2014

BACKGROUND AND AIMS: Aggressive fluid resuscitation with 0.9% saline is a corner-stone of early management in severe paediatric sepsis. There is emerging evidence for harm from this practice.

Aims: Tis study aimed to describe current emergency physician fluid resuscitation practices for severe paediatric sepsis.

METHODS: A piloted electronic survey was circulated to senior emergency physicians in paediatric and mixed Emergency Departments (EDs) in Australia and New Zealand through the Paediatric Research in Emergency Departments International Collaborative (PREDICT) Network. Human Research and Ethics Committee waived the need for Informed consent. Results: 110 of 120 (92%) senior medical staff responded; 57% of respondents were members of the paediatric college and 43% of the emergency college; 65% worked in a paediatric ED, 35% worked in a mixed ED. 98% of respondents used 0.9% saline as their primary resuscitation fluid. Second line fluids were used by 32% of respondents, most commonly 4% albumin, most commonly following large volume first line fluid administration. 62% of respondents used 20ml/kg for every bolus. Response to fluid bolus administration was based on clinical parameters in all respondents, with 75% also using serum lactate. Harm from fluid bolus administration was not routinely monitored for by 19% of respondents. In those assessing for harm clinical parameters were the most common method.

CONCLUSIONS: Severe paediatric sepsis is managed by senior ED physicians according to published guidelines. At this time emerging evidence for possible harm from large volume fluid resuscitation with 0.9% saline has not altered practice.

BACKGROUND AND OBJECTIVES: There are no effective medications to improve the outcome of infants with bronchiolitis. Studies have shown the management of bronchiolitis to be varied. We set out to describe medication use at the 7 study hospitals from a recent multi-centre randomized controlled trial on hydration in bronchiolitis (Comparative Rehydration in Bronchiolitis (CRIB)).

METHODS: A retrospective analysis of extant data of infants between 2 months (corrected for prematurity) and 12 months of age admitted with bronchiolitis identified through the CRIB trial. CRIB study records and medical records were used to collect data using a standardized form and entered in a single site database. Medications investigated included salbutamol, adrenaline, steroids, ipratropium bromide, normal saline, hypertonic saline, steroids and antibiotics.

RESULTS: There were 3456 available for analysis, of which 42.0% received at least one medication during hospitalization. Medication use varied by site between 27.0% and 48.7%. The most frequently used medication was salbutamol (25.5%). Medication use and salbutamol use increased by 8.2% and 9.3% respectively per month of age after 4 months from 22.9% and 3.6% at 4 months to 81.4% and 68.8% at 11 months. In patients admitted to ICU, 81.6% received medication at one point during the hospital stay and of patients not admitted to ICU, 39.5% received medication.

CONCLUSIONS: Medication is being used frequently and variably in Australia and New Zealand. Medication use and salbutamol use increased with age higher than expected or supported by existing evidence. Thresholds for “trials of salbutamol” should be more closely defined.

BACKGROUND AND OBJECTIVES: Up to 20% of injured children develop persistent posttraumatic stress symptoms that impair functioning and development. ED staff could be key providers of psychosocial care for children and families. Our goals were to examine a) the knowledge and confidence of ED staff in providing psychosocial care, b) differences according to demography, profession, and organisation, and c) training preferences.

METHODS: Based on the Psychological First Aid framework (PFA; The National Child Traumatic Stress Network and the National Center for PTSD, 2006) and international literature, we developed an online survey (35 questions). ED staff were primarily targeted via the Pediatric Emergency Research Network (PERN- North America, Europe & Australasia) but staff from any hospital worldwide were eligible to participate.

RESULTS: So far, 1522 professionals from 63 countries have participated. Most respondents were doctors (60%) and nurses (33%); from urban (79%) or suburban hospitals (16%). While participants’ knowledge of traumatic stress reactions was moderate to good, several areas for improvement (e.g. stress reactions in young children) were identified. Confidence scores varied across the eight elements of PFA and participants differed according to their background characteristics. Several barriers to optimal psychosocial care for children were identified, including lack of time or knowledge, lack of space, and cultural barriers. Over 85% of the participants had not received and 91% wished to participate in training in psychosocial care.

CONCLUSION: Psychosocial care is seen as an important domain of ED care. The survey indicates a range of focal areas for ED staff education.