Sepsis is a leading cause of death and disability in children, globally accounting for more than one million childhood deaths per year. Recommended sepsis treatment currently consists of intravenous antibiotics and aggressive fluid boluses followed by inotropes and consideration for intravenous steroids. However, the evidence for interventions other than antibiotics is limited and aggressive fluid administration may be associated with harm. Therefore, fluid-sparing algorithms using early inotropes to treat shock have been proposed. Another strategy to hasten shock resolution consists in intravenous steroids, alone or in combination with thiamine and vitamin C, postulated to support metabolic dysfunction in recent studies.
In this project, the research team is conducting a randomised controlled pilot trial in children presenting with septic shock. They are assessing the feasibility of a fluid-sparing algorithm using early inotropes and early intravenous administration of Vitamin C, Thiamine and Hydrocortisone and the impact on survival free of organ dysfunction.READ MORE
The question of fluid volume in resuscitation has been identified as the top priority in sepsis research by emergency physicians in the United Kingdom, Australia and New Zealand. Guidelines and sepsis pathways recommend an initial intravenous (IV) fluid bolus of 30ml/kg isotonic crystalloid for patients with sepsis and hypotension. However, there is a lack of evidence from clinical trials to support this strategy. Both observational data as well as randomised studies suggest there may be harm associated with injudicious use of fluids in sepsis. Since there is equipoise regarding a more liberal or restricted fluid volume resuscitation as first line treatment for sepsis-related hypotension, we conducted the pilot multicentre REstricted Fluid REsuscitation in Sepsis-associated Hypotension (REFRESH) trial comparing a restricted fluid protocol with early initiation of vasopressor support against standard guideline care.
The data from REFRESH will inform feasibility of a large, multicentre phase III study. However, further ground work is essential for the optimal design of a Phase III trial that will provide valuable information on feasibility (road test recruitment rate and screening processes) as well as refinement of the protocol (sample size estimation, processes of care, prevalence of the population of interest, real world clinical practice regarding fluid use).
In this ARISE Fluids study, we aim to provide more insight into current practice by conducting a bi-national multi-site prospective observational study of fluid administration in (suspected) sepsis and hypotension in the Emergency Departments of Australia and New Zealand hospitals. Sites have been selected on the basis of having expressed interest in participating in a phase III trial.READ MORE
This study will collect information from the records of 3000 children from 30 hospitals presenting after a head injury in 2016 and will interview staff to look at different factors influencing the care provided. APHIRST-Gap is expected to provided crucial information on scan rates and inform strategies, including national guideline development to standardise and improve the care of children with head injury across Australia and New Zealand.
Head injury is a common reason children present to Emergency Departments in Australia and New Zealand. While most are minor the important issue for emergency clinicians is to determine whether a particular child is at risk of a serious head injury such as a bleed on the brain. A computerised tomography(CT) scan is the investigation of choice to look for these injuries. Its use is not without risks though, including those of sedation, and radiation induced cancer.
Several “rules” have been designed to guide doctors in the decision between risk of injury and risk of scan. The recently published Australasian APHIRST study examined three of these rules in our context. It found that all three rules performed well, clinicians made good judgements on who to scan, and the overall rate of CT scan use was low(10%). APHIRST was limited to 10 large metropolitan, and predominately children specific hospitals. Most children in Australia are not seen in these hospitals. Further research is required to determine whether there is a large variation in scan use between different hospitals and how best to apply these findings to a broader range of hospitals.
This trial is being run by the PREDICT network and the Principal Investigator is A/Prof Franz Babl.READ MORE
Bell’s palsy or acute idiopathic lower motor neurone facial paralysis is characterised by sudden onset paralysis or weakness of the muscles to one side of the face controlled by the facial nerve. It is the third most common neurological reason for children to present acutely to hospital.
In adults, there is conclusive evidence from two major recent trials that a short course of prednisolone, a cheap, widely available and safe steroid, can significantly increase the number of Bell’s palsy patients who completely recover. While the medical problems associated with Bell’s palsy are similar, in children there is no good evidence that prednisolone is an effective treatment.
Many neurological conditions progress differently in children and treatment methods sometimes vary. Children may react differently to prednisolone and without paediatric evidence; treatment guidelines for children with Bell’s palsy remain absent or vague, with variable and overall low rates of steroid use in children by physicians.
The lack of evidence and clinical uncertainty in the treatment of Bell’s palsy in children warrants a definitive trial to determine the efficacy of prednisolone as a treatment for this condition in children. The aim of this study is to assess the utility of steroids in Bell’s palsy in children in a large multicentre randomised, placebo-controlled, trial. The trial will take place in at least 10 hospitals within Australia and New Zealand, involving more than 500 children.READ MORE
Patients with infections are a leading cause of presentations to the Emergency Department (ED), with severe sepsis and infection causing an estimated 20,000 deaths each day across the world. Treatment is aimed at eradicating the infection and supporting the patient while recovery can take place. Frequently patients develop low blood pressure as a result of immune response that can ultimately result in further organ injury (termed septic shock). Intravenous fluids are recommended by international guidelines as the first line therapy in the ED to treat low blood pressure of sepsis with the hope of preventing organ injury and death. Despite 50 years of use in sepsis, the rationale for fluids remains based in theory rather than clear evidence it is effective in saving lives. Disconcertingly, there is now increasing evidence that fluids in sepsis are ineffective and may actually worsen patient survival. Despite this fluids continue to be recommended and used liberally in the ED resulting in conflict between our historical practice and the best evidence.
We have developed an animal model of septic shock and resuscitation in order to test the effectiveness of fluid resuscitation. This will allow us to both understand the true effect but also investigate the underlying physiological mechanisms of any harms.READ MORE
Shortness of breath (dyspnoea) is a terrifying symptom experienced by patients and is a common reason for presentation to Emergency Departments. There are a wide range of causes including flair up due to chronic conditions such as asthma, heart failure, chronic lung disease or liver or kidney failure. Acute conditions such as a collapsed lung, chest infection (including pneumonia), trauma (including fractured ribs), airway blockage or an allergic reaction can also be the cause.
There is significant knowledge about patients who are admitted to hospital with common causes, however there is little conclusive information about Dyspnoea as a symptom, the distribution of causes, the proportion of patients requiring admission and whether treatment complies with evidence-based guidelines.
A recent pilot study in Europe found that 53 per cent of patients had a respiratory cause for symptoms, 22 per cent had a cardiac cause, and 15 per cent had both cardiac and respiratory components. Almost two-thirds were admitted to hospital with over one-third discharged from ED. However, in many ways, the study raised more questions than it answered. The study was also too small to comment on adherence to evidence-based guidelines.
For that reason, a larger EuroDEM (digital elevation model) study is planned for 2014. The study will be complemented by the Australia, Asia and New Zealand Dyspnoea Departments of Emergency Medicine (AANZDEM) which will collect data from a different region with different systems of care. It will focus on the range of causes, variation over seasons and geographical areas, and compliance with recommended treatments.READ MORE
Gastrointestinal (GI) bleeding is a common emergency with a substantial mortality rate. Bleeding from the upper gastrointestinal system is caused by ulcers, stomach inflammation and oesophageal varices and carries a fatality rate of up to 10%. Lower GI bleeding has a variety of causes and a case fatality of about 15%. Between 10% and 25% of patients will have a repeat bleed after their first episode, and these people are four times more likely to die than people without repeated bleeding.
The clotting of blood helps to stem bleeding and blood clot break down may play an important role in GI bleeding and re-bleeding. Tranexamic acid (TXA) is a drug used to reduce clot breakdown. It has been shown to reduce the probability of requiring a blood transfusion by about a third in surgical patients, without causing serious side effects from promoting clotting. This high quality randomised controlled trial will investigate the effectiveness and safety of TXA in GI bleeding.READ MORE