Kevin P Morris

Birmingham Children's Hospital NHS Foundation Trust · Paediatric Intensive Care Unit (PICU)

Background and Aims: Previous trials evaluating remote ischaemic preconditioning in children undergoing cardiac surgery showed mixed results. We sought to determine whether adequately delivered bilateral preconditioning is cardioprotective in young children, with or without cyanosis, undergoing surgery. Methods: Prospective, double-blind, randomise...

Introduction Detection of neurological complications during extracorporeal membrane oxygenation (ECMO) may be enhanced with non-invasive neuro-monitoring. We investigated the feasibility of non-invasive neuro-monitoring in a paediatric intensive care (PIC) setting. Methods In a single centre, prospective cohort study we assessed feasibility of rec...

Importance: The optimal first-line mode of noninvasive respiratory support for acutely ill children is not known. Objective: To evaluate the noninferiority of high-flow nasal cannula therapy (HFNC) as the first-line mode of noninvasive respiratory support for acute illness, compared with continuous positive airway pressure (CPAP), for time to li...

Importance: Diversion of cerebrospinal fluid (CSF) has been used for decades as a treatment for children with severe traumatic brain injury (TBI) and is recommended by evidenced-based guidelines. However, these recommendations are based on limited studies. Objective: To determine whether CSF diversion is associated with improved Glasgow Outcome...

Objective To understand the context and professional perspectives of delivering early rehabilitation and mobilisation (ERM) within UK paediatric intensive care units (PICUs). Design A web-based survey administered from May 2019 to August 2019. Setting UK PICUs. Participants A total of 124 staff from 26 PICUs participated, including 22 (18%) doct...

Importance: The optimal first-line mode of noninvasive respiratory support following extubation of critically ill children is not known. Objective: To evaluate the noninferiority of high-flow nasal cannula (HFNC) therapy as the first-line mode of noninvasive respiratory support following extubation, compared with continuous positive airway press...

Importance: Hyperosmolar agents are cornerstone therapies for pediatric severe traumatic brain injury. Guideline recommendations for 3% hypertonic saline (HTS) are based on limited numbers of patients, and no study to date has supported a recommendation for mannitol. Objectives: To characterize current use of hyperosmolar agents in pediatric sev...

Background: Daily assessment of patient readiness for liberation from invasive mechanical ventilation can reduce the duration of ventilation. However, there is uncertainty about the effectiveness of this in a paediatric population. Objectives: To determine the effect of a ventilation liberation intervention in critically ill children who are antici...

Objectives: To investigate the relationship between ICU admission blood lactate, base excess, and ICU mortality and to explore the effect of incorporating blood lactate into the Pediatric Index of Mortality. Design: Retrospective cohort study based on data prospectively collected on every PICU admission submitted to the U.K. Pediatric Intensive...

Importance There is limited evidence on the optimal strategy for liberating infants and children from invasive mechanical ventilation in the pediatric intensive care unit. Objective To determine if a sedation and ventilator liberation protocol intervention reduces the duration of invasive mechanical ventilation in infants and children anticipated...

Introduction The I-KID study aims to determine the clinical efficacy, outcomes and safety of a novel non-CE-marked infant haemodialysis machine, the Newcastle Infant Dialysis Ultrafiltration System (NIDUS), compared with currently available therapy in the UK. NIDUS is specifically designed for renal replacement therapy in small babies between 0.8 a...

Objective To measure inter- and intra-rater agreement in the interpretation of cortical somatosensory evoked potential (SSEP) components following paediatric cardiac arrest (CA) in multi-professional neurophysiology teams. Methods Thirteen professionals blinded to patient outcome interpreted 96 SSEPs in paediatric patients 24-/48-/72-hours followi...

Purpose: Absent cortical somatosensory evoked potentials (SSEPs) reliably predict poor neurologic outcome in adults after cardiac arrest (CA). However, there is less evidence to support this in children. In addition, targeted temperature management, test timing, and a lack of blinding may affect test accuracy. Methods: A single-center, prospecti...

Background The FIRST-ABC trial comprises of two pragmatic, multicentre, parallel groups, non-inferiority randomised clinical trials designed to evaluate the clinical non-inferiority of first-line use of high flow nasal cannula (HFNC) to continuous positive airway pressure (CPAP) in critically ill children who require non-invasive respiratory suppor...

Objectives: Traumatic brain injury in children is a leading cause of morbidity and mortality. Lack of high-quality evidence may lead to variation in management within and between PICUs. We examined U.K. pediatric traumatic brain injury management guidelines for extent of variability. Design: Analysis of U.K. PICU traumatic brain injury guideline...

Introduction: Myocardial protection against ischaemic-reperfusion injury is a key determinant of heart function and outcome following cardiac surgery in children. However, with current strategies, myocardial injury occurs routinely following aortic cross-clamping, as demonstrated by the ubiquitous rise in circulating troponin. Remote ischaemic pre...

Introduction: Currently, we are unable to accurately predict mortality or neurological morbidity following resuscitation after paediatric out of hospital (OHCA) or in-hospital (IHCA) cardiac arrest. A clinical prediction model may improve communication with parents and families and risk stratification of patients for appropriate postcardiac arrest...

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...

Core Topics in Cardiac Anaesthesia - edited by Joseph Arrowsmith April 2020

Core Topics in Cardiac Anaesthesia - edited by Joseph Arrowsmith April 2020

Objectives: To describe implementation and early evaluation of using quantitative electroencephalography for electrographic seizure detection by PICU clinician staff. Design: Prospective observational study of electrographic seizure detection by PICU clinicians in patients monitored with quantitative electroencephalography. Quantitative electroe...

Background: Pupillary light reflex (PLR) has traditionally been assessed using a pen torch (light). Although the terms "brisk" or "sluggish" are often used, it is unclear what characteristics of the PLR result in this description. More recently, automated infrared pupillometry has enabled us to quantify the different components of a PLR. Methods:...

Objective Prolonged admission to a paediatric intensive care unit (PICU) consumes significant healthcare resource. An increase in the number of long-stay admissions and bed utilisation has been reported elsewhere in the world but not in the UK. If an increasing trend of long-stay admissions is evident, this may have significant implications for pro...

The Full Outline of UnResponsiveness Score (FOUR: range: 0-16) was developed in 2005 to compensate for the shortcomings of the Glasgow Coma Scale (GCS: range 3-15). FOUR includes the ability to assess brainstem reflexes and respiratory pattern instead of verbal responses even in intubated patients (Fig 1). Literature suggests that both scores have...

Introduction Weaning from ventilation is a complex process involving several stages that include recognition of patient readiness to begin the weaning process, steps to reduce ventilation while optimising sedation in order not to induce distress and removing the endotracheal tube. Delay at any stage can prolong the duration of mechanical ventilatio...

OBJECTIVE There is no consensus on the optimal timing and specific brain MRI sequences in the evaluation and management of severe pediatric traumatic brain injury (TBI), and information on current practices is lacking. The authors performed a survey of MRI practices among sites participating in a multicenter study of severe pediatric TBI to provide...

There is interest in the association between partial pressure of carbon dioxide (PCO 2 ) and neurological outcome following cardiac arrest. Extracorporeal life support is increasingly used in the setting of refractory cardiac arrest (ECPR) but there is a lack of standardisation of PCO 2 management during ECPR. We prospectively evaluated CO 2 values...

OBJECTIVES: To identify injury patterns and characteristics associated with severe traumatic brain injury course and outcome, within a well-characterized cohort, which may help guide new research and treatment initiatives. DESIGN: A secondary analysis of a phase 3, randomized, controlled trial that compared therapeutic hypothermia versus normo...

Objectives: The role of venoarterial extracorporeal membrane oxygenation in the treatment of severe pediatric septic shock continues to be intensely debated. Our objective was to determine whether the use of venoarterial extracorporeal membrane oxygenation in severe septic shock was associated with altered patient mortality, morbidity, and/or leng...

Objectives: To identify injury patterns and characteristics associated with severe traumatic brain injury course and outcome, within a well-characterized cohort, which may help guide new research and treatment initiatives. Design: A secondary analysis of a phase 3, randomized, controlled trial that compared therapeutic hypothermia versus normoth...

Abstract OBJECTIVE: To implement a standardized approach to characterize neurologic outcomes among 12-month survivors in the Therapeutic Hypothermia after Pediatric Cardiac Arrest (THAPCA) trials. METHODS: Two multicenter trials enrolled children age 48 hours to 18 years who remained comatose after cardiac arrest (CA) occurring out-of-hospital (THA...

BACKGROUND: Although small series have suggested that younger age is associated with less favorable outcome after severe traumatic brain injury (TBI), confounders and biases have limited our understanding of this relationship. We hypothesized that there would be an association between age and mortality in children within an ongoing observational, c...

Objectives: Although renal replacement therapy is widely used in critically ill children, there have been few comprehensive population-based studies of its use. This article describes renal replacement therapy use, and associated outcomes, in critically ill children across the United Kingdom in the largest cohort study of this patient group. Desi...

Objectives: Validated optimal cerebral perfusion pressure (CPP) treatment thresholds in children do not exist. To improve the intensive care unit (ICU) management of the paediatric traumatic brain injury (TBI) population, we are forming a new paediatric multi-centre collaboration to recruit standardised ICU data for running and reporting upon mode...

The Glasgow Coma Scale (GCS) score has not been validated in children < 5y and the clinical circumstances at the time of assignment can limit its applicability. This study describes the distribution of GCS scores in the population, the relationship between injury characteristics with the GCS score and the association between the tripartite stratifi...

Traumatic brain injury (TBI) is a leading killer of children in the developed and developing world. Despite evidence-based guidelines and several recent clinical trials, the progress in developing best practices for children with severe TBI has been slow. This article describes (i) the burden of the disease, (ii) the inadequacies of the evidence-ba...

OBJECTIVES: Small series have suggested that outcomes after abusive head trauma are less favorable than after other injury mechanisms. We sought to determine the impact of abusive head trauma on mortality and identify factors that differentiate children with abusive head trauma from those with traumatic brain injury from other mechanisms. DESIGN: F...

We performed an online survey regarding critical care treatment preferences for status asthmaticus amongst all public PICU´s in Spain, UK and Ireland (UK-I). One response per centre was required from a senior medical member of staff. Currently, paediatric severe asthma treatment is not homogeneous across European countries; further research to info...

BACKGROUND: Targeted temperature management is recommended for comatose adults and children after out-of-hospital cardiac arrest; however, data on temperature management after in-hospital cardiac arrest are limited. METHODS: In a trial conducted at 37 children's hospitals, we compared two temperature interventions in children who had had in-hospita...

Conclusions: Staff on paediatric intensive care units in the United Kingdom and Ireland tends to treat temperatures within the febrile range. There was a willingness to conduct a randomized controlled trial of treatment of fever. What is known: • The effect of fever on the outcome in paediatric critical illness is unknown. • Paediatricians have tr...

Plain English summary Paediatric Intensive Care (PIC) provides care to extremely ill children. Research in this area can be difficult because children are often too sick to discuss being involved in a study and parents are too upset about their child to think about taking part. This makes it even more important that research is well designed. We co...

OBJECTIVES: Early posttraumatic seizures may contribute to worsened outcomes after traumatic brain injury. Evidence to guide the evaluation and management of early posttraumatic seizures in children is limited. We undertook a survey of current practices of continuous electroencephalographic monitoring, seizure prophylaxis, and the management of ear...

Background Analysis of the ‘weekend effect’ and discussions about ‘seven-day working’ in the NHS are witnessing a resurgence. Funnel plots have been used as the graphical tool of choice to compare institutional performance, but have not been used to compare performance of days of admission so far. Aims Methods We analysed all admissions from 2008–1...

Background and aims Long-stay patients in paediatric intensive care units (PICU) are associated with disproportionately high healthcare resource utilisation and unfavourable outcomes. Increase in long-stay admissions and bed-occupancy have been reported elsewhere but not in the UK. Methods We performed a retrospective analysis of PICU admissions ov...

Objectives: To describe an experience of circuit survival in extracorporeal continuous renal replacement therapy using small-calibre (< 7 French gauge [F]) venous cannulae. Design: An observational study. Setting: A multidisciplinary, university-affiliated PICU. Subjects: Case note review of all continuous renal replacement therapy episodes...

BACKGROUND: Neonates who are in pain or are stressed during care in the intensive care unit (ICU) are often given sedation or analgesia. We investigated the current use of sedation or analgesia in neonatal ICUs (NICUs) in European countries. METHODS: EUROPAIN (EUROpean Pain Audit In Neonates) was a prospective cohort study of the management of seda...

Factors influencing the development of hyperglycemia and pattern of insulin requirement in children undergoing cardiac surgery are poorly understood. This study investigated the impact of age on the pattern of hyperglycemia and insulin requirement in children after cardiac surgery. Cohort study, based on a prospectively collected dataset for patien...

To estimate the prevalence of children admitted after out-of-hospital cardiac arrest (OHCA) to UK and Republic of Ireland (RoI) Paediatric Intensive Care Units (PICUs) and factors associated with mortality to inform future clinical trial feasibility. Observational study using a prospectively collected dataset of the Paediatric Intensive Care Audit...

Aims To describe the characteristics of children resident in England and Wales admitted to a paediatric intensive care unit (PICU) who required prolonged invasive ventilation over the last decade and to compare their demographic and clinical characteristics to those who required a shorter period of invasive ventilation. Methods Clinical and demogr...

It is unknown whether targeted temperature management (TTM) improves survival after paediatric out-of-hospital cardiac arrest (OHCA). The aim of this study was to assess the evolution, safety and efficacy of TTM (32-34°C) compared to standard temperature management (STM) (<38°C). Retrospective, single centre cohort study. Patients aged >one day up...

Background and aims Previous studies have established an association between hyperglycaemia and hyperlactataemia. We investigated the effect of a more intensive blood glucose (BG)/insulin algorithm on blood lactate levels. Methods Children with admission glucose>7mmol/L were recruited into a randomised trial (CHiP) comparing tight glycaemic cont...

Introduction: Absence of N20 response in somatosensory evoked potentials (SSEPs) reliably predicts poor outcome in adults postcardiac arrest (CA). Reliability in children treated with therapeutic hypothermia (TH) is unknown. Objectives: Assess predictive ability of blinded SSEPs for neurological outcome during TH post paediatric CA. Methods: SSEPs...

Increased lactate is commonly seen following cardiac surgery, is associated with hyperglycaemia and does not necessarily reflect worse outcome 1. A previous paediatric RCT suggested lower lactate levels when tight glycaemic control was targeted compared to normal glucose control 2. The mechanism by which insulin lowers lactate levels could relate t...

Introduction Innovative education and learning processes are increasingly important tools to enhance the knowledge and experience of trainees in Paediatric Intensive Care (PIC). Working within the constraints of European working time directives has placed severe restriction on the continuity and overall duration of PIC training. The experience gain...

Early research in adults admitted to intensive care suggested that tight control of blood glucose during acute illness can be associated with reductions in mortality, length of hospital stay and complications such as infection and renal failure. Prior to our study, it was unclear whether or not children could also benefit from tight control of bloo...

Internationally there is no consensus on defining and funding of paediatric high dependency care (HDC). This study tested whether a new UK Healthcare Resource Group (HRG) classification for HDC, with two categories of basic and advanced HDC, can identify children who consume greater staff resource. It also explored the impact of a change in basic H...

The International Liaison Committee for Resuscitation recommends that comatose adult patients with spontaneous circulation after cardiac arrest are cooled to 32-34°C for 12-24 hours based on analysis of data from two randomised controlled trials and 17 observational studies.1 However, these studies were mostly in a specific subgroup of cardiac arre...

Whether an insulin infusion should be used for tight control of hyperglycemia in critically ill children remains unclear. We randomly assigned children (≤16 years of age) who were admitted to the pediatric intensive care unit (ICU) and were expected to require mechanical ventilation and vasoactive drugs for at least 12 hours to either tight glycemi...

OBJECTIVES: To describe the differences in goals for their usual practice for various medical therapies from a number of international centers for children with severe traumatic brain injury. DESIGN: A survey of the goals from representatives of the international centers. SETTING: Thirty-two pediatric traumatic brain injury centers in the United St...

Background: Cardiopulmonary arrest in paediatric patients often results in death or survival with severe brain injury. Therapeutic hypothermia, lowering of the core body temperature to 32°C to 34°C, may reduce injury to the brain in the period after the circulation has been restored. This therapy has been effective in neonates with hypoxic ischaem...

Paediatric trauma is the leading cause of death in children more than 1 year. Traumatic brain injury (TBI) makes up a significant contribution to overall mortality.This paper reviews current and historical evidence for the way these patients are managed. It reflects on the pathophysiological insult and the proposed physiological mechanisms by which...

Objective: Hyperglycaemia is associated with increased mortality in critically ill patients. A number of studies have highlighted an association between increased variability of blood glucose (BG) concentration and mortality, supporting a survival disadvantage if BG homeostasis is lost. By exploring the longitudinal BG profile of individual childr...

Introduction Blood lactate concentration predicts mortality in neonates, infants, children and adults, with evidence that it has better predictive power than other markers of acid–base status such as absolute base excess or pH. Objective To investigate whether blood lactate concentration on admission predicts mortality in paediatric intensive care...

Background There is good evidence that hyperoxia after resuscitation in the newborn period can be detrimental to neurological outcome and survival. The association between hyperoxia and survival after out-of-hospital cardiac arrest (OHCA) in children has not been evaluated. Methods A retrospective, observational study of children admitted to 3 PICU...

Introduction Survival after paediatric out-of-hospital cardiac arrest (OHCA) is poor, even amongst those who are successfully resuscitated and admitted to PICU. Better prediction of survival would be of benefit to clinical teams and to research teams designing trials. This study aimed to identify predictive factors for survival to inform the design...

A Plunkett and colleagues describe a new rota system for implementing consultant delivered care in acute hospital specialties

Children with Down syndrome (DS) have several genetic anomalies within chromosome 21 which may influence their response to critical illness. We compared the intensive care course and outcome of children with DS versus those without. Retrospective cohort study in four English paediatric intensive care units (ICUs) (2003-2009, n = 33,485). We examine...

Since the publication of the first edition of Core Topics in Cardiac Anesthesia, the clinical landscape has undergone significant change. Recent developments include the increased use of electrophysiology, the resurgence of primary percutaneous intervention in acute coronary syndromes, the use of percutaneous devices in patients previously consider...

This chapter highlights the similarities and differences between pediatric and adult cardiac critical care. Routine postoperative care Direct measurement of CO is rarely undertaken in pediatric critical care. If specific problems have been anticipated, direct LA and PA pressure monitoring may have been instituted during surgery. Indirect measures o...

Staged palliation of a functionally univentricular heart A number of lesions are not suitable for a two-ventricle repair and are managed with a series of two or three palliative procedures. Examples include mitral atresia, tricuspid atresia, some forms of pulmonary atresia, double inlet LV and hypoplastic left heart syndrome (HLHS). In the neonatal...