number, duration of attempts, oxygen saturation, heart rate, chest compressions, adrenaline administration, or oral trauma.
Why does it matter?
Neonatal intubation is a challenging procedure. First-attempt success may reduce hypoxia and complications. VL seems to improve intubation rates in the first attempt, and so could become the standard of care in neonatal resuscitation. The fact that other colleagues can view the screen provides additional benefits over DL in facilitating training, situational awareness, and teamwork.
Clinically Relevant Bottom Line
We already have good evidence that VL outperforms DL in key metrics in adult and
paediatric intubations. Now we have the same for neonatal intubations. Is it time for VL to become routine for all intubations in high-income countries? It seems so. Time to get practising!
Reviewed by PICSTAR team
About PICSTAR
PICSTAR is a trainee-led research network open to all doctors, nurses and allied health trainees within Paediatric Intensive Care. We are the trainee arm of the Paediatric Critical Care Society – Study Group (PCCS-SG) and work with them on research, audit and service evaluation.
If you would like to join PICSTAR and get involved in projects, have ideas you would like to propose or get advice/mentorship via PCCS-SG, don’t hesitate to contact us at picstar.network@gmail.com. See their website for more: https://pccsociety.uk/research/picstar/
Joshua Hodgson
Josh is a Paediatric Trainee Doctor based in London. He is the RCPCH Trainee Representative for ePortfolio and Curriculum with interests in medical education and leadership. He loves exploring the world, and he hates celery.
Claire Rafferty
Claire is a paediatric trainee with an interest in PICU and medical education. She is currently working in Bristol Children’s Hospital PICU and with the WATCH transfer service. Outside work, she enjoys muddy cycle rides and going to gigs.
Ciara O’ Regan
Ciara is an ST6 PICM GRID trainee at Evelina London Children’s Hospital. She is interested in research in PICM. Outside of the hospital, she’d be off cycling or skiing in the mountains.Â
Amina Joarder
Amina is a paediatric trainee in Scotland who is highly interested in PICU, particularly POCUS and US-guided procedures. She loves teaching and is the current representative for the South-East of Scotland in teaching. Outside work you will find her in her kitchen trying out newly learnt culinary skills. Her neighbours love her!Â
Manisha Kumar
Manisha is a Paeds registrar with an interest in PICU and travel, currently taking time out of training at the Children’s Acute Transport Service. Outside of work, you can generally find her on a rooftop bar with cocktails and friends. If it’s not sunset weather, she’s probably at home cuddling her cats and planning her next holiday.
If we missed something useful or you think other articles are worth sharing, please add them in the comments!
That’s it for this month—many thanks to our reviewers for scouring the literature so you don’t have to.
Vicki Currie, DFTB Bubble Wrap Lead, reviewed and edited all articles.
