Do paediatric early warning systems reduce mortality and critical deterioration events among children? A systematic review and meta-analysis

Aim

We conducted a systematic review and meta-analysis to answer the question: Does the implementation of Paediatric Early Warning Systems (PEWS) in the hospital setting reduce mortality, cardiopulmonary arrests, unplanned codes and critical deterioration events among children, as compared to usual care without PEWS?

Methods

We conducted a comprehensive search using Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Web of Science. We included studies published between January 2006 and April 2022 on children <18 years old performed in inpatient units and emergency departments, and compared patient populations with PEWS to those without PEWS. We excluded studies without a comparator, case control studies, systematic reviews, and studies published in non-English languages. We employed a random effects meta-analysis and synthesised the risk and rate ratios from individual studies. We used the Scottish Intercollegiate Guidelines Network (SIGN) to appraise the risk of bias.

Results

Among 911 articles screened, 15 were included for descriptive analysis. Fourteen of the 15 studies were pre- versus post-implementation studies and one was a multi-centre cluster randomised controlled trial (RCT). Among 10 studies (580,604 hospital admissions) analysed for mortality, we found an increased risk (pooled RR 1.18, 95% CI 1.01–1.38, p = 0.036) in the group without PEWS compared to the group with PEWS. The sensitivity analysis performed without the RCT (436,065 hospital admissions) showed a non-significant relationship (pooled RR 1.17, 95% CI 0.98–1.40, p = 0.087). Among four studies (168,544 hospital admissions) analysed for unplanned code events, there was an increased risk in the group without PEWS (pooled RR 1.73, 95%CI 1.01–2.96, p = 0.046) There were no differences in the rate of cardiopulmonary arrests or critical deterioration events between groups. Our findings were limited by potential confounders and imprecision among included studies.

Conclusions

Healthcare systems that implemented PEWS were associated with reduced mortality and code rates. We recognise that these gains vary depending on resource availability and efferent response systems.

PROSPERO registration: CRD42021269579.

Family presence during resuscitation in paediatric and neonatal cardiac arrest: A systematic review

CONTEXT

Parent/family presence at pediatric resuscitations has been slow to become consistent practice in hospital settings and has not been universally implemented. A systematic review of the literature on family presence during pediatric and neonatal resuscitation has not been previously conducted.

OBJECTIVE

To conduct a systematic review of the published evidence related to family presence during pediatric and neonatal resuscitation.

DATA SOURCES

Six major bibliographic databases was undertaken with defined search terms and including literature up to June 14, 2020.

STUDY SELECTION

3200 titles were retrieved in the initial search; 36 ultimately included for review.

DATA EXTRACTION

Data was double extracted independently by two reviewers and confirmed with the review team. All eligible studies were either survey or interview-based and as such we turned to narrative systematic review methodology.

RESULTS

The authors identified two key sets of findings: first, parents/family members want to be offered the option to be present for their child's resuscitation. Secondly, health care provider attitudes varied widely (ranging from 15% to >85%), however, support for family presence increased with previous experience and level of seniority.

LIMITATIONS

English language only; lack of randomized control trials; quality of the publications.

CONCLUSIONS

Parents wish to be offered the opportunity to be present but opinions and perspectives on the family presence vary greatly among health care providers. This topic urgently needs high quality, comparative research to measure the actual impact of family presence on patient, family and staff outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020140363.

Oxygenation and ventilation targets after cardiac arrest: A systematic review and meta-analysis

AIM

To perform a systematic review and meta-analysis of the literature on oxygenation and ventilation targets after successful resuscitation from cardiac arrest in order to inform an update of international guidelines.

METHODS

The review was performed according to PRISMA and registered on PROSPERO (ID: X). Medline, EMBASE, and the Cochrane Library were searched on August 22, 2019. The population included both adult and pediatric patients with cardiac arrest. Two investigators reviewed abstracts, extracted data, and assessed the risk of bias. Meta-analyses were performed for studies without excessive bias. Certainty of evidence was evaluated using GRADE.

RESULTS

We included 7 trials and 36 observational studies comparing oxygenation or ventilation targets. Most of the trials and observational studies included adults with out-of-hospital cardiac arrest. There were 6 observational studies in children. Bias for trials ranged from low to high risk, with group imbalances and blinding being primary concerns. Bias for observational studies was rated as serious or critical risk with confounding and exposure classification being primary sources of bias. Meta-analyses including two trials comparing low vs high oxygen therapy and two trials comparing hypercapnia vs no hypercapnia were inconclusive. Point estimates of individual studies generally favored normoxemia and normocapnia over hyper- or hypoxemia and hyper- or hypocapnia.

CONCLUSIONS

We identified a large number of studies related to oxygenation and ventilation targets in cardiac arrest. The majority of studies did not reach statistical significance and were limited by excessive risk of bias. Point estimates of individual studies generally favored normoxemia and normocapnia.

Current status of scoliosis school screening: targeted screening of underserved populations may be the solution

OBJECTIVES

The growing body of evidence documenting the effectiveness of brace treatment for scoliosis has renewed interest in potential benefits of early detection through school screening. We aimed to assess the prevalence and identify barriers of screening. We hypothesized that school screening is more frequent in schools that have a nurse on staff compared to schools without nurse on staff.

STUDY DESIGN

A questionnaire survey.

METHODS

All schools located in four counties in Louisiana, United States of America comprising the New Orleans metropolitan area between September 2015 and January 2016 were contacted by phone to assess rates of scoliosis screening, report the availability of a school nurse, and specify barriers if screening was not performed.

RESULTS

Two hundred and ninety-one schools responded to the survey including 152 public, 30 charter, and 109 private schools (101 had religious affiliation). A staff nurse was available in 180 schools (61.8%). Only 21 schools (7.2%) performed scoliosis screening. The majority were charter schools (11 schools), while six were private and four were public (P < 0.0001). Of these 21 schools, 16 (76.2%) had a nurse on staff while five schools did not (P = 0.16). Lack of a referral pathway in the event of a positive screen was the most common barrier to performing scoliosis screening.

CONCLUSION

Scoliosis screening is infrequent in the examined school districts. Efforts to support school screening can facilitate clear referral pathways for schools in the event of a positive screen. These findings suggest a potential need for different pathway of scoliosis screening. Pediatricians and family physicians can assist with scoliosis screening during the annual visit. While universal screening is overburdensome and likely unnecessary, targeted screening of underserved populations may prove to be beneficial. Further investigation should include assessment of the economic viability of targeted screening programs.

LEVEL OF EVIDENCE

IV.

The pharmacokinetics of continuous infusion pralidoxime in children with organophosphate poisoning

OBJECTIVE

To define the pharmacokinetics of continuous infusion pralidoxime in organophosphate-poisoned children.

STUDY DESIGN

Open-label study in 11 children and adolescents poisoned with organophosphates or carbamates. Serial blood samples were obtained during continuous pralidoxime infusion and after the drug was stopped.

RESULTS

Patients were treated for 12-43 hours. Steady-state concentrations were (mean +/- SD) 22.2 +/- 12.3 mg/L. Volume of distribution ranged from 1.7 to 13.8 L/kg and was significantly higher in the more severely poisoned subjects. Elimination half-life was 3.6 +/- 0.8 hours, and clearance was 0.88 +/- 0.55 L/h/kg. After initiation of continuous infusion pralidoxime, only 1 patient required any additional atropine to control recurrent muscarinic symptoms. All patients exhibited complete clinical recovery.

CONCLUSIONS

The pharmacokinetics of pralidoxime in poisoned children following continuous intravenous infusion are widely variable and differ from those previously reported in both healthy and poisoned adults. A loading dose of 25-50 mg/kg is recommended followed by a continuous infusion of 10-20 mg/kg/h. A loading dose of 50 mg/kg may be appropriate in more severely poisoned patients.

Clinical and toxicological findings in two young siblings and autopsy findings in one sibling with multiple hospital admissions resulting in death. Evidence suggesting Munchausen syndrome by proxy

A 15-month-old girl underwent several emergency department (ED) visits and two admissions for parent-reported histories of ingestions, apnea, and seizures. She was initially admitted following reports of several unusual episodes of syncope accompanied by convulsive movements and was discharged on mephobarbital with a diagnosis of atypical seizure disorder. The day after discharge, she was brought to the ED in cardiopulmonary arrest and was resuscitated after a prolonged period. She was declared brain dead 2 days later. Ante- and postmortem toxicology produced several inconclusive findings, none of which explained death. Autopsy findings, including neuropathology, failed to demonstrate any significant disease processes. Approximately 3 months later, a 4-month-old female sibling was brought to the ED with a parent-reported history of apnea and seizures similar to the deceased child. A stool specimen obtained 2 days after admission contained numerous tiny seeds, which were found by gas chromatography-mass spectrometry analysis to contain lorazepam and temazepam. The role of these benzodiazepines in the apnea episodes in this infant was unknown, but the presence of the seeds in such a young infant coupled with the parent's aberrant behavior, led to the tentative diagnosis of Munchausen syndrome by proxy. This diagnosis was strengthened when results from these studies persuaded legal authorities to remove the surviving sibling from the parents, resulting in an asymptomatic recovery.