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Deja E, Weeks A, Van Netten C, Gamble C, Meher S, Gyte G, Lavender T, Woolfall K. Questioning approaches to consent in time critical obstetric trials: findings from a mixed-methods study. BMJ Open 2024; 14:e081874. [PMID: 38341214 PMCID: PMC10862288 DOI: 10.1136/bmjopen-2023-081874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/15/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVE Trial legislation enables research to be conducted without prior consent (RWPC) in emergency situations, yet this approach has rarely been used in time-critical obstetric trials. This study explored views and experiences of antenatal recruitment and consent and RWPC in an emergency intrapartum randomised clinical trial. DESIGN Embedded, mixed-methods study within a trial, involving questionnaires, recorded recruitment discussions, interviews and focus groups in the first 13 months of trial recruitment (December 2020-January 2022). SETTING COPE is a double-blind randomised controlled trial, comparing the effectiveness of carboprost or oxytocin as first-line treatment of postpartum haemorrhage. PARTICIPANTS Two hundred and eighty-six people (190 women/96 birth partners), linked to 198/380 (52%) COPE recruits participated in the embedded study. Of these, 272 completed a questionnaire (178 women/94 birth partners), 22 were interviewed (19 women/3 birth partners) and 16 consent discussions with 12 women were recorded. Twenty-seven staff took part in three focus groups and nine staff were interviewed. RESULTS Participants recommended that information about the study should be more accessible antenatally for those who wish to be informed. Most women and staff did not think it would be appropriate to seek consent during pregnancy or early labour as it may cause 'unnecessary panic' and lead to research waste, as most women would not become eligible. There was support for the use of RWPC as COPE interventions are used in standard clinical practice and viewed as low risk. Women who were approached about the trial while having a postpartum haemorrhage also supported RWPC as they could not recall research discussions. CONCLUSIONS Findings support the use of RWPC for time-critical interventions, and raise questions about the appropriateness of other commonly used consent pathways, including antenatal consent and verbal assent.
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Affiliation(s)
- Elizabeth Deja
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Andrew Weeks
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | | | - Carrol Gamble
- Health Data Science, University of Liverpool, Liverpool, UK
| | | | | | - Tina Lavender
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
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Deja E, Donohue C, Semple MG, Woolfall K. Stakeholders' perspectives on clinical trial acceptability and approach to consent within a limited timeframe: a mixed methods study. BMJ Open 2024; 14:e077023. [PMID: 38167280 PMCID: PMC10773389 DOI: 10.1136/bmjopen-2023-077023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/24/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVES The Bronchiolitis Endotracheal Surfactant Study (BESS) is a randomised controlled trial to determine the efficacy of endo-tracheal surfactant therapy for critically ill infants with bronchiolitis. To explore acceptability of BESS, including approach to consent within a limited time frame, we explored parent and staff experiences of trial involvement in the first two bronchiolitis seasons to inform subsequent trial conduct. DESIGN A mixed-method embedded study involving a site staff survey, questionnaires and interviews with parents approached about BESS. SETTING Fourteen UK paediatric intensive care units. PARTICIPANTS Of the 179 parents of children approached to take part in BESS, 75 parents (of 69 children) took part in the embedded study. Of these, 55/69 (78%) completed a questionnaire, and 15/69 (21%) were interviewed. Thirty-eight staff completed a questionnaire. RESULTS Parents and staff found the trial acceptable. All constructs of the Adapted Theoretical Framework of Acceptability were met. Parents viewed surfactant as being low risk and hoped their child's participation would help others in the future. Although parents supported research without prior consent in studies of time critical interventions, they believed there was sufficient time to consider this trial. Parents recommended that prospective informed consent should continue to be sought for BESS. Many felt that the time between the consent process and intervention being administered took too long and should be 'streamlined' to avoid delays in administration of trial interventions. Staff described how the training and trial processes worked well, yet patients were missed due to lack of staff to deliver the intervention, particularly at weekends. CONCLUSION Parents and staff supported BESS trial and highlighted aspects of the protocol, which should be refined, including a streamlined informed consent process. Findings will be useful to inform proportionate approaches to consent in future paediatric trials where there is a short timeframe for consent discussions. TRIAL REGISTRATION NUMBER ISRCTN11746266.
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Affiliation(s)
- Elizabeth Deja
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Chloe Donohue
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Malcolm G Semple
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, Liverpool, UK
- Respiratory Medicine, Alder Hey Children's Hospital, Liverpool, UK
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
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Mitchell TK, Hall NJ, Yardley I, Cole C, Hardy P, King A, Murray D, Nuthall E, Roehr C, Stanbury K, Williams R, Pearce J, Woolfall K. Mixed-methods feasibility study to inform a randomised controlled trial of proton pump inhibitors to reduce strictures following neonatal surgery for oesophageal atresia. BMJ Open 2023; 13:e066070. [PMID: 37080617 PMCID: PMC10124212 DOI: 10.1136/bmjopen-2022-066070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
OBJECTIVES This mixed-methods feasibility study aimed to explore parents' and medical practitioners' views on the acceptability and design of a clinical trial to determine whether routine prophylactic proton pump inhibitors (PPI) reduce the incidence of anastomotic stricture in infants with oesophageal atresia (OA). DESIGN Semi-structured interviews with UK parents of an infant with OA and an online survey, telephone interviews and focus groups with clinicians. Data were analysed using reflexive thematic analysis and descriptive statistics. PARTICIPANTS AND SETTING We interviewed 18 parents of infants with OA. Fifty-one clinicians (49 surgeons, 2 neonatologists) from 20/25 (80%) units involved in OA repair completed an online survey and 10 took part in 1 of 2 focus groups. Interviews were conducted with two clinicians whose survey responses indicated they had concerns about the trial. OUTCOME MEASURES Parents and clinicians ranked the same top four outcomes ('Severity of anastomotic stricture', 'Incidence of anastomotic stricture', 'Need for treatment of reflux' and 'Presence of symptoms of reflux') as important to measure for the proposed trial. RESULTS All parents and most clinicians found the use, dose and duration of omeprazole as the intervention medication, and the placebo control, as acceptable. Parents stated they would hypothetically consent to their child's participation in the trial. Concerns of a few parents and clinicians about infants suffering with symptomatic reflux, and the impact of this for study retention, appeared to be alleviated through the symptomatic reflux treatment pathway. Hesitant clinician views appeared to change through discussion of parental support for the study and by highlighting existing research that questions current practice of PPI treatment. CONCLUSIONS Our findings indicate that parents and most clinicians view the proposed Treating Oesophageal Atresia with prophylactic proton pump inhibitors to prevent STricture (TOAST) trial to be feasible and acceptable so long as infants can be given PPI if clinicians deem it clinically necessary. This insight into parent and clinician views and concerns will inform pilot phase trial monitoring, staff training and the development of the trial protocol.
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Affiliation(s)
- Tracy Karen Mitchell
- Department of Public Health, Policy and Systems, Faculty of Health and Life Sciences, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Nigel J Hall
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Iain Yardley
- Evelina Children's Hospital, Guy's & St. Thomas's NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Christina Cole
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andy King
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David Murray
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elizabeth Nuthall
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Charles Roehr
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rachel Williams
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Kerry Woolfall
- Department of Public Health, Policy and Systems, Faculty of Health and Life Sciences, Institute of Population Health, University of Liverpool, Liverpool, UK
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Groff E, Orzechowski M, Schuetz C, Steger F. Ethical Aspects of Personalized Research and Management of Systemic Inflammatory Response Syndrome (SIRS) in Children. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:470. [PMID: 36612792 PMCID: PMC9819223 DOI: 10.3390/ijerph20010470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 06/17/2023]
Abstract
Systemic inflammatory response syndrome (SIRS) is a life-threatening condition with nonspecific symptoms. Because of that, defining a targeted therapy against SIRS in children and adults remains a challenge. The identification of diagnostic patterns from individualized immuneprofiling can lead to development of a personalized therapy. The aim of this study was to identify and analyze ethical issues associated with personalized research and therapy for SIRS in pediatric populations. We conducted an ethical analysis based on a principled approach according to Beauchamp and Childress' four bioethical principles. Relevant information for the research objectives was extracted from a systematic literature review conducted in the scientific databases PubMed, Embase and Web of Science. We searched for pertinent themes dealing with at least one of the four bioethical principles: "autonomy", "non-maleficence", "beneficence" and "justice". 48 publications that met the research objectives were included in the thorough analysis, structured and discussed in a narrative synthesis. From the analysis of the results, it has emerged that traditional paradigms of patient's autonomy and physician paternalism need to be reexamined in pediatric research. Standard information procedures and models of informed consent should be reconsidered as they do not accommodate the complexities of pediatric omics research.
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Affiliation(s)
- Elisa Groff
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, 89073 Ulm, Germany
| | - Marcin Orzechowski
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, 89073 Ulm, Germany
| | - Catharina Schuetz
- Paediatric Immunology, Medical Faculty “Carl Gustav Carus”, Technic University Dresden, 01307 Dresden, Germany
| | - Florian Steger
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, 89073 Ulm, Germany
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Paddock K, Woolfall K, Kearney A, Pattison N, Frith L, Gamble C, Welters I, Trinder J, Young B. Learning from stakeholders to inform good practice guidance on consent to research in intensive care units: a mixed-methods study. BMJ Open 2022; 12:e066149. [PMID: 36375987 PMCID: PMC9664286 DOI: 10.1136/bmjopen-2022-066149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Obtaining informed consent from patients in intensive care units (ICUs) prior to enrolment in a study is practically and ethically complex. Decisions about the participation of critically ill patients in research often involve substitute decision makers (SDMs), such as a patient's relatives or doctors. We explored the perspectives of different stakeholder groups towards these consent procedures. DESIGN AND METHODS Mixed-methods study comprising surveys completed by ICU patients, their relatives and healthcare practitioners in 14 English ICUs, followed by qualitative interviews with a subset of survey participants. Empirical bioethics informed the analysis and synthesis of the data. Survey data were analysed using descriptive statistics of Likert responses, and analysis of interview data was informed by thematic reflective approaches. RESULTS Analysis included 1409 survey responses (ICU patients n=333, relatives n=488, healthcare practitioners n=588) and 60 interviews (ICU patients n=13, relatives n=30, healthcare practitioners n=17). Most agreed with relatives acting as SDMs based on the perception that relatives often know the patient well enough to reflect their views. While the practice of doctors serving as SDMs was supported by most survey respondents, a quarter (25%) disagreed. Views were more positive at interview and shifted markedly depending on particularities of the study. Participants also wanted reassurance that patient care was prioritised over research recruitment. Findings lend support for adaptations to consent procedures, including collaborative decision-making to correct misunderstandings of the implications of research for that patient. This empirical evidence is used to develop good practice guidance that is to be published separately. CONCLUSIONS Participants largely supported existing consent procedures, but their perspectives on these consent procedures depended on their perceptions of what the research involved and the safeguards in place. Findings point to the importance of explaining clearly what safeguards are in place to protect the patient.
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Affiliation(s)
- Katie Paddock
- Department of Childhood, Youth and Education Studies, Manchester Metropolitan University, Manchester, UK
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Anna Kearney
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Natalie Pattison
- East and North Hertfordshire National Health Service Trust, Hertfordshire, UK
- School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Lucy Frith
- Centre for Social Ethics and Policy, The University of Manchester, Manchester, UK
| | - Carrol Gamble
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Ingeborg Welters
- Department of Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - John Trinder
- Ulster Hospital, Belfast, South Eastern Health & Social Services Trust, Belfast, Ireland
| | - Bridget Young
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
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Raman S, Brown G, Long D, Gelbart B, Delzoppo C, Millar J, Erickson S, Festa M, Schlapbach LJ. Priorities for paediatric critical care research: a modified Delphi study by the Australian and New Zealand Intensive Care Society Paediatric Study Group. CRIT CARE RESUSC 2021; 23:194-201. [PMID: 38045513 PMCID: PMC10692499 DOI: 10.51893/2021.2.oa6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Most interventions in paediatric critical care lack high grade evidence. We aimed to identify the key research priorities and key clinical outcome measures pertinent to research in paediatric intensive care patients. Design: Modified three-stage Delphi study combining staged online surveys, followed by a face-to-face discussion and final voting. Setting: Paediatric intensive care units in Australia and New Zealand. Participants: Medical and nursing staff working in intensive care. Main outcome measurements: Self-reported priorities for research. Results: 193 respondents provided a total of 267 research questions and 234 outcomes. In Stage 3, the top 56 research questions and 50 outcomes were discussed face to face, which allowed the identification of the top 20 research questions with the Hanlon prioritisation score and the top 20 outcomes. Topics centred on the use of intravenous fluids (restrictive v liberal fluids, use of fluid resuscitation bolus, early inotrope use, type of intravenous fluid, and assessment of fluid responsiveness), and patient- and family-centred outcomes (health-related quality of life, liberation) emerged as priorities. While mortality, length of stay, and organ support/organ dysfunction were considered important and the most feasible outcomes, long term quality of life and neurodevelopmental measures were rated highly in terms of their importance. Conclusions: Using a modified Delphi method, this study provides guidance towards prioritisation of research topics in paediatric critical care in Australia and New Zealand, and identifies study outcomes of key relevance to clinicians and experts in the field.
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Affiliation(s)
- Sainath Raman
- Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland, Children’s, Hospital, Brisbane, QLD, Australia
| | - Georgia Brown
- University of Melbourne, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Debbie Long
- Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland, Children’s, Hospital, Brisbane, QLD, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Ben Gelbart
- University of Melbourne, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Carmel Delzoppo
- University of Melbourne, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Johnny Millar
- University of Melbourne, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Simon Erickson
- Paediatric Intensive Care Unit, Perth Children’s Hospital, Perth, WA, Australia
| | - Marino Festa
- Paediatric Intensive Care Unit, Children’s Hospital Westmead, Sydney, NSW, Australia
- Kids Critical Care Research Group, Kids Research, Sydney Children’s Hospitals Network, Sydney, NSW, Australia
| | - Luregn J. Schlapbach
- Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland, Children’s, Hospital, Brisbane, QLD, Australia
- Pediatric and Neonatal Intensive Care Unit, University Children’s Hospital Zurich, and Children’s Research Center, University of Zurich, Zurich, Switzerland
| | - for the Australian and New Zealand Intensive Care Society Paediatric Study Group (ANZICS PSG)
- Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland, Children’s, Hospital, Brisbane, QLD, Australia
- University of Melbourne, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Perth Children’s Hospital, Perth, WA, Australia
- Paediatric Intensive Care Unit, Children’s Hospital Westmead, Sydney, NSW, Australia
- Kids Critical Care Research Group, Kids Research, Sydney Children’s Hospitals Network, Sydney, NSW, Australia
- Pediatric and Neonatal Intensive Care Unit, University Children’s Hospital Zurich, and Children’s Research Center, University of Zurich, Zurich, Switzerland
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Gale C, Dorling J, Arch B, Woolfall K, Deja E, Roper L, Jones AP, Latten L, Eccleson H, Hickey H, Pathan N, Preston J, Beissel A, Andrzejewska I, Valla F, Tume L. Optimal outcome measures for a trial of not routinely measuring gastric residual volume in neonatal care: a mixed methods consensus process. Arch Dis Child Fetal Neonatal Ed 2021; 106:292-297. [PMID: 33127738 DOI: 10.1136/archdischild-2020-319469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 09/15/2020] [Accepted: 10/11/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Routine measurement of gastric residual volume to guide feeding is widespread in neonatal units but not supported by high-quality evidence. Outcome selection is critical to trial design. OBJECTIVE To determine optimal outcome measures for a trial of not routinely measuring gastric residual volume in neonatal care. DESIGN A focused literature review, parent interviews, modified two-round Delphi survey and stakeholder consensus meeting. PARTICIPANTS Sixty-one neonatal healthcare professionals participated in an eDelphi survey; 17 parents were interviewed. 19 parents and neonatal healthcare professionals took part in the consensus meeting. RESULTS Literature review generated 14 outcomes, and parent interviews contributed eight additional outcomes; these 22 outcomes were then ranked by 74 healthcare professionals in the first Delphi round where four further outcomes were proposed; 26 outcomes were ranked in the second round by 61 healthcare professionals. Five outcomes were categorised as 'consensus in', and no outcomes were voted 'consensus out'. 'No consensus' outcomes were discussed and voted on in a face-to-face meeting by 19 participants, where four were voted 'consensus in'. The final nine consensus outcomes were: mortality, necrotising enterocolitis, time to full enteral feeds, duration of parenteral nutrition, time feeds stopped per 24 hours, healthcare-associated infection; catheter-associated bloodstream infection, change in weight between birth and neonatal discharge and pneumonia due to milk aspiration. CONCLUSIONS AND RELEVANCE We have identified outcomes for a trial of no routine measurement of gastric residual volume to guide feeding in neonatal care. This outcome set will ensure outcomes are important to healthcare professionals and parents.
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Affiliation(s)
- Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Jon Dorling
- Division of Neonatal-Perinatal Medicine, Dalhousie University - Faculty of Medicine, Halifax, Nova Scotia, Canada
| | - Barbara Arch
- Liverpool Clinical Trials Unit, University of Liverpool, Liverpool, Merseyside, UK
| | - Kerry Woolfall
- Institute of Psychology, University of Liverpool, Liverpool, Merseyside, UK
| | - Elizabeth Deja
- Department of Health Services Research, University of Liverpool, Liverpool, Merseyside, UK
| | - Louise Roper
- Department of Health Services Research, University of Liverpool, Liverpool, Merseyside, UK
| | - Ashley P Jones
- Medicines for Children Clinical Trials Unit, Clinical Trial Research Centre, University of Liverpool, Liverpool, UK
| | - Lynne Latten
- Department of Nutrition and Dietetics, Alder Hey Children's Hospital, Liverpool, UK
| | - Helen Eccleson
- Liverpool Clinical Trials Unit, University of Liverpool, Liverpool, Merseyside, UK
| | - Helen Hickey
- Clinical Trial Research Centre, Medicines for Children Clinical Trials Unit, Liverpool, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Jennifer Preston
- Women's and Children's Health, University of Liverpool School of Life Sciences, Liverpool, UK
| | - Anne Beissel
- Neonatal Intensive Care Unit, Hôpital Femme Mère Enfant, Lyon-Bron, France
| | - Izabela Andrzejewska
- Department of Neonatal Medicine, Chelsea and Westminster Healthcare NHS Trust, London, UK
| | - Frederic Valla
- Service de réanimation pédiatrique, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Université Claude-Bernard Lyon 1, Lyon, France
| | - Lyvonne Tume
- Department of Child Health, University of Salford, Salford, Greater Manchester, UK
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Roper L, Lyttle MD, Gamble C, Humphreys A, Messahel S, Lee ED, Noblet J, Hickey H, Rainford N, Iyer A, Appleton R, Woolfall K. Planning for success: overcoming challenges to recruitment and conduct of an open-label emergency department-led paediatric trial. Emerg Med J 2021; 38:191-197. [PMID: 33051276 PMCID: PMC7907583 DOI: 10.1136/emermed-2020-209487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 08/03/2020] [Accepted: 09/01/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Key challenges to the successful conduct of The Emergency treatment with Levetiracetam or Phenytoin in Status Epilepticus in children (EcLiPSE) trial were identified at the pre-trial stage. These included practitioner anxieties about conducting research without prior consent (RWPC), inexperience in conducting an ED-led trial and use of a medication that was not usual ED practice. As part of an embedded study, we explored parent and practitioner experiences of recruitment, RWPC and conduct of the trial to inform the design and conduct of future ED-led trials. METHODS A mixed-methods study within a trial involving (1) questionnaires and interviews with parents of randomised children, (2) interviews and focus groups with EcLiPSE practitioners and (3) audio-recorded trial discussions. We analysed data using thematic analysis and descriptive statistics as appropriate. RESULTS A total of 143 parents (93 mothers, 39 fathers, 11 missing information) of randomised children completed a questionnaire and 30 (25 mothers, 5 fathers) were interviewed. We analysed 76 recorded trial recruitment discussions. Ten practitioners (4 medical, 6 nursing) were interviewed, 36 (16 medical, 20 nursing) participated in one of six focus groups. Challenges to the success of the trial were addressed by having a clinically relevant research question, pragmatic trial design, parent and practitioner support for EcLiPSE recruitment and research without prior consent processes, and practitioner motivation and strong leadership. Lack of leadership negatively affected practitioner engagement and recruitment. EcLiPSE completed on time, achieving its required sample size target. CONCLUSIONS Successful trial recruitment and conduct in a challenging ED-led trial was driven by trial design, recruitment experience, teamwork and leadership. Our study provides valuable insight from parents and practitioners to inform the design and conduct of future trials in this setting.
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Affiliation(s)
- Louise Roper
- Institute of Population Health & Society, University of Liverpool, Liverpool, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Children's Hospital, Bristol, UK
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Amy Humphreys
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Shrouk Messahel
- Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Elizabeth D Lee
- Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Joanne Noblet
- Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Helen Hickey
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Naomi Rainford
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Anand Iyer
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Richard Appleton
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Kerry Woolfall
- Institute of Population Health & Society, University of Liverpool, Liverpool, UK
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Deja E, Roper L, Tume LN, Dorling J, Gale C, Arch B, Latten L, Pathan N, Eccleson H, Hickey H, Preston J, Beissel A, Andrzejewska I, Valla FV, Woolfall K. Can they stomach it? Parent and practitioner acceptability of a trial comparing gastric residual volume measurement versus no gastric residual volume in UK NNU and PICUs: a feasibility study. Pilot Feasibility Stud 2021; 7:49. [PMID: 33593416 PMCID: PMC7885383 DOI: 10.1186/s40814-021-00784-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 01/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Routine measurement of gastric residual volume (GRV) to guide feeding in neonatal and paediatric intensive care is widespread. However, this practice is not evidence based and may cause harm. As part of a feasibility study, we explored parent and practitioner views on the acceptability of a trial comparing GRV measurement or no GRV measurement. METHODS A mixed-methods study involving interviews and focus groups with practitioners and interviews with parents with experience of tube feeding in neonatal and/or paediatric intensive care. A voting system recorded closed question responses during practitioner data collection, enabling the collection of quantitative and qualitative data. Data were analysed using thematic analysis and descriptive statistics. RESULTS We interviewed 31 parents and nine practitioners and ran five practitioner focus groups (n=42). Participants described how the research question was logical, and the intervention would not be invasive and potential benefits of not withholding the child's feeds. However, both groups held concerns about the potential risk of not measuring GRV, including delayed diagnosis of infection and gut problems, increased risk of vomiting into lungs and causing discomfort or pain. Parent's views on GRV measurement and consent decision making were influenced by their views on the importance of feeding in the ICU, their child's prognosis and associated comorbidities or complications. CONCLUSIONS The majority of parents and practitioners viewed the proposed trial as acceptable. Potential concerns and preferences were identified that will need careful consideration to inform the development of the proposed trial protocol and staff training.
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Affiliation(s)
- Elizabeth Deja
- Institute of Population Health, University of Liverpool, Liverpool, UK.
| | - Louise Roper
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Lyvonne N Tume
- School of Health & Society, University of Salford, Manchester, M6 6PU, UK
| | - Jon Dorling
- Division of Pediatrics and Neonatal-Perinatal Medicine, Dalhousie University, Halifax, Canada
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital campus, London, UK
| | - Barbara Arch
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, University of Liverpool Institute of Child Health Alder Hey Children's NHS Foundation Trust Liverpool, Liverpool, UK
| | - Lynne Latten
- Department of Dietetics, Alder Hey Children's Hospital, Liverpool, UK
| | - Nazima Pathan
- Paediatric Intensive Care, University of Cambridge, Addenbrooke's Hospital Cambridge, Campbridge, UK
| | - Helen Eccleson
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, University of Liverpool Institute of Child Health Alder Hey Children's NHS Foundation Trust Liverpool, Liverpool, UK
| | - Helen Hickey
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, University of Liverpool Institute of Child Health Alder Hey Children's NHS Foundation Trust Liverpool, Liverpool, UK
| | - Jenny Preston
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Anne Beissel
- Neonatal Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon-Bron, France
| | | | - Frédéric V Valla
- Faculty of Health & Applied Sciences, University of the West of England, Bristol, UK.,Pediatric Intensive Care Unit, CarMEN INSERM UMR 1060 Equipe INFOLIP, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon-Bron, France
| | - Kerry Woolfall
- Institute of Population Health, University of Liverpool, Liverpool, UK
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10
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Gent J, Bullough S, Harrold J, Jackson R, Woolfall K, Andronis L, Kenny L, Cornforth C, Heazell AEP, Benbow E, Alfirevic Z, Sharp A. The PLANES study: a protocol for a randomised controlled feasibility study of the placental growth factor (PlGF) blood test-informed care versus standard care alone for women with a small for gestational age fetus at or after 32 + 0 weeks' gestation. Pilot Feasibility Stud 2020; 6:179. [PMID: 33292754 PMCID: PMC7677818 DOI: 10.1186/s40814-020-00722-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 11/03/2020] [Indexed: 11/10/2022] Open
Abstract
Background Stillbirth remains a major concern across the globe and in some high-resource countries, such as the UK; efforts to reduce the rate have achieved only modest reductions. One third of stillborn babies are small for gestational age (SGA), and these pregnancies are also at risk of neonatal adverse outcomes and lifelong health problems, especially when delivered preterm. Current UK clinical guidance advocates regular monitoring and early term delivery of the SGA fetus; however, the most appropriate regimen for surveillance of these babies remains unclear and often leads to increased intervention for a large number of these women. This pilot trial will determine the feasibility of a large-scale trial refining the risk of adverse pregnancy outcome in SGA pregnancies using biomarkers of placental function sFlt-1/PlGF, identifying and intervening in only those deemed at highest risk of stillbirth. Methods PLANES is a randomised controlled feasibility study of women with an SGA fetus that will be conducted at two tertiary care hospitals in the UK. Once identified on ultrasound, women will be randomised into two groups in a 3:1 ratio in favour of sFlt-1/PlGF ratio led management vs standard care. Women with an SGA fetus and a normal sFlt-1/PlGF ratio will have a repeat ultrasound and sFlt-1/PlGF ratio every 2 weeks with planned birth delayed until 40 weeks. In those women with an SGA fetus and an abnormal sFlt-1/PlGF ratio, we will offer birth from 37 weeks or sooner if there are other concerning features on ultrasound. Women assigned to standard care will have an sFlt-1/PlGF ratio taken, but the results will be concealed from the clinical team, and the woman’s pregnancy will be managed as per the local NHS hospital policy. This integrated mixed method study will also involve a health economic analysis and a perspective work package exploring trial feasibility through interviews and questionnaires with participants, their partners, and clinicians. Discussion Our aim is to determine feasibility through the assessment of our ability to recruit and retain participants to the study. Results from this pilot study will inform the design of a future large randomised controlled trial that will be adequately powered for adverse pregnancy outcome. Such a study would provide the evidence needed to guide future management of the SGA fetus. Trial registration ISRCTN58254381. Registered on 4 July 2019
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Affiliation(s)
- Joanna Gent
- Harris-Wellbeing Research Centre, University of Liverpool, Liverpool, UK
| | - Sian Bullough
- Harris-Wellbeing Research Centre, University of Liverpool, Liverpool, UK
| | - Jane Harrold
- Harris-Wellbeing Research Centre, University of Liverpool, Liverpool, UK
| | - Richard Jackson
- Liverpool Clinical Trials Unit, University of Liverpool, Liverpool, UK
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Lazaros Andronis
- Division of Health Sciences and Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Louise Kenny
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | | | - Alexander E P Heazell
- Maternal and Fetal Research Centre, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, 5th Floor (Research), St Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Emily Benbow
- Harris-Wellbeing Research Centre, University of Liverpool, Liverpool, UK
| | - Zarko Alfirevic
- Harris-Wellbeing Research Centre, University of Liverpool, Liverpool, UK
| | - Andrew Sharp
- Harris-Wellbeing Research Centre, University of Liverpool, Liverpool, UK.
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11
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Roper L, Lyttle MD, Gamble C, Humphreys A, Messahel S, Lee ED, Noblet J, Hickey H, Rainford N, Iyer A, Appleton R, Woolfall K. Seven-step framework to enhance practitioner explanations and parental understandings of research without prior consent in paediatric emergency and critical care trials. Emerg Med J 2020; 38:198-204. [PMID: 32862140 PMCID: PMC7907554 DOI: 10.1136/emermed-2020-209488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/27/2020] [Accepted: 06/24/2020] [Indexed: 11/06/2022]
Abstract
Background Alternatives to prospective informed consent enable the conduct of paediatric emergency and critical care trials. Research without prior consent (RWPC) involves practitioners approaching parents after an intervention has been given and seeking consent for their child to continue in the trial. As part of an embedded study in the ‘Emergency treatment with Levetiracetam or Phenytoin in Status Epilepticus in children’ (EcLiPSE) trial, we explored how practitioners described the trial and RWPC during recruitment discussions, and how well this information was understood by parents. We aimed to develop a framework to assist trial conversations in future paediatric emergency and critical care trials using RWPC. Methods Qualitative methods embedded within the EcLiPSE trial processes, including audiorecorded practitioner–parent trial discussions and telephone interviews with parents. We analysed data using thematic analysis, drawing on the Realpe et al (2016) model for recruitment to trials. Results We analysed 76 recorded trial discussions and conducted 30 parent telephone interviews. For 19 parents, we had recorded trial discussion and interview data, which were matched for analysis. Parental understanding of the EcLiPSE trial was enhanced when practitioners: provided a comprehensive description of trial aims; explained the reasons for RWPC; discussed uncertainty about which intervention was best; provided a balanced description of trial intervention; provided a clear explanation about randomisation and provided an opportunity for questions. We present a seven-step framework to assist recruitment practice in trials involving RWPC. Conclusion This study provides a framework to enhance recruitment practice and parental understanding in paediatric emergency and critical care trials involving RWPC. Further testing of this framework is required.
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Affiliation(s)
- Louise Roper
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Children's Hospital, Bristol, UK.,Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Carrol Gamble
- Clinical Trials Research Centre (CTRC), University of Liverpool, Liverpool, UK
| | - Amy Humphreys
- Clinical Trials Research Centre (CTRC), University of Liverpool, Liverpool, UK
| | - Shrouk Messahel
- Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Elizabeth D Lee
- Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Joanne Noblet
- Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Helen Hickey
- Clinical Trials Research Centre (CTRC), University of Liverpool, Liverpool, UK
| | - Naomi Rainford
- Clinical Trials Research Centre (CTRC), University of Liverpool, Liverpool, UK
| | - Anand Iyer
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Richard Appleton
- Department of Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Kerry Woolfall
- Institute of Population Health, University of Liverpool, Liverpool, UK
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12
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Richards-Belle A, Davis P, Drikite L, Feltbower R, Grieve R, Harrison DA, Lester J, Morris KP, Mouncey PR, Peters MJ, Rowan KM, Sadique Z, Tume LN, Ramnarayan P. FIRST-line support for assistance in breathing in children (FIRST-ABC): a master protocol of two randomised trials to evaluate the non-inferiority of high-flow nasal cannula (HFNC) versus continuous positive airway pressure (CPAP) for non-invasive respiratory support in paediatric critical care. BMJ Open 2020; 10:e038002. [PMID: 32753452 PMCID: PMC7406113 DOI: 10.1136/bmjopen-2020-038002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/12/2020] [Accepted: 06/25/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Even though respiratory support is a common intervention in paediatric critical care, there is no randomised controlled trial (RCT) evidence regarding the effectiveness of two commonly used modes of non-invasive respiratory support (NRS), continuous positive airway pressure (CPAP) and high-flow nasal cannula therapy (HFNC). FIRST-line support for assistance in breathing in children is a master protocol of two pragmatic non-inferiority RCTs to evaluate the clinical and cost-effectiveness of HFNC (compared with CPAP) as the first-line mode of support in critically ill children. METHODS AND ANALYSIS We will recruit participants over a 30-month period at 25 UK paediatric critical care units (paediatric intensive care units/high-dependency units). Patients are eligible if admitted/accepted for admission, aged >36 weeks corrected gestational age and <16 years, and assessed by the treating clinician to require NRS for an acute illness (step-up RCT) or within 72 hours of extubation following a period of invasive ventilation (step-down RCT). Due to the emergency nature of the treatment, written informed consent will be deferred to after randomisation. Randomisation will occur 1:1 to CPAP or HFNC, stratified by site and age (<12 vs ≥12 months). The primary outcome is time to liberation from respiratory support for a continuous period of 48 hours. A total sample size of 600 patients in each RCT will provide 90% power with a type I error rate of 2.5% (one sided) to exclude the prespecified non-inferiority margin of HR of 0.75. Primary analyses will be undertaken separately in each RCT in both the intention-to-treat and per-protocol populations. ETHICS AND DISSEMINATION This master protocol received favourable ethical opinion from National Health Service East of England-Cambridge South Research Ethics Committee (reference: 19/EE/0185) and approval from the Health Research Authority (reference: 260536). Results will be disseminated via publications in peer-reviewed medical journals and presentations at national and international conferences. TRIAL REGISTRATION NUMBER ISRCTN60048867.
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Affiliation(s)
- Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Peter Davis
- Paediatric Intensive Care, Bristol Royal Hospital for Children, Bristol, UK
| | - Laura Drikite
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | - Kevin P Morris
- Paediatric Intensive Care Unit, Birmingham Women's and Children's Hospitals NHS Foundation Trust, Birmingham, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Mark J Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital For Children NHS Trust, London, UK
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Lyvonne N Tume
- School of Health and Society, University of Salford, Salford, Greater Manchester, UK
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital For Children NHS Trust, London, UK
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13
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Peters MJ, Khan I, Woolfall K, Deja E, Mouncey PR, Wulff J, Mason A, Agbeko R, Draper ES, Fenn B, Gould DW, Koelewyn A, Klein N, Mackerness C, Martin S, O'Neill L, Ramnarayan P, Tibby S, Tume L, Watkins J, Thorburn K, Wellman P, Harrison DA, Rowan KM. Different temperature thresholds for antipyretic intervention in critically ill children with fever due to infection: the FEVER feasibility RCT. Health Technol Assess 2020; 23:1-148. [PMID: 30793698 DOI: 10.3310/hta23050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Fever accelerates host immune system control of pathogens but at a high metabolic cost. The optimal approach to fever management and the optimal temperature thresholds used for treatment in critically ill children are unknown. OBJECTIVES To determine the feasibility of conducting a definitive randomised controlled trial (RCT) to evaluate the clinical effectiveness and cost-effectiveness of different temperature thresholds for antipyretic management. DESIGN A mixed-methods feasibility study comprising three linked studies - (1) a qualitative study exploring parent and clinician views, (2) an observational study of the epidemiology of fever in children with infection in paediatric intensive care units (PICUs) and (3) a pilot RCT with an integrated-perspectives study. SETTING Participants were recruited from (1) four hospitals in England via social media (for the FEVER qualitative study), (2) 22 PICUs in the UK (for the FEVER observational study) and (3) four PICUs in England (for the FEVER pilot RCT). PARTICIPANTS (1) Parents of children with relevant experience were recruited to the FEVER qualitative study, (2) patients who were unplanned admissions to PICUs were recruited to the FEVER observational study and (3) children admitted with infection requiring mechanical ventilation were recruited to the FEVER pilot RCT. Parents of children and clinicians involved in the pilot RCT. INTERVENTIONS The FEVER qualitative study and the FEVER observational study had no interventions. In the FEVER pilot RCT, children were randomly allocated (1 : 1) using research without prior consent (RWPC) to permissive (39.5 °C) or restrictive (37.5 °C) temperature thresholds for antipyretics during their PICU stay while mechanically ventilated. MAIN OUTCOME MEASURES (1) The acceptability of FEVER, RWPC and potential outcomes (in the FEVER qualitative study), (2) the size of the potentially eligible population and the temperature thresholds used (in the FEVER observational study) and (3) recruitment and retention rates, protocol adherence and separation between groups and distribution of potential outcomes (in the FEVER pilot RCT). RESULTS In the FEVER qualitative study, 25 parents were interviewed and 56 clinicians took part in focus groups. Both the parents and the clinicians found the study acceptable. Clinicians raised concerns regarding temperature thresholds and not using paracetamol for pain/discomfort. In the FEVER observational study, 1853 children with unplanned admissions and infection were admitted to 22 PICUs between March and August 2017. The recruitment rate was 10.9 per site per month. The majority of critically ill children with a maximum temperature of > 37.5 °C received antipyretics. In the FEVER pilot RCT, 100 eligible patients were randomised between September and December 2017 at a recruitment rate of 11.1 per site per month. Consent was provided for 49 out of 51 participants in the restrictive temperature group, but only for 38 out of 49 participants in the permissive temperature group. A separation of 0.5 °C (95% confidence interval 0.2 °C to 0.8 °C) between groups was achieved. A high completeness of outcome measures was achieved. Sixty parents of 57 children took part in interviews and/or completed questionnaires and 98 clinicians took part in focus groups or completed a survey. Parents and clinicians found the pilot RCT and RWPC acceptable. Concerns about children being in pain/discomfort were cited as reasons for withdrawal and non-consent by parents and non-adherence to the protocol by clinicians. LIMITATIONS Different recruitment periods for observational and pilot studies may not fully reflect the population that is eligible for a definitive RCT. CONCLUSIONS The results identified barriers to delivering the definitive FEVER RCT, including acceptability of the permissive temperature threshold. The findings also provided insight into how these barriers may be overcome, such as by limiting the patient inclusion criteria to invasive ventilation only and by improved site training. A definitive FEVER RCT using a modified protocol should be conducted, but further work is required to agree important outcome measures for clinical trials among critically ill children. TRIAL REGISTRATION The FEVER observational study is registered as NCT03028818 and the FEVER pilot RCT is registered as Current Controlled Trials ISRCTN16022198. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Mark J Peters
- Respiratory, Critical Care and Anaesthesia Unit, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Imran Khan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Kerry Woolfall
- Department of Psychological Sciences, North West Hub for Trials Methodology, University of Liverpool, Liverpool, UK
| | - Elizabeth Deja
- Department of Psychological Sciences, North West Hub for Trials Methodology, University of Liverpool, Liverpool, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Jerome Wulff
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Alexina Mason
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Rachel Agbeko
- Paediatric Intensive Care Unit, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - Doug W Gould
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Abby Koelewyn
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Nigel Klein
- Institute of Child Health, University College London, London, UK
| | - Christine Mackerness
- Paediatric Intensive Care Unit, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sian Martin
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Lauran O'Neill
- Respiratory, Critical Care and Anaesthesia Unit, University College London Great Ormond Street Institute of Child Health, London, UK
| | | | - Shane Tibby
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Lyvonne Tume
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | | | - Kent Thorburn
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Paul Wellman
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
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14
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den Boer MC, Houtlosser M, Foglia EE, Lopriore E, de Vries MC, Engberts DP, Te Pas AB. Deferred consent for delivery room studies: the providers' perspective. Arch Dis Child Fetal Neonatal Ed 2020; 105:310-315. [PMID: 31427459 DOI: 10.1136/archdischild-2019-317280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/22/2019] [Accepted: 08/03/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To gain insight into neonatal care providers' perceptions of deferred consent for delivery room (DR) studies in actual scenarios. METHODS We conducted semistructured interviews with 46 neonatal intensive care unit (NICU) staff members of the Leiden University Medical Center (the Netherlands) and the Hospital of the University of Pennsylvania (USA). At the time interviews were conducted, both NICUs conducted the same DR studies, but differed in their consent approaches. Interviews were audio-recorded, transcribed and analysed using the qualitative data analysis software Atlas.ti V.7.0. RESULTS Although providers reported to regard the prospective consent approach as the most preferable consent approach, they acknowledged that a deferred consent approach is needed for high-quality DR management. However, providers reported concerns about parental autonomy, approaching parents for consent and ethical review of study protocols that include a deferred consent approach. Providers furthermore differed in perceived appropriateness of a deferred consent approach for the studies that were being conducted at their NICUs. Providers with first-hand experience with deferred consent reported positive experiences that they attributed to appropriate communication and timing of approaching parents for consent. CONCLUSION Insight into providers' perceptions of deferred consent for DR studies in actual scenarios suggests that a deferred consent approach is considered acceptable, but that actual usage of the approach for DR studies can be improved on.
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Affiliation(s)
- Maria C den Boer
- Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands .,Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands
| | - Mirjam Houtlosser
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands
| | - Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Enrico Lopriore
- Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Martine Charlotte de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands.,Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dirk P Engberts
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands
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15
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Tume LN, Woolfall K, Arch B, Roper L, Deja E, Jones AP, Latten L, Pathan N, Eccleson H, Hickey H, Parslow R, Preston J, Beissel A, Andrzejewska I, Gale C, Valla FV, Dorling J. Routine gastric residual volume measurement to guide enteral feeding in mechanically ventilated infants and children: the GASTRIC feasibility study. Health Technol Assess 2020; 24:1-120. [PMID: 32458797 DOI: 10.3310/hta24230] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The routine measurement of gastric residual volume to guide the initiation and delivery of enteral feeding is widespread in paediatric intensive care and neonatal units, but has little underlying evidence to support it. OBJECTIVE To answer the question: is a trial of no gastric residual volume measurement feasible in UK paediatric intensive care units and neonatal units? DESIGN A mixed-methods study involving five linked work packages in two parallel arms: neonatal units and paediatric intensive care units. Work package 1: a survey of units to establish current UK practice. Work package 2: qualitative interviews with health-care professionals and caregivers of children admitted to either setting. Work package 3: a modified two-round e-Delphi survey to investigate health-care professionals' opinions on trial design issues and to obtain consensus on outcomes. Work package 4: examination of national databases to determine the potential eligible populations. Work package 5: two consensus meetings of health-care professionals and parents to review the data and agree consensus on outcomes that had not reached consensus in the e-Delphi study. PARTICIPANTS AND SETTING Parents of children with experience of ventilation and tube feeding in both neonatal units and paediatric intensive care units, and health-care professionals working in neonatal units and paediatric intensive care units. RESULTS Baseline surveys showed that the practice of gastric residual volume measurement was very common (96% in paediatric intensive care units and 65% in neonatal units). Ninety per cent of parents from both neonatal units and paediatric intensive care units supported a future trial, while highlighting concerns around possible delays in detecting complications. Health-care professionals also indicated that a trial was feasible, with 84% of staff willing to participate in a trial. Concerns expressed by junior nurses about the intervention arm of not measuring gastric residual volumes were addressed by developing a simple flow chart and education package. The trial design survey and e-Delphi study gained consensus on 12 paediatric intensive care unit and nine neonatal unit outcome measures, and identified acceptable inclusion and exclusion criteria. Given the differences in physiology, disease processes, environments, staffing and outcomes of interest, two different trials are required in the two settings. Database analyses subsequently showed that trials were feasible in both settings in terms of patient numbers. Of 16,222 children who met the inclusion criteria in paediatric intensive care units, 12,629 stayed for > 3 days. In neonatal units, 15,375 neonates < 32 weeks of age met the inclusion criteria. Finally, the two consensus meetings demonstrated 'buy-in' from the wider UK neonatal communities and paediatric intensive care units, and enabled us to discuss and vote on the outcomes that did not achieve consensus in the e-Delphi study. CONCLUSIONS AND FUTURE WORK Two separate UK trials (one in neonatal units and one in paediatric intensive care units) are feasible to conduct, but they cannot be combined as a result of differences in outcome measures and treatment protocols, reflecting the distinctness of the two specialties. TRIAL REGISTRATION Current Controlled Trials ISRCTN42110505. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 23. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Lyvonne N Tume
- School of Health and Society, University of Salford, Salford, UK
| | - Kerry Woolfall
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Barbara Arch
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Louise Roper
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Elizabeth Deja
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Ashley P Jones
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Lynne Latten
- Nutrition and Dietetics, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Helen Eccleson
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Helen Hickey
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | | | - Jennifer Preston
- Department of Women's and Children's Health, Institute of Translational Medicine (Child Health), Alder Hey Children's NHS Foundation Trust, University of Liverpool, Liverpool, UK
| | - Anne Beissel
- Neonatal Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon-Bron, France
| | | | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Frederic V Valla
- Paediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon-Bron, France
| | - Jon Dorling
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
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16
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Woolfall K, O’Hara C, Deja E, Canter R, Khan I, Mouncey P, Carter A, Jones N, Watkins J, Lyttle MD, Tume L, Agbeko R, Tibby SM, Pappachan J, Thorburn K, Rowan KM, Peters MJ, Inwald D. Parents' prioritised outcomes for trials investigating treatments for paediatric severe infection: a qualitative synthesis. Arch Dis Child 2019; 104:1077-1082. [PMID: 31175125 PMCID: PMC6837249 DOI: 10.1136/archdischild-2019-316807] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/22/2019] [Accepted: 05/11/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To identify parents' prioritised outcomes by combining qualitative findings from two trial feasibility studies of interventions for paediatric suspected severe infection. DESIGN Qualitative synthesis combining parent interview data from the Fluids in Shock (FiSh) and Fever feasibility studies. Parents had experience of their child being admitted to a UK emergency department or intensive care unit with a suspected infection. PARTICIPANTS n=: 85 parents. FiSh study: n=41 parents, 37 mothers, 4 fathers, 7 were bereaved. Fever study: n=44 parents, 33 mothers, 11 fathers, 7 were bereaved. RESULTS In addition to survival, parents prioritised short-term outcomes including: organ and physiological functioning (eg, heart rate, breathing rate and temperature); their child looking and/or behaving more like their normal self; and length of time on treatments or mechanical support. Longer term prioritised outcomes included effects of illness on child health and development. We found that parents' prioritisation of outcomes was influenced by their experience of their child's illness, survival and the point at which they are asked about outcomes of importance in the course of their child's illness. CONCLUSIONS Findings provide insight into parent prioritised outcomes to inform the design of future trials investigating treatments for paediatric suspected or proven severe infection as well as core outcome set development work.
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Affiliation(s)
- Kerry Woolfall
- Health Services Research, University of Liverpool, Liverpool, UK
| | - Caitlin O’Hara
- Health Services Research, University of Liverpool, Liverpool, UK
| | - Elizabeth Deja
- Health Services Research, University of Liverpool, Liverpool, UK
| | - Ruth Canter
- Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Imran Khan
- Centre of Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Paul Mouncey
- Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | | | | | | | - Mark David Lyttle
- Emergency Department, University Hospitals Bristol NHS Foundation Trust, Bristol, UK,Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Lyvonne Tume
- Emergency Department, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Rachel Agbeko
- Paediatric Intensive Care, Great North Children’s Hospital, Newcastle upon Tyne, UK
| | - Shane M Tibby
- Department of Paediatric Intensive Care, Evelina Childrens Hospital, Guys St Thomas NHS Foundation Trust, London, UK
| | - John Pappachan
- Paediatric Intensive Care, Southampton Children’s Hospital, Southampton, UK
| | - Kent Thorburn
- Paediatric Intensive Care, Royal Liverpool Childrens Hospital Alder Hey, Liverpool, UK
| | - Kathryn M Rowan
- Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Mark John Peters
- Paediatric Intensive Care, Great Ormond St Hospital NHS Trust, London, UK
| | - David Inwald
- Paediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, UK
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17
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Waterfield T, Lyttle MD, Shields M, Fairley D, Roland D, McKenna J, Woolfall K. Parents' and clinicians' views on conducting paediatric diagnostic test accuracy studies without prior informed consent: qualitative insight from the Petechiae in Children study (PiC). Arch Dis Child 2019; 104:979-983. [PMID: 31175126 DOI: 10.1136/archdischild-2019-317117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/22/2019] [Accepted: 04/25/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The Petechiae in Children (PiC) study assesses the utility of presenting features and rapid diagnostic tests in the diagnosis of serious bacterial infection in feverish children with non-blanching rashes. An embedded qualitative study explored parents' and clinicians' views on the acceptability of the PiC study, including the use of research without prior consent (RWPC) in studies of diagnostic test accuracy. DESIGN Semistructured qualitative interviews. Analysis was thematic and broadly interpretive, informed by the constant comparative approach. PARTICIPANTS Fifteen parents were interviewed 55 (median) days since their child's hospital attendance (range 13-95). Five clinicians involved in recruitment, and consent were interviewed. RESULTS Parents and clinicians supported RWPC for the PiC study and future emergency paediatric diagnostic test accuracy studies as long as there is no harm to the child and emergency care is not delayed. Parents and clinicians made recommendations around the timing and conduct of a consent discussion, which were in line with RWPC guidance. Parents enrolled in the PiC study preferred a design that included consent discussions with the research team over the alternative of 'opt-out' consent only. CONCLUSIONS This embedded qualitative study demonstrates that RWPC is appropriate for use in paediatric emergency studies of diagnostic test accuracy and that the approach used in PiC was appropriate. Future diagnostic studies involving additional invasive procedures or an opt-out only approach to consent would benefit from exploring parent and clinician views on acceptability at the pretrial stage. TRIAL REGISTRATION NUMBER NCT03378258.
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Affiliation(s)
- Thomas Waterfield
- Centre for Experimental Medicine, Wellcome Wolfson Institute of Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, University of the West of England Bristol, Bristol, UK
| | - Michael Shields
- Centre for Experimental Medicine, Wellcome Wolfson Institute of Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Derek Fairley
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Damian Roland
- SAPPHIRE Group, University of Leicester, Leicester, UK
| | - James McKenna
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Kerry Woolfall
- Institute of Population Health and Society, University of Liverpool, Liverpool, UK
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18
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Morin L, Kneyber M, Jansen NJG, Peters MJ, Javouhey E, Nadel S, Maclaren G, Schlapbach LJ, Tissieres P. Translational gap in pediatric septic shock management: an ESPNIC perspective. Ann Intensive Care 2019; 9:73. [PMID: 31254125 PMCID: PMC6598895 DOI: 10.1186/s13613-019-0545-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 06/13/2019] [Indexed: 02/06/2023] Open
Abstract
Background The Surviving Sepsis Campaign and the American College of Critical Care Medicine guidelines have provided recommendations for the management of pediatric septic shock patients. We conducted a survey among the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) members to assess variations to these recommendations. Methods A total of 114 pediatric intensive care physicians completed an electronic survey. The survey consisted of four standardized clinical cases exploring seven clinical scenarios. Results Among the seven different clinical scenarios, the types of fluids were preferentially non-synthetic colloids (albumin) and crystalloids (isotonic saline) and volume expansion was not limited to 60 ml/kg. Early intubation for mechanical ventilation was used by 70% of the participants. Norepinephrine was stated to be used in 94% of the PICU physicians surveyed, although dopamine or epinephrine is recommended as first-line vasopressors in pediatric septic shock. When norepinephrine was used, the addition of another inotrope was frequent. Specific drugs such as vasopressin or enoximone were used in < 20%. Extracorporeal life support was used or considered by 91% of the physicians audited in certain specific situations, whereas the use of high-flow hemofiltration was considered for 44%. Conclusions This pediatric septic shock management survey outlined variability in the current clinician-reported practice of pediatric septic shock management. As most recommendations are not supported by evidence, these findings outline some limitation of existing pediatric guidelines in regard to context and patient’s specificity. Electronic supplementary material The online version of this article (10.1186/s13613-019-0545-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luc Morin
- Pediatric Intensive Care Unit, Bicêtre University Hospital, AP-HP, South Paris University, Le Kremlin-Bicêtre, France
| | - Martin Kneyber
- Pediatric Intensive Care Unit, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands.,Critical Care, Anesthesiology, Peri-operative and Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Nicolaas J G Jansen
- Paediatric Intensive Care Unit, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark J Peters
- Pediatric Intensive Care Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Etienne Javouhey
- Pediatric Intensive Care Unit, Lyon University Hospitals, Hospices Civils de Lyon, Bron, France
| | - Simon Nadel
- Paediatric Intensive Care Unit, Saint-Mary's Hospital, London, UK
| | - Graeme Maclaren
- Department of Pediatrics, Royal Children's Hospital, University of Melbourne, Melbourne, Australia.,Cardiothoracic Intensive Care Unit, National University Health System, Singapore, Singapore
| | - Luregn Jan Schlapbach
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Paediatric Critical Care Research Group, Mater Research Institute, The University of Queensland, Brisbane, Australia.,Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Children's Health Queensland, Brisbane, Australia.,Department of Pediatrics, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Pierre Tissieres
- Pediatric Intensive Care Unit, Bicêtre University Hospital, AP-HP, South Paris University, Le Kremlin-Bicêtre, France. .,Integrative Biology of the Cell, CNRS, CEA, Paris South University, Paris Saclay University, Gif-sur-Yvette, France.
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19
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Inwald DP, Canter R, Woolfall K, Mouncey P, Zenasni Z, O’Hara C, Carter A, Jones N, Lyttle MD, Nadel S, Peters MJ, Harrison DA, Rowan KM. Restricted fluid bolus volume in early septic shock: results of the Fluids in Shock pilot trial. Arch Dis Child 2019; 104:426-431. [PMID: 30087153 PMCID: PMC6557227 DOI: 10.1136/archdischild-2018-314924] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 07/10/2018] [Accepted: 07/15/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine the feasibility of Fluids in Shock, a randomised controlled trial (RCT) of restricted fluid bolus volume (10 mL/kg) versus recommended practice (20 mL/kg). DESIGN Nine-month pilot RCT with embedded mixed-method perspectives study. SETTING 13 hospitals in England. PATIENTS Children presenting to emergency departments with suspected infection and shock after 20 mL/kg fluid. INTERVENTIONS Patients were randomly allocated (1:1) to further 10 or 20 mL/kg fluid boluses every 15 min for up to 4 hours if still in shock. MAIN OUTCOME MEASURES These were based on progression criteria, including recruitment and retention, protocol adherence, separation, potential trial outcome measures, and parent and staff perspectives. RESULTS Seventy-five participants were randomised; two were withdrawn. 23 (59%) of 39 in the 10 mL/kg arm and 25 (74%) of 34 in the 20 mL/kg arm required a single trial bolus before the shock resolved. 79% of boluses were delivered per protocol in the 10 mL/kg arm and 55% in the 20 mL/kg arm. The volume of study bolus fluid after 4 hours was 44% lower in the 10 mL/kg group (mean 14.5 vs 27.5 mL/kg). The Paediatric Index of Mortality-2 score was 2.1 (IQR 1.6-2.7) in the 10 mL/kg group and 2.0 (IQR 1.6-2.5) in the 20 mL/kg group. There were no deaths. Length of hospital stay, paediatric intensive care unit (PICU) admissions and PICU-free days at 30 days did not differ significantly between the groups. In the perspectives study, the trial was generally supported, although some problems with protocol adherence were described. CONCLUSIONS Participants were not as unwell as expected. A larger trial is not feasible in its current design in the UK. TRIAL REGISTRATION NUMBER ISRCTN15244462.
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Affiliation(s)
- David Philip Inwald
- Paediatric Intensive Care Unit, St Mary’s Hospital, Imperial College Healthcare London NHS Trust, London, UK
| | - Ruth Canter
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Kerry Woolfall
- Department of Psychological Sciences, North West Hub for Trials Methodology, University of Liverpool, Liverpool, UK
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Zohra Zenasni
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Caitlin O’Hara
- Department of Psychological Sciences, North West Hub for Trials Methodology, University of Liverpool, Liverpool, UK
| | | | | | - Mark D Lyttle
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK,Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
| | - Simon Nadel
- Paediatric Intensive Care Unit, St Mary’s Hospital, Imperial College Healthcare London NHS Trust, London, UK
| | - Mark J Peters
- Respiratory, Critical Care and Anaesthesia Section, Institute of Child Health, University College London Great Ormond Street, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
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20
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Piehl M, Smith-Ramsey C, Teeter WA. Improving fluid resuscitation in pediatric shock with LifeFlow ®: a retrospective case series and review of the literature. Open Access Emerg Med 2019; 11:87-93. [PMID: 31118839 PMCID: PMC6503651 DOI: 10.2147/oaem.s188110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/28/2019] [Indexed: 11/23/2022] Open
Abstract
Rapid delivery of an intravenous fluid bolus is commonly used in pediatric emergency care for the treatment of shock and hypotension. Early fluid delivery targeted at shock reversal results in improved patient outcomes, yet current methods of fluid resuscitation often limit the ability of providers to achieve fluid delivery goals. We report on the early clinical experience of a new technique for rapid fluid resuscitation. The LifeFlow® infuser is a manually operated device that combines a syringe, automatic check valve, and high-flow tubing set with an ergonomic handle to enable faster and more efficient delivery of fluid by a single health care provider. LifeFlow is currently FDA-cleared for the delivery of crystalloid and colloids. Four cases are presented in which the LifeFlow device was used for emergent fluid resuscitation: a 6-month-old with septic shock, a 2-year-old with intussusception and shock, an 11-year-old with pneumonia and septic shock, and a 15-year-old with trauma and hemorrhagic shock.
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Affiliation(s)
- Mark Piehl
- Department of Pediatrics, Division of Pediatric Critical Care, WakeMed Health and Hospitals, Raleigh, NC, USA.,410 Medical, Inc, Durham, NC, USA.,Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Cherrelle Smith-Ramsey
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - William A Teeter
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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21
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Waterfield T, Lyttle MD, Fairley D, Mckenna J, Woolfall K, Lynn F, Maney JA, Roland D, Weir A, Shields MD. The "Petechiae in children" (PiC) study: evaluating potential clinical decision rules for the management of feverish children with non-blanching rashes, including the role of point of care testing for Procalcitonin & Neisseria meningitidis DNA - a study protocol. BMC Pediatr 2018; 18:246. [PMID: 30060751 PMCID: PMC6065062 DOI: 10.1186/s12887-018-1220-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 07/11/2018] [Indexed: 12/04/2022] Open
Abstract
Background Children commonly present to Emergency Departments (ED) with a non-blanching rash in the context of a feverish illness. While most have a self-limiting viral illness, this combination of features potentially represents invasive serious bacterial infection, including meningococcal septicaemia. A paucity of definitive diagnostic testing creates diagnostic uncertainty for clinicians; a safe approach mandates children without invasive disease are often admitted and treated with broad-spectrum antibiotics. Conversely, a cohort of children still experience significant mortality and morbidity due to late diagnosis. Current management is based on evidence which predates (i) the introduction of meningococcal B and C vaccines and (ii) availability of point of care testing (POCT) for procalcitonin (PCT) and Neisseria meningitidis DNA. Methods This PiC study is a prospective diagnostic accuracy study evaluating (i) rapid POCT for PCT and N. meningitidis DNA and (ii) performance of existing clinical practice guidelines (CPG) for feverish children with non-blanching rash. All children presenting to the ED with a history of fever and non-blanching rash are eligible. Children are managed as normal, with detailed prospective collection of data pertinent to CPGs, and a throat swab and blood used for rapid POCT. The study is running over 2 years and aims to recruit 300 children. Primary objective:Report on the diagnostic accuracy of POCT for (i) N. meningitidis DNA and (ii) PCT in the diagnosis of early MD Report on the diagnostic accuracy of POCT for PCT in the diagnosis of Invasive bacterial infection
Secondary objectives:Evaluate the performance accuracy of existing CPGs Evaluate cost-effectiveness of available diagnostic testing strategies Explore views of (i) families and (ii) clinicians on research without prior consent using qualitative methodology Report on the aetiology of NBRs in children with a feverish illness
Discussion The PiC study will provide important information for policy makers regarding the value of POCT and on the utility and cost of emerging diagnostic strategies. The study will also identify which elements of existing CPGs may merit inclusion in any future study to derive clinical decision rules for this population. Trial registration NCT03378258. Retrospectively registered on December 19, 2017.
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Affiliation(s)
- Thomas Waterfield
- Centre for Experimental Medicine, Wellcome Wolfson Institute of Experimental Medicine, Queen's University Belfast, Belfast, UK.,Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Mark D Lyttle
- Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, UK.,Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Derek Fairley
- Belfast Health and Social Care Trust, Belfast, Northern Ireland.
| | - James Mckenna
- Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Kerry Woolfall
- Psychological Sciences, University of Liverpool, Liverpool, UK
| | - Fiona Lynn
- School of Nursing and Midwifery Centre for Evidence and Social Innovation Queen's University Belfast, Belfast, UK
| | - Julie-Ann Maney
- Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Damian Roland
- SAPPHIRE Group, College of Life Sciences, University of Leicester and Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester, UK
| | - Aoife Weir
- Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Michael D Shields
- Centre for Experimental Medicine, Wellcome Wolfson Institute of Experimental Medicine, Queen's University Belfast, Belfast, UK
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22
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Roper L, Sherratt FC, Young B, McNamara P, Dawson A, Appleton R, Crawley E, Frith L, Gamble C, Woolfall K. Children's views on research without prior consent in emergency situations: a UK qualitative study. BMJ Open 2018; 8:e022894. [PMID: 29886449 PMCID: PMC6009563 DOI: 10.1136/bmjopen-2018-022894] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES We explored children's views on research without prior consent (RWPC) and sought to identify ways of involving children in research discussions. DESIGN Qualitative interview study. SETTING Participants were recruited through a UK children's hospital and online advertising. PARTICIPANTS 16 children aged 7-15 years with a diagnosis of asthma (n=14) or anaphylaxis (n=2) with recent (<12 months) experience of emergency care. RESULTS Children were keen to be included in medical research and viewed RWPC as acceptable in emergency situations if trial interventions were judged safe. Children trusted that doctors would know about their trial participation and act in their best interests. All felt that children should be informed about the research following their recovery and involved in discussions with a clinician or their parent(s) about the use of data already collected as well as continued participation in the trial (if applicable). Participants suggested methods to inform children about their trial participation including an animation. CONCLUSIONS Children supported, and were keen to be involved in, clinical trials in emergency situations. We present guidance and an animation that practitioners and parents might use to involve children in trial discussions following their recovery.
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Affiliation(s)
- Louise Roper
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| | - Frances C Sherratt
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| | - Bridget Young
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| | - Paul McNamara
- Department of Child Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Angus Dawson
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Richard Appleton
- Neurology Department, Alder Hey Children’s Hospital, Liverpool, UK
| | - Esther Crawley
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Lucy Frith
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| | - Carrol Gamble
- Clinical Trials Research Centre (CTRC), University of Liverpool, Liverpool, UK
| | - Kerry Woolfall
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
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23
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Ramnarayan P, Lister P, Dominguez T, Habibi P, Edmonds N, Canter RR, Wulff J, Harrison DA, Mouncey PM, Peters MJ. FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): a multicentre pilot randomised controlled trial of high-flow nasal cannula therapy versus continuous positive airway pressure in paediatric critical care. Crit Care 2018; 22:144. [PMID: 29866165 PMCID: PMC5987627 DOI: 10.1186/s13054-018-2080-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/22/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although high-flow nasal cannula therapy (HFNC) has become a popular mode of non-invasive respiratory support (NRS) in critically ill children, there are no randomised controlled trials (RCTs) comparing it with continuous positive airway pressure (CPAP). We performed a pilot RCT to explore the feasibility, and inform the design and conduct, of a future large pragmatic RCT comparing HFNC and CPAP in paediatric critical care. METHODS In this multi-centre pilot RCT, eligible patients were recruited to either Group A (step-up NRS) or Group B (step-down NRS). Participants were randomised (1:1) using sealed opaque envelopes to either CPAP or HFNC as their first-line mode of NRS. Consent was sought after randomisation in emergency situations. The primary study outcomes were related to feasibility (number of eligible patients in each group, proportion of eligible patients randomised, consent rate, and measures of adherence to study algorithms). Data were collected on safety and a range of patient outcomes in order to inform the choice of a primary outcome measure for the future RCT. RESULTS Overall, 121/254 eligible patients (47.6%) were randomised (Group A 60%, Group B 44.2%) over a 10-month period (recruitment rate for Group A, 1 patient/site/month; Group B, 2.8 patients/site/month). In Group A, consent was obtained in 29/33 parents/guardians approached (87.9%), while in Group B 84/118 consented (71.2%). Intention-to-treat analysis included 113 patients (HFNC 59, CPAP 54). Most reported adverse events were mild/moderate (HFNC 8/59, CPAP 9/54). More patients switched treatment from HFNC to CPAP (Group A: 7/16, 44%; Group B: 9/43, 21%) than from CPAP to HFNC (Group A: 3/13, 23%; Group B: 5/41, 12%). Intubation occurred within 72 h in 15/59 (25.4%) of HFNC patients and 10/54 (18.5%) of CPAP patients (p = 0.38). HFNC patients experienced fewer ventilator-free days at day 28 (Group A: 19.6 vs. 23.5; Group B: 21.8 vs. 22.2). CONCLUSIONS Our pilot trial confirms that, following minor changes to consent procedures and treatment algorithms, it is feasible to conduct a large national RCT of non-invasive respiratory support in the paediatric critical care setting in both step-up and step-down NRS patients. TRIAL REGISTRATION clinicaltrials.gov, NCT02612415 . Registered on 23 November 2015.
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Affiliation(s)
- Padmanabhan Ramnarayan
- Children's Acute Transport Service, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, 26-27 Boswell Street, London, WC1N 3JZ, UK. .,Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK.
| | - Paula Lister
- Paediatric and Neonatal Intensive Care Unit, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Troy Dominguez
- Cardiac Intensive Care Unit, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Parviz Habibi
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Naomi Edmonds
- Paediatric Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Ruth R Canter
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, High Holborn, London, UK
| | - Jerome Wulff
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, High Holborn, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, High Holborn, London, UK
| | - Paul M Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, High Holborn, London, UK
| | - Mark J Peters
- Paediatric and Neonatal Intensive Care Unit, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK.,Respiratory, Critical Care and Anaesthesia Unit, Infection, Immunity and Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK
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24
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Conservative versus liberal oxygenation targets in critically ill children: the randomised multiple-centre pilot Oxy-PICU trial. Intensive Care Med 2018; 44:1240-1248. [PMID: 29868973 DOI: 10.1007/s00134-018-5232-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 05/15/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Oxygen saturation monitoring for children receiving respiratory support is standard worldwide. No randomised clinical trials have compared peripheral oxygen saturation (SpO2) targets for critically ill children. The harm of interventions to raise SpO2 to > 94% may exceed their benefits. METHODS We undertook an open, parallel-group randomised trial of children > 38 weeks completed gestation and < 16 years of age receiving invasive or non-invasive respiratory support and supplemental oxygen who were admitted urgently to one of three paediatric intensive care units. A 'research without prior consent' approach was employed. Children were randomly assigned to a liberal oxygenation group (SpO2 targets > 94%) or a conservative oxygenation group (SpO2 = 88-92% inclusive). Outcomes were measures of feasibility: recruitment rate, protocol adherence and acceptability, between-group separation of SpO2 and safety. The Oxy-PICU trial was registered before recruitment: ClinicalTrials.gov identifier NCT03040570. RESULTS A total of 159 children met the inclusion criteria, of whom 119 (75%) were randomised between April and July 2017, representing a rate of 10 patients per month per site. The mean time to randomisation from first contact with an intensive care team was 1.9 (SD 2.2) h. Consent to continue in the study was obtained in 107 cases (90%); the children's parents/legal representatives were supportive of the consent process. The median (interquartile range, IQR) of time-weighted individual mean SpO2 was 94.9% (92.6-97.1) in the conservative oxygenation group and 97.5% (96.2-98.4) in the liberal group [difference 2.7%, 95% confidence interval (95% CI) 1.3-4.0%, p < 0.001]. Median (IQR) time-weighted individual mean FiO2 was 0.28 (0.24-0.37) in the conservative group and 0.37 (0.30-0.42) in the liberal group (difference 0.08, 95% CI 0.03-0.13, p < 0.001). There were no significant between-group differences in length of stay, duration of organ support or mortality. Two prespecified serious adverse events (cardiac arrests) occurred, both in the liberal oxygenation group. CONCLUSION A definitive clinical trial of peripheral oxygen saturation targets is feasible in critically ill children.
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25
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Gelbart B. Fluid Bolus Therapy in Pediatric Sepsis: Current Knowledge and Future Direction. Front Pediatr 2018; 6:308. [PMID: 30410875 PMCID: PMC6209667 DOI: 10.3389/fped.2018.00308] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 10/01/2018] [Indexed: 12/21/2022] Open
Abstract
Sepsis is a leading cause of morbidity and mortality in children with a worldwide prevalence in pediatric intensive care units of approximately 8%. Fluid bolus therapy (FBT) is a first line therapy for resuscitation of septic shock and has been a recommendation of international guidelines for nearly two decades. The evidence base supporting these guidelines are based on limited data including animal studies and case control studies. In recent times, evidence suggesting harm from fluid in terms of morbidity and mortality have generated interest in evaluating FBT. In view of this, studies of fluid restrictive strategies in adults and children have emerged. The complexity of studying FBT relates to several points. Firstly, the physiological and haemodynamic response to FBT including magnitude and duration is not well described in children. Secondly, assessment of the circulation is based on non-specific clinical signs and limited haemodynamic monitoring with limited physiological targets. Thirdly, FBT exists in a complex myriad of pathophysiological responses to sepsis and other confounding therapies. Despite this, a greater understanding of the role of FBT in terms of the physiological response and possible harm is warranted. This review outlines current knowledge and future direction for FBT in sepsis.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit Royal Children's Hospital, Melbourne, VIC, Australia.,Murdoch Childrens Research Institute, Melbourne, VIC, Australia.,The University of Melbourne, Melbourne, VIC, Australia
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Jones GAL, Ramnarayan P, Raman S, Inwald D, Grocott MPW, Eaton S, Ray S, Griksaitis MJ, Pappachan J, Wiley D, Mouncey PR, Wulff J, Harrison DA, Rowan KM, Peters MJ. Protocol for a randomised pilot multiple centre trial of conservative versus liberal oxygenation targets in critically ill children (Oxy-PICU). BMJ Open 2017; 7:e019253. [PMID: 29247112 PMCID: PMC5736024 DOI: 10.1136/bmjopen-2017-019253] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Optimal targets for systemic oxygenation in paediatric critical illness are unknown. Observational data indicate that high levels of arterial oxygenation are associated with poor outcomes in resuscitation of the newborn and in adult critical illness. Within paediatric intensive care units (PICUs), staff prevent severe hypoxia wherever possible, but beyond this there is no consensus. Practice varies widely with age, diagnosis, treating doctor and local or national guidelines followed, though peripheral blood oxygen saturations (SpO2) of >95% are often targeted. The overall aim of this pilot study is to determine the feasibility of performing a randomised trial in critically ill children comparing current practice of liberal SpO2 targets with a more conservative target. METHODS AND ANALYSIS Oxy-PICU is a pragmatic, open, pilot randomised controlled trial in infants and children requiring mechanical ventilation and receiving supplemental oxygen for abnormal gas exchange accepted for emergency admission to one of three participating UK PICUs. The study groups will be either a conservative SpO2 target of 88%-92% (inclusive) or a liberal SpO2 target of >94%. Infants and children who fulfil all inclusion criteria and none of the exclusion criteria will be randomised 1:1 by a secure web-based system to one of the two groups. Baseline demographics and clinical status will be recorded as well as daily measures of oxygenation and organ support. Discharge outcomes will also be recorded. In addition to observational data, blood and urine samples will be taken to identify biochemical markers of oxidative stress. Outcomes are targeted at assessing study feasibility with a primary outcome of adequate study recruitment (target: 120 participants). ETHICS AND DISSEMINATION The trial received Health Research Authority approval on 1 June 2017 (16/SC/0617). Study findings will be disseminated in national and international conferences and peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03040570.
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Affiliation(s)
- Gareth A L Jones
- Respiratory Critical Care and Anaesthesia Unit, UCL Great Ormond Street Institute of Child Health, London, UK
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital, London, UK
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Sainath Raman
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK
| | - David Inwald
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Michael P W Grocott
- Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Simon Eaton
- Stem Cells and Regenerative Medicine Section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Samiran Ray
- Respiratory Critical Care and Anaesthesia Unit, UCL Great Ormond Street Institute of Child Health, London, UK
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK
| | - Michael J Griksaitis
- Paediatric Intensive Care Unit, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - John Pappachan
- Paediatric Intensive Care Unit, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Daisy Wiley
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, 24 High Holborn, London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, 24 High Holborn, London, UK
| | - Jerome Wulff
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, 24 High Holborn, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, 24 High Holborn, London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, 24 High Holborn, London, UK
| | - Mark J Peters
- Respiratory Critical Care and Anaesthesia Unit, UCL Great Ormond Street Institute of Child Health, London, UK
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK
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