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Objective: To report the performance of clinical practice guidelines (CPG) in the diagnosis of serious/invasive bacterial infections (SBI/IBI) in infants presenting with a fever to emergency care in the UK and Ireland. Two CPGs were from the National Institutes for Health and Care Excellence (NICE guidelines NG51 and NG143) and one was from the British Society for Antimicrobial Chemotherapy (BSAC).Design: Retrospective multicentre cohort study.Patients: Febrile infants aged 90 days or less attending between the 31 August 2018 to 1 September 2019.Main Outcome Measures: The sensitivity, specificity and predictive values of CPGs in identifying SBI and IBI.Setting: Six paediatric Emergency Departments in the UK/Ireland.Results: 555 participants were included in the analysis. The median age was 53 days (IQR 32 to 70), 447 (81%) underwent blood testing and 421 (76%) received parenteral antibiotics. There were five participants with bacterial meningitis (1%), seven with bacteraemia (1%) and 66 (12%) with urinary tract infections. The NICE NG51 CPG was the most sensitive: 1.00 (95% CI 0.95 to 1.00). This was significantly more sensitive than NICE NG143: 0.91 (95% CI 0.82 to 0.96, p=0.0233) and BSAC: 0.82 (95% 0.72 to 0.90, p=0.0005). NICE NG51 was the least specific 0.0 (95% CI 0.0 to 0.01), and this was significantly lower than the NICE NG143: 0.09 (95% CI 0.07 to 0.12, p<0.0001) and BSAC: 0.14 (95% CI 0.1 to 0.17, p<0.0001).Conclusion: None of the studied CPGs demonstrated ideal performance characteristics. CPGs should be improved to guide initial clinical decision making.Trial Registration Number: NCT04196192. [ABSTRACT FROM AUTHOR]

Objective: To describe the epidemiology and aetiology of paediatric traumatic cardiac arrest (TCA) in England and Wales.Design: Population-based analysis of the UK Trauma Audit and Research Network (TARN) database.Patients and Setting: All paediatric and adolescent patients with TCA recorded on the TARN database for a 10-year period (2006-2015).Measures: Patient demographics, Injury Severity Score (ISS), location of TCA ('prehospital only', 'in-hospital only' or 'both'), interventions performed and outcome.Results: 21 710 paediatric patients were included in the database; 129 (0.6%) sustained TCA meeting study inclusion criteria. The majority, 103 (79.8%), had a prehospital TCA. 62.8% were male, with a median age of 11.7 (3.4-16.6) years, and a median ISS of 34 (25-45). 110 (85.3%) had blunt injuries, with road-traffic collision the most common mechanism (n=73, 56.6%). 123 (95.3%) had severe haemorrhage and/or traumatic brain injury. Overall 30-day survival was 5.4% ((95% CI 2.6 to 10.8), n=7). 'Pre-hospital only' TCA was associated with significantly higher survival (n=6) than those with TCA in both 'pre-hospital and in-hospital' (n=1)-13.0% (95% CI 6.1% to 25.7%) and 1.2% (95% CI 0.1% to 6.4%), respectively, p<0.05. The greatest survival (n=6, 10.3% (95% CI 4.8% to 20.8%)) was observed in those transported to a paediatric major trauma centre (MTC) (defined as either a paediatric-only MTC or combined adult-paediatric MTC).Conclusions: Survival is possible from the resuscitation of children in TCA, with overall survival comparable to that reported in adults. The highest survival was observed in those with a pre-hospital only TCA, and those who were transported to an MTC. Early identification and aggressive management of paediatric TCA is advocated. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: The Fluids in Shock (FiSh) Trial proposes to evaluate whether restrictive fluid bolus therapy (10 mL/kg) is more beneficial than current recommended practice (20 mL/kg) in the resuscitation of children with septic shock in the UK. This qualitative feasibility study aimed to explore acceptability of the FiSh Trial, including research without prior consent (RWPC), potential barriers to recruitment and participant information for a pilot trial.Design: Qualitative interview study involving parents of children who had presented to a UK emergency department or been admitted to a paediatric intensive care unit with severe infection in the previous 3 years.Participants: Twenty-one parents (seven bereaved) were interviewed 16 (median) months since their child's hospital admission (range: 1-41).Results: All parents said they would have provided consent for the use of their child's data in the FiSh Trial. The majority were unfamiliar with RWPC, yet supported its use. Parents were initially concerned about the change from currently recommended treatment, yet were reassured by explanations of the current evidence base, fluid bolus therapy and monitoring procedures. Parents made recommendations about the timing of the research discussion and content of participant information. Bereaved parents stated that recruiters should not discuss research immediately after a child's death, but supported a personalised postal 'opt-out' approach to consent.Conclusions: Findings show that parents whose child has experienced severe infection supported the proposed FiSh Trial, including the use of RWPC. Parents' views informed the development of the pilot trial protocol and site staff training.Trial Registration Number: ISRCTN15244462-results. [ABSTRACT FROM AUTHOR]

Objective: Estimating weight is essential in order to prepare appropriate sized equipment and doses of resuscitation drugs in cases where children are critically ill or injured. Many methods exist with varying degrees of complexity and accuracy. The most recent version of the Advanced Paediatric Life Support (APLS) course has changed their teaching from an age-based calculation method to the use of a reference table. We aimed to evaluate the potential implications of this change.Method: Using a bespoke online simulation platform we assessed the ability of acute paediatric staff to apply different methods of weight estimation. Comparing the time taken, rate and magnitude of errors were made using the APLS single and triple age-based formulae, Best Guess and reference table methods. To add urgency and an element of cognitive stress, a time-based competitive component was included.Results: 57 participants performed a total of 2240 estimates of weight. The reference table was the fastest (25 (22-28) vs 35 (31-38) to 48 (43-51) s) and most preferred, but errors were made using all methods. There was no significant difference in the percentage accuracy between methods (93%-97%) but the magnitude of errors made was significantly smaller using the three APLS formulae 10% (6.5-21) compared with reference table (69% (34-133)) mainly from month/year table confusion.Conclusion: In this exploratory study under psychological stress none of the methods of weight estimation were free from error. Reference tables were the fastest method and also had the largest errors and should be designed to minimise the risk of picking errors. [ABSTRACT FROM AUTHOR]