Intraosseous Versus Intravenous Access in Pediatric Septic Shock Patients Admitted to Alexandria University Pediatric Intensive Care Unit

Assessment of adherence to the 2020 Surviving Sepsis Campaign guidelines for fluid resuscitation in children with suspected septic shock in paediatric emergency departments: a prospective multicentre study

BACKGROUND

Paediatric sepsis is the leading cause of death in children under 5 years. No studies have evaluated the application of the Surviving Sepsis Campaign 2020 (SSC-2020) guidelines in paediatric emergency departments (PEDs).

OBJECTIVE

To assess physician adherence to the SSC-2020 fluid resuscitation guidelines in children with suspected septic shock in PEDs.

METHODS

This was a prospective multicentre observational study conducted in 21 French hospitals over 5 sequential weeks, between November 2021 and March 2022. Children with suspected septic shock and who received antimicrobial therapy within 72 hours were included. Primary outcome was SSC-2020 fluid resuscitation guidelines adherence (low 0-24%; moderate 25-74%; high 75-100%) according to: bolus volume of 10-20 mL/kg each, exclusive administration of balanced crystalloids at 1 and 24 hours of management, and initiation of fluid resuscitation within 1 hour of septic shock recognition.

RESULTS

63 children were included. 10 (16%) children had severe sepsis and 2 (3%) met the definition of septic shock. Compared with the SSC-2020 guidelines, 43 (68%) patients received boluses of 10-20 mL/kg; fluid resuscitation was initiated within 1 hour of septic shock recognition in 42 (76%) cases; balanced crystalloids were the only fluids administrated in 35 (56%) and 34 (55%) children at 1 and 24 hours of management, respectively. Main barriers reported by physicians were difficult intravenous access (43%), lack of team training (29%), workload constraints (28%), and absence or out-of-date protocols (24%).

CONCLUSIONS

This study found high adherence for fluid resuscitation initiation but moderate adherence for bolus volume and fluid choice.

TRIAL REGISTRATION NUMBER

NCT05066464.

Integration of Intraosseous Approach Method in Georgia

OBJECTIVE

In pediatric emergencies, as in case of shock, the use of intraosseous (IO) route is recommended to get rapid vascular access as soon as possible, as it revealed better outcome. Nevertheless, the IO approach is not used at all and/or is limited because of lack of demand and lack of training on the issue of medical staff. The aim of the study was to test applicable and/or demand of IO in clinics providing pediatric critical care services and assess the opportunities to integrate IO access use in emergency care in Georgia.

METHODS

A quasi-experimental study was conducted, following a training of medical staff to perform IO access procedure. Our study involved 140 children admitted to emergency department, 114 of whom underwent venous access and 26 underwent IO access. Several parameters were monitored and reported. Outcomes were compared between the 2 procedures.

RESULTS

Use of an IO catheter has significantly altered the clinical outcome of the patient's condition; 35% of the total number of patients needed to continue their treatment in the intensive care unit, whereas 65% of the patient's continued treatment in the various general wards (compared with 99% and 1%, respectively, in intravenous access patients). None of IO patients were transferred to other clinics because of the deterioration of their clinical condition. Complications in the form of local infection were not observed in any of the patients using the IO approach (which is interesting in terms of infection control).

CONCLUSION

With proper training and in certain indications, the internationally approved method can be safely used in pediatric emergency management in Georgian and similar country health system contexts. Several urgent conditions with high rates of requiring hospitalization could benefit from the IO approach.

Comparison of intravascular access methods applied by nurses wearing personal protective equipment in simulated COVID-19 resuscitation: A randomized crossover simulation trial

BACKGROUND

Prehospital emergency care of children is challenging. In the era of the COVID-19 pandemic, when medical personnel should use personal protective equipment against aerosol-generating procedures, the efficiency of medical procedures may decrease. The study objective was to evaluate the effectiveness of different intravascular access methods applied by nurses wearing biosafety Level-2 suits in simulated paediatric COVID-19 resuscitation.

METHODS

A prospective, randomized, crossover, single-blinded simulation trial was performed. Nursing staff attending Advanced Cardiovascular Life Support courses accredited by the American Heart Association participated in the study. A total of 65 nurses were recruited and randomly assigned to different study groups. They received standard training on intravascular access methods employing distinct devices. The participants wore biosafety Level-2 suits and performed vascular access with the following intraosseous devices: NIO-P, EZ-IO, and Jamshidi needle; intravenous (IV) access was used as a reference method. Both the order of participants and the access methods were random. Each participant performed intravascular access with each of the four methods tested. The effectiveness of the first attempt to obtain intravascular access and the following time parameters were analysed: the time between grasping the intravascular device out of the original packing until infusion line connection. The ease of the procedure was measured with a visual analogue scale (1 - easy; 10 - difficult).

RESULTS

The first attempt success rate of intravascular access by using NIO-P and EZ-IO equalled 100% and was statistically significantly higher than that with the Jamshidi needle (80.0%; p = 0.02) and with the IV method (69.2%; p = 0.005). The time required to connect the infusion line varied and amounted to 33 ± 4 s for NIO-P compared to 37 ± 6.7 s for EZ-IO (p<0.001), 43 ± 7 s for Jamshidi (p<0.001), and 98.5 ± 10 s for IV access (p<0.001). The procedure was easiest in the case of NIO-P and EZ-IO (2 ± 1 points; p=1.0) compared with Jamshidi (5 ± 3 points; p<0.001) and IV access (7 ± 2 points; p<0.001).

CONCLUSION

The study provides evidence that nurses wearing biosafety Level-2 suits were able to obtain intraosseous access faster and more effectively as compared with IV access during simulated COVID-19 paediatric resuscitation. The most effective method of intravascular access was the NIO-P intraosseous device. Further clinical trials are necessary to confirm the results.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Pediatric Critical Care in Resource Limited Settings-Lessening the Gap Through Ongoing Collaboration, Advancement in Research and Technological Innovations

Pediatric critical care has continued to advance since our last article, "Pediatric Critical Care in Resource-Limited Settings-Overview and Lessons Learned" was written just 3 years ago. In that article, we reviewed the history, current state, and gaps in level of care between low- and middle-income countries (LMICs) and high-income countries (HICs). In this article, we have highlighted recent advancements in pediatric critical care in LMICs in the areas of research, training and education, and technology. We acknowledge how the COVID-19 pandemic has contributed to increasing the speed of some developments. We discuss the advancements, some lessons learned, as well as the ongoing gaps that need to be addressed in the coming decade. Continued understanding of the importance of equitable sustainable partnerships in the bidirectional exchange of knowledge and collaboration in all advancement efforts (research, technology, etc.) remains essential to guide all of us to new frontiers in pediatric critical care.