A twelve-year neonatal and pediatric high-frequency oscillatory ventilation transport experience.

OBJECTIVE: To describe the evolution over a 12-year period of a pediatric intensive care unit transport team's (PICU-TT) experience of pediatric and neonatal interhospital transportation on high-frequency oscillation ventilation (HFOV). METHODS: This was a monocentric retrospective observational study from January 2006 to December 2017. All patients aged under 18 years old who were transported on HFOV by the Robert Debré Hospital PICU-TT were included. RESULTS: Over a 12-year period, 125 patients were transported on HFOV, including 107 newborns and 18 children. Median (range) age and weight were 9 days (1 h-9 years) and 3.3 (0.6-39) kg, respectively. Initial median oxygenation index, SpO2 /FiO2 ratio and mean airway pressure were 32, 91, and 18 cmH2 O, respectively, without significant difference between values before and after transport. Adverse events occurred during 28 transportations (22%) including three recovered cardiac arrests and one death. Overall survival rate at discharge was 74%, 78% in neonates and 56% in pediatrics, respectively. HFOV transportation rate increased over the last four years of the study for neonates and remained stable for older children. Extra-corporeal membrane oxygenation (ECMO) initiation rate on arrival decreased and survival rate increased significantly during the last four years of the study (p < .05). CONCLUSION: This study showed the feasibility of HFOV transportation by a PICU-TT, despite some challenges. A trend towards using ECMO more than HFOV for the most severe respiratory and/or circulatory failures was seen over the 12-year period. The HFOV transportation rate has increased for less severe neonatal patients.

Premedication practices for tracheal intubation in neonates transported by French medical transport teams: a prospective observational study.

OBJECTIVES: Premedication practices for neonatal tracheal intubations have not yet been described for neonatal transport teams. Our objective is to describe the use of sedation/analgesia (SA) for tracheal intubations and to assess its tolerance in neonates transported by medical transport teams in France. SETTING: This prospective observational study was part of the EPIPPAIN 2 project and collected around-the-clock data on SA practices in neonates intubated by all five paediatric medical transport teams of the Paris region during a 2-month period. Intubations were classified as emergent, semiemergent and non-emergent. Sedation level and conditions of intubation were assessed with the Tonus, Reactivity, Awareness and Conditions of intubation to Help in Endotracheal intubation Assessment (TRACHEA score). The scores range from 0 to 10 representing an increasing ladder from adequate to inadequate sedation, and from excellent to very poor conditions of intubation. PARTICIPANTS: 40 neonates intubated in 28 different centres. RESULTS: The mean (SD) age was 34.9 (3.9) weeks, and 62.5% were intubated in the delivery room. 30/40 (75%) of intubations were performed with the use of SA. In 18/30 (60.0%) intubations performed with SA, the drug regimen was the association of sufentanil and midazolam. Atropine was given in 19/40 intubations. From the 16, 21 and 3 intubations classified as emergent, semiemergent and non-emergent, respectively, 8 (50%), 19 (90.5%) and 3 (100%) were performed with SA premedication. 79.3% of intubations performed with SA had TRACHEA scores of 3 or less. 22/40 (55%) infants had at least one of the following adverse events: muscle rigidity, bradycardia below 100/min, desaturation below 80% and nose or pharynx-larynx bleeding. 7/24 (29.2%) of those who had only one attempt presented at least one of these adverse events compared with 15/16 (93.8%) of those who needed two or more attempts (p<0.001). CONCLUSION: SA premedication is largely feasible for tracheal intubations performed in neonates transported by medical transport teams including intubations judged as emergent or semiemergent. TRIAL REGISTRATION NUMBER: NCT01346813; Results.

Pain Assessment in Children Younger Than 8 Years in Out-of-Hospital Emergency Medicine: Reliability and Validity of EVENDOL Score.

OBJECTIVE: Pain in children is underestimated and undertreated in out-of-hospital emergency medicine. In this setting, caregivers need a reliable pain scale, but none has been validated. A single observational pain scale for all children younger than 8 years, EVENDOL, has been validated in emergency pediatric units. We study the feasibility of EVENDOL score in an out-of-hospital emergency setting. METHODS: This prospective multicenter study included all conscious children younger than 8 years transported by a mobile intensive care unit between October 2008 and May 2010. The emergency physician and nurse independently assessed the child's pain using first a numeric rating scale (score 0-10), then the 5-item EVENDOL scale (verbal/vocal expression, facial expression, movements, postures, and relationship with entourage) (score 0-3/item) at 3 time points (at rest, during examination, and after analgesia). We studied the scale's internal validity, interrater reliability, discriminant ability (influence of fever and anxiety), and face validity. RESULTS: Of the 422 included children, 82 and 62 (29%-39%) were in pain according to the emergency physician and nurses (numeric rating scale >3/10). All EVENDOL scale attributes were satisfied at all 3 time points, for all population subsets. Values for the first assessment (entire study population) were as follows: internal validity (0.78-0.89), interrater reliability (r = 0.63-0.76, weighted κ = 0.49-0.65), construct validity, and discriminant ability (r = 0.6-0.7). Fever did not impact on EVENDOL score. Anxiety level and pain were correlated. Completion time was fast (mean, 2.3-3.4 minutes). Face validity was good. CONCLUSION: EVENDOL is a quick, easy-to-use, discriminant instrument to assess pain in young children in out-of-hospital emergency settings.

Atropine for critical care intubation in a cohort of 264 children and reduced mortality unrelated to effects on bradycardia.

BACKGROUND: Atropine has is currently recommended to facilitate haemodynamic stability during critical care intubation. Our objective was to determine whether atropine use at induction influences ICU mortality. METHODOLOGY/PRINCIPAL FINDINGS: A 2-year prospective, observational study of all first non-planned intubations, September 2007-9 in PICU and Intensive Care Transport team of Hôpital Robert Debré, Paris, 4 other PICUs and 5 NICUs in the Paris Region, France. Follow-up was from intubation to ICU discharge. A propensity score was used to adjust for patient specific characteristics influencing atropine prescription. 264/333 (79%) intubations were included. The unadjusted ICU mortality was 7.2% (9/124) for those who received atropine compared to 15.7% (22/140) for those who did not (OR 0.42, 95%CI 0.19-0.95, p=0.04). One child died during intubation (1/264, 0.4%). Two age sub-groups of neonates (≤28 days) and older children (>28 days, <8 years) were examined. This difference in mortality arose from the higher mortality in children aged over one month when atropine was not used (propensity score adjusted OR 0.22, 95%CI 0.06-0.85, p=0.028). No effect was seen in neonates (propensity score adjusted OR 1.3, 95%CI 0.31-5.1 p=0.74). Using the propensity score, atropine maintained the mean heart rate 45.9 bpm above that observed when no atropine was used in neonates (95%CI 34.3-57.5, p<0.001) and 43.5 bpm for older children (95%CI 25.5-61.5 bpm, p<0.001). CONCLUSIONS/SIGNIFICANCE: Atropine use during induction was associated with a reduction in ICU mortality in children over one month. This effect is independent of atropine's capacity to attenuate bradycardia during intubation which occurred similarly in neonates and older children. This result needs to be confirmed in a study using randomised methodology.