When might you suspect a brain tumour in a child who presents with, say, nausea and vomiting, or behavioural disturbance? A guideline has been produced which might prompt one to think of this important but often delayed diagnosis.
The diagnosis of brain tumours in children: a guideline to assist healthcare professionals in the assessment of children who may have a brain tumour Arch Dis Child. 2010 Jul;95(7):534-9
Tag Archives: paediatric
New College Ketamine Guideline
The College of Emergency Medicine (UK) has updated its guideline on ketamine sedation in children.
The summary is copied below
Full text is available here
Guideline for ketamine sedation of children in Emergency Departments
- Before ketamine is used all other options should be fully considered, including analgesia, reassurance, distraction, entonox, intranasal diamorphine, etc.
- The doses advised for analgesic sedation are designed to leave the patient capable of protecting their airway. There is a significant risk of a failure of sedation if the procedure is prolonged, and the clinician must recognise that the option of general anaesthesia may be preferred in these circumstances.
- There is no evidence that complications are reduced if the child is fasted, however traditional anaesthetic practice favours a period of fasting prior to any sedative procedure. The fasting state of the child should be considered in relation to the urgency of the procedure, but recent food intake should not be considered as an absolute contraindication to ketamine use.
- Ketamine should be only used by clinicians experienced in its use and capable of managing any complications, particularly airway obstruction, apnoea and laryngospasm. The doctor managing the ketamine sedation and airway should be suitably trained and experienced in ketamine use, with a full range of advanced airway skills.
- At least three staff are required: a doctor to manage the sedation and airway, a clinician to perform the procedure and an experienced nurse to monitor and support the patient, family and clinical staff. Observations should be regularly taken and recorded.
- The child should be managed in a high dependency or resuscitation area with immediate access to full resuscitation facilities. Monitoring should include ECG, blood pressure, respiration and pulse oximetry. Supplemental oxygen should be given and suction must be available.
- After the procedure the child should recover in a quiet, observed and monitored area under the continuous observation of a trained member of staff. Recovery should be complete between 60 and 120 minutes, depending on the dose and route used.
- There should be a documentation and audit system in place within a system of clinical governance.
Infant CPR: two thumbs even when alone
Infant CPR guidelines recommend two-finger chest compressions with a lone rescuer and two-thumb with two rescuers. Two-thumb provides better chest compression but is perceived to be associated with increased ventilation hands-off time. A manikin study revealed more effective compressions with the two-thumb technique with only four fewer compressions per minute compared with two-fingers.
Two-thumb technique is superior to two-finger technique during lone rescuer infant manikin CPR
Resuscitation. 2010 Jun;81(6):712-7
HFOV in preterms – no clear benefit
Pre-term infants lacking surfactant often require mechanical ventilation, but the consequent barotrauma and volutrauma may contribute to chronic lung disease, or bronchopulmonary dysplasia. Consequently high frequency oscillatory ventilation (HFOV) has been tried, but results from trials are mixed. A new systematic review of 3229 preterm newborns of less than 35 weeks’ gestation in 10 randomised trials fails to show a benefit of HFOV over conventional ventilation.
Elective high-frequency oscillatory versus conventional ventilation in preterm infants: a systematic review and meta-analysis of individual patients’ data
The Lancet, Volume 375, Issue 9731, Pages 2082 – 2091, 12 June 201o
Terlipressin for refractory cardiac arrest in kids
Okay so it’s a small case series – but the results warrant further investigation: 10-20 mcg/kg terlipressin was given to five infants and children who arrested in the paediatric intensive care unit and who had not responded to several doses of adrenaline (epinephrine)1. Sustained return of spontaneous circulation (ROSC) was achieved in four, and two survived to be discharged home without sequelae and with good neurologic status at 6 and 12 month follow up. Interestingly, the four patients who had ROSC all had septic shock as the cause of their arrest. The two survivors had severe bradycardia and severe bradycarda-asystole as the arrest rhythms, and both received 20 mcg/kg terlipressin.
Terlipressin is a synthetic arginine vasopressin analog with a significantly longer duration of effect, which previously showed positive effects when administered to a small group of children unresponsive to prolonged resuscitative efforts2.
1. Pediatric cardiac arrest refractory to advanced life support: Is there a role for terlipressin?
Pediatr Crit Care Med. 2010 Jan;11(1):139-41
2. Beneficial effects of terlipressin in prolonged pediatric cardiopulmonary resuscitation: A case series.
Crit Care Med. 2007 Apr;35(4):1161-4
Guideline improved pre-hospital RSI in kids
French physicians provide pre-hospital critical care in medical teams of regional SAMU (service d’aide me ́dicale urgente). A national guideline was introduced in France to guide the management of traumatic brain injury (TBI), which included airway management. A study was conducted which examined the practice of paediatric pre-hospital intubation in TBI in comatose children both before and after the introduction of the guideline.
After the guideline there were more pre-hospital intubations, with more standardised approach to rapid sequence induction(RSI). There were fewer complications and a 100% intubation success rate. Despite an increase in portable capnography use, PaCO2 was measured outside the recommended range of 35– 40 mmHg (3.5-4.5 kPa) in 70% of the cases upon arrival.
Emergency tracheal intubation of severely head-injured children: Changing daily practice after implementation of national guidelines
Pediatr Crit Care Med. 2010 May 13. [Epub ahead of print]
Paediatric Retrieval – what's the rush?
The Children’s Acute Transport Service (CATS) in the UK performed 2106 interfacility transports between April 2006 and March 2008. The stabilisation time averaged just over 2 hrs. Stabilisation time was prolonged by the number of major interventions required to stabilise the patient before transfer and differed significantly between various diagnostic groups. The length of time spent by the retrieval team outside the intensive care environment had no independent effect on subsequent patient mortality.
They have shown that stabilisation time can be influenced by a number of patient- and transport team-related factors, and that time spent undertaking intensive care interventions early in the course of patient illness at the referring hospital does not increase patient mortality. In the authors’ words: ‘the “scoop and run” model can be safely abandoned in favor of early goal-directed management during interhospital transport for intensive care.‘
There’s NO rush guys!
Effect of patient- and team-related factors on stabilization time during pediatric intensive care transport
Pediatr Crit Care Med. 2010 May 6
Target Oxygen Saturation in Extreme Prems
1316 infants who were born between 24 weeks 0 days and 27 weeks 6 days of gestation were randomised to one of two different target ranges of oxygen saturation: 85 – 89% vs. 91 – 95%. The primary outcome was a composite of severe retinopathy of prematurity (defined as the presence of threshold retinopathy, the need for surgical ophthalmologic intervention, or the use of bevacizumab), death before discharge from the hospital, or both.
All infants were also randomly assigned to continuous positive airway pressure or intubation and surfactant in a 2-by-2 factorial design.
The rates of severe retinopathy or death did not differ significantly between the lower-oxygen-saturation group and the higher-oxygen-saturation group (28.3% and 32.1%, respectively; relative risk with lower oxygen saturation, 0.90; 95% confidence interval [CI], 0.76 to 1.06; P=0.21). Death before discharge occurred more frequently in the lower-oxygen-saturation group (in 19.9% of infants vs. 16.2%; relative risk, 1.27; 95% CI, 1.01 to 1.60; P=0.04), whereas severe retinopathy among survivors occurred less often in this group (8.6% vs. 17.9%; relative risk, 0.52; 95% CI, 0.37 to 0.73; P<0.001). There were no significant differences in the rates of other adverse events.
An editorial notes that the unmasked trial data showed that the distribution of oxygen saturation levels was within or above the target range in the higher-oxygen-saturation group, but in the lower-oxygen-saturation group, it was about 90 to 95% (i.e., above the target range). The difference in oxygen saturation levels between the groups was about 3 percentage points instead of the 6 percentage points that had been planned. Therefore, this study actually compared saturation levels of about 89 to 97% with saturation levels of 91 to 97%; the results should be ascribed to these higher ranges.
Targeting oxygen saturation levels is difficult, and a recommended oxygen saturation range that is effective yet safe remains elusive. A lower oxygen saturation level significantly reduces the incidence of severe retinopathy of prematurity but may increase the rate of death.
Target Ranges of Oxygen Saturation in Extremely Preterm Infants
N Engl J Med. 2010 May 16. [Epub ahead of print]
Early CPAP versus Surfactant in Extreme Prems
In a randomised, multicentre trial of 1316 infants born between 24 weeks 0 days and 27 weeks 6 days of gestation, infants were randomly assigned to intubation and surfactant treatment (within 1 hour after birth) or to CPAP treatment initiated in the delivery room, with subsequent use of a protocol-driven limited ventilation strategy. The primary outcome was death or bronchopulmonary dysplasia as defined by the requirement for supplemental oxygen at 36 weeks.
Infants who received CPAP treatment, as compared with infants who received surfactant treatment, less frequently required intubation or postnatal corticosteroids for bronchopulmonary dysplasia (P<0.001), required fewer days of mechanical ventilation (P=0.03), and were more likely to be alive and free from the need for mechanical ventilation by day 7 (P=0.01). However the rates of the primary outcome did not differ significantly between the CPAP group and the surfactant group (47.8% and 51.0%, respectively; relative risk with CPAP, 0.95; 95% confidence interval [CI], 0.85 to 1.05).
The infants randomised to CPAP could receive limited invasive ventilation if necessary; 83.1% of the infants in the CPAP group were intubated. They did not include infants who were born at a gestational age of less than 24 weeks, since the results of a pilot trial showed that 100% of such infants required intubation in the delivery room.
This study had a 2-by-2 factorial design in which infants were also randomly assigned to one of two target ranges of oxygen saturation.
Early CPAP versus Surfactant in Extremely Preterm Infants
N Engl J Med. 2010 May 16. [Epub ahead of print]
Vital signs of severely injured children
Systolic blood pressures of severely injured children are very often hypertensive compared with APLS ‘norms’. A lower pulse rate is associated with more severe brain injury
Comparing the systolic blood pressure (SBP) and pulse rate (PR) in injured children with and without traumatic brain injury
Resuscitation. 2010 Apr;81(4):418-21