Admissions of Children and Adolescents With Deliberate Self-harm to Intensive Care During the SARS-CoV-2 Outbreak in Australia

Importance: Identification of potential indirect outcomes associated with the COVID-19 pandemic in the pediatric population may be essential for understanding the challenges of the current global public health crisis for children and adolescents. Objective: To investigate whether the SARS-CoV-2 outbreak and subsequent effective public health measures in Australia were associated with an increase in admissions to intensive care units (ICUs) of children and adolescents with deliberate self-harm (DSH). Design, setting, and participants: This national, multicenter cohort study was conducted using the Australian data subset of the binational Australian and New Zealand Paediatric Intensive Care registry, a collaborative containing more than 200 000 medical records with continuous contributions from all 8 Australian specialist, university-affiliated pediatric ICUs, along with 1 combined neonatal-pediatric ICU and 14 general (adult) ICUs in Australia. The study period encompassed 6.5 years from January 1, 2015, to June 30, 2021. Patients aged 12 to 17 years were included. Data were analyzed from December 2021 through February 2022. Exposures: Any of the following admission diagnoses: ingestion of a drug, ingestion of a nondrug, hanging or strangulation, or self-injury. Main outcomes and measures: The primary outcome measure was the temporal trend for national incidence of DSH ICU admissions per 1 million children and adolescents aged 12 to 17 years in Australia. Results: A total of 813 children and adolescents aged 12 to 17 years admitted to ICUs with DSH were identified among 64 145 patients aged 0 to 17 years in the Australian subset of the registry during the study period. Median (IQR) age was 15.1 (14.3-15.8) years; there were 550 (67.7%) female patients, 261 (32.2%) male patients, and 2 (0.2%) patients with indeterminate sex. At the onset of the pandemic, monthly incidence of DSH ICU admissions per million children and adolescents increased from 7.2 admissions in March 2020 to a peak of 11.4 admissions by August 2020, constituting a significant break in the temporal trend (odds ratio of DSH ICU admissions on or after vs before March 2020, 4.84; 95% CI, 1.09 to 21.53; P = .04). This occurred while the rate of all-cause admissions to pediatric ICUs of children and adolescents of all ages (ie, ages 0-17 years) per 1 million children and adolescents decreased from a long-term monthly median (IQR) of 150.9 (138.1-159.8) admissions to 91.7 admissions in April 2020. Conclusions and relevance: This cohort study found that the coronavirus pandemic in Australia was associated with a significant increase in admissions of children and adolescents to intensive care with DSH

Withdrawal of life-support in paediatric intensive care - a study of time intervals between discussion, decision and death

<p>Abstract</p> <p>Background</p> <p>Scant information exists about the time-course of events during withdrawal of life-sustaining treatment. We investigated the time required for end-of-life decisions, subsequent withdrawal of life-sustaining treatment and the time to death.</p> <p>Methods</p> <p>Prospective, observational study in the ICU of a tertiary paediatric hospital.</p> <p>Results</p> <p>Data on 38 cases of withdrawal of life-sustaining treatment were recorded over a 12-month period (75% of PICU deaths). The time from the first discussion between medical staff and parents of the subject of withdrawal of life-sustaining treatment to parents and medical staff making the decision varied widely from immediate to 457 hours (19 days) with a median time of 67.8 hours (2.8 days). Large variations were subsequently also observed from the time of decision to actual commencement of the process ranging from 30 minutes to 47.3 hrs (2 days) with a median requirement of 4.7 hours. Death was apparent to staff at a median time of 10 minutes following withdrawal of life support varying from immediate to a maximum of 6.4 hours. Twenty-one per cent of children died more than 1 hour after withdrawal of treatment. Medical confirmation of death occurred at 0 to 35 minutes thereafter with the physician having left the bedside during withdrawal in 18 cases (48%) to attend other patients or to allow privacy for the family.</p> <p>Conclusions</p> <p>Wide case-by-case variation in timeframes occurs at every step of the process of withdrawal of life-sustaining treatment until death. This knowledge may facilitate medical management, clinical leadership, guidance of parents and inform organ procurement after cardiac death.</p

Fluid bolus therapy in critically ill children: a survey of practice among paediatric intensive care doctors in Australia and New Zealand

Fluid bolus therapy (FBT) is a widely used intervention in paediatric critical illness. The aim of this study was to describe the attitudes and practices towards FBT of paediatric intensive care doctors in Australia and New Zealand.An internet-based survey of paediatric intensive care doctors in Australia and New Zealand between 7 and 30 November 2016.Paediatric intensive care units with greater than 400 admissions annually.Paediatric intensive care specialists and junior medical staff.Preferences for FBT and markers of fluid responsiveness.There were 106/175 respondents (61%); 0.9% saline and 4% albumin are used frequently or almost always by 86% and 57% of respondents respectively. The preferred volume and duration were 10 mL/kg in less than 10 minutes. The highest rated markers of fluid responsiveness were heart rate and blood pressure - rated as "good" or "very good" by 75% and 58% of respondents respectively. Central venous saturations and serum lactate were the highest rated biochemical markers. The most frequently expected magnitude of change for heart rate and blood pressure was 6-15% by 89% and 76% of respondents respectively. The preferred fluid composition for sepsis, trauma, traumatic brain injury and acute lung injury was 0.9% saline, and 4% albumin for post-operative cardiac surgery.Paediatric intensive care doctors prefer 0.9% saline and 4% albumin for FBT. Heart rate and blood pressure are the most preferred markers to assess fluid responsiveness. Preferences for FBT in specific conditions exist

Machine learning to predict poor school performance in paediatric survivors of intensive care: a population-based cohort study

Purpose: Whilst survival in paediatric critical care has improved, clinicians lack tools capable of predicting long-term outcomes. We developed a machine learning model to predict poor school outcomes in children surviving intensive care unit (ICU). Methods: Population-based study of children < 16 years requiring ICU admission in Queensland, Australia, between 1997 and 2019. Failure to meet the National Minimum Standard (NMS) in the National Assessment Program-Literacy and Numeracy (NAPLAN) assessment during primary and secondary school was the primary outcome. Routine ICU information was used to train machine learning classifiers. Models were trained, validated and tested using stratified nested cross-validation. Results: 13,957 childhood ICU survivors with 37,200 corresponding NAPLAN tests after a median follow-up duration of 6 years were included. 14.7%, 17%, 15.6% and 16.6% failed to meet NMS in school grades 3, 5, 7 and 9. The model demonstrated an Area Under the Receiver Operating Characteristic curve (AUROC) of 0.8 (standard deviation SD, 0.01), with 51% specificity to reach 85% sensitivity [relative Area Under the Precision Recall Curve (rel-AUPRC) 3.42, SD 0.06]. Socio-economic status, illness severity, and neurological, congenital, and genetic disorders contributed most to the predictions. In children with no comorbidities admitted between 2009 and 2019, the model achieved a AUROC of 0.77 (SD 0.03) and a rel-AUPRC of 3.31 (SD 0.42). Conclusions: A machine learning model using data available at time of ICU discharge predicted failure to meet minimum educational requirements at school age. Implementation of this prediction tool could assist in prioritizing patients for follow-up and targeting of rehabilitative measures.</p

Resuscitation with Vitamin C, Hydrocortisone, and Thiamin in Children with Septic Shock: A Multicenter Randomized Pilot Study

OBJECTIVES: Adjunctive therapy with vitamin C, hydrocortisone, and thiamin has been evaluated in adults, but randomized controlled trial (RCT) data in children are lacking. We aimed to test the feasibility of vitamin C, hydrocortisone, and thiamin in PICU patients with septic shock; and to explore whether the intervention is associated with increased survival free of organ dysfunction. DESIGN: Open-label parallel, pilot RCT multicenter study. The primary endpoint was feasibility. Clinical endpoints included survival free of organ dysfunction censored at 28 days and nine secondary outcomes, shock reversal, and two proxy measures of intervention efficacy. SETTING: Six PICUs in Australia and New Zealand. PATIENTS: Children of age between 28 days and 18 years requiring vasoactive drugs for septic shock between August 2019 and March 2021. INTERVENTIONS: Patients were assigned 1:1 to receive 1 mg/kg hydrocortisone every 6 hours (q6h), 30 mg/kg ascorbic acid q6h, and 4 mg/kg thiamin every 12 hours (n = 27), or standard septic shock management (n = 33). MEASUREMENTS AND MAIN RESULTS: Sixty of 77 (78%) eligible patients consented with 91% of approached parents providing consent. The median time from randomization to intervention was 44 (interquartile range [IQR] 29-120) min. Seventy of seventy-seven (28%) patients had received IV steroids before randomization. Median survival alive and free of organ dysfunction was 20.0 (0.0-26.0) days in the intervention and 21.0 (0.0-25.0) days in the standard care group. Median PICU length of stay was 5.3 (2.5-11.3) days in the intervention group versus 6.9 (3.0-11.5) days in the control group. Shock reversal occurred at a median of 35.2 (14.6-101.2) hours in the intervention group versus 47.3 (22.4-106.8) hours in the standard care group (median difference -12 hr; 95% CI, -56.8 to 32.7 hr). CONCLUSIONS: In children requiring vasopressors for septic shock, a protocol comparing adjunctive treatment with high-dose vitamin C, hydrocortisone, and thiamin versus standard care was feasible. These findings assist in making modifications to the trial protocol to enable a better-designed larger RCT.</p

Fluid management and active fluid removal practices: a global survey of paediatric critical care physicians

Aims Fluid accumulation (FA) in critically ill children is associated with poor clinical outcomes. While conservative fluid management has been proposed, evidence to guide practice is scarce. We surveyed paediatric critical care (PCC) physicians worldwide regarding their perceptions of FA, active fluid removal (AFR) practices, safety parameters, and willingness to participate in a clinical trial on the topic. Methods Cross-sectional international electronic survey of PCC physicians, distributed through research networks worldwide. ResultsA total of 409 PCC physicians from 48 countries participated in the survey; 40% (164/409) cared for cardiac patients. The majority believed FA was a modifiable source of morbidity (88%, 359/407) and expressed support for a trial on conservative fluid management trial (94%, 383/407). Restriction of maintenance fluid was more commonly practiced (87%, 335/387) than resuscitation fluid (54%, 210/387), with variability observed among individuals and patient categories. AFR was widely practiced (93%, 361/387), yet significant differences existed in patient selection, timing, modality, and rate. The most common reported time for starting AFR was 48 h (49%, 172/384), with most respondents (92%, 355/385) comfortable doing so in the setting of catecholamine infusions. While most respondents would continue diuretics with mild electrolyte or acid–base disturbances, 52% (179/342) would withhold them in cases of mild hypotension. Conclusions Fluid accumulation remains a significant concern among paediatric intensivists. The observed practice variability underscores the challenges in establishing evidence-based guidelines. Our survey highlights an urgent need for randomized trials in this field and provides valuable insights to inform the design of such future studies

Online Learning and Residents' Acquisition of Mechanical Ventilation Knowledge:Sequencing Matters

OBJECTIVE: Rapid advancements in medicine and changing standards in medical education require new, efficient educational strategies. We investigated whether an online intervention could increase residents' knowledge and improve knowledge retention in mechanical ventilation when compared with a clinical rotation and whether the timing of intervention had an impact on overall knowledge gains. DESIGN: A prospective, interventional crossover study conducted from October 2015 to December 2017. SETTING: Multicenter study conducted in 33 PICUs across eight countries. SUBJECTS: Pediatric categorical residents rotating through the PICU for the first time. We allocated 483 residents into two arms based on rotation date to use an online intervention either before or after the clinical rotation. INTERVENTIONS: Residents completed an online virtual mechanical ventilation simulator either before or after a 1-month clinical rotation with a 2-month period between interventions. MEASUREMENTS AND MAIN RESULTS: Performance on case-based, multiple-choice question tests before and after each intervention was used to quantify knowledge gains and knowledge retention. Initial knowledge gains in residents who completed the online intervention (average knowledge gain, 6.9%; SD, 18.2) were noninferior compared with those who completed 1 month of a clinical rotation (average knowledge gain, 6.1%; SD, 18.9; difference, 0.8%; 95% CI, -5.05 to 6.47; p = 0.81). Knowledge retention was greater following completion of the online intervention when compared with the clinical rotation when controlling for time (difference, 7.6%; 95% CI, 0.7-14.5; p = 0.03). When the online intervention was sequenced before (average knowledge gain, 14.6%; SD, 15.4) rather than after (average knowledge gain, 7.0%; SD, 19.1) the clinical rotation, residents had superior overall knowledge acquisition (difference, 7.6%; 95% CI, 2.01-12.97;p = 0.008). CONCLUSIONS: Incorporating an interactive online educational intervention prior to a clinical rotation may offer a strategy to prime learners for the upcoming rotation, augmenting clinical learning in graduate medical education