Improving outcomes for critically ill children on ventilation

Major UK trial greatly improves outcomes for critically ill children on mechanical ventilation: A major UK clinical trial led by Queen’s University Belfast has shown how a new approach to reduce the use of mechanical ventilation can greatly improve outcomes for critically ill infants and children.

The study, funded by the National Institute for Health Research (NIHR) Health Technology Programme, found that a greater involvement of nurses, minimising sedation use and increasing daily testing to assess the child’s readiness to come off the ventilator significantly reduced the time on mechanical ventilation. It is the largest trial of its kind and has already led to changes in practice for two-thirds of the UK paediatric ICUs for the benefit of infants and children.

The clinical trial lead, Bronagh Blackwood, Professor of Critical Care from The Wellcome-Wolfson Institute for Experimental Medicine at Queen’s University Belfast, said: “To minimize the risks associated with mechanical ventilation, the sooner children are weaned off the ventilator, the better their outcomes.

“We have shown that nurse-led care, with daily screening to test for readiness to come off the ventilator and reduced sedation, is safe and greatly improved their chances of getting off the ventilator earlier than before.”

Annually, in the UK, approximately 20,000 infants and children are treated in a paediatric ICU and, of these, around 12,000 receive mechanical ventilation. Mechanical ventilation is a lifesaving therapy but may involve related risk caused by the breathing tube in the mouth and throat, the sedative drugs needed to reduce anxiety, and remaining confined to bed.

The Sedation AND Weaning In CHildren (SANDWICH) trial is the world’s largest trial recruiting infants and children in paediatric Intensive Care Units (ICU). The study involved more than 10,000 admissions to 18 ICUs, accounting for two-thirds of the UK’s paediatric ICUs.

The results have been published in the Journal of American Medical Association.

Compared to the current standard care, the study reported that in children who were expected to be on a ventilator for more than 24 hours, the intervention reduced the time on the mechanical ventilator by an average of six hours. Furthermore, in all children regardless if they were expected to be on a ventilator for more or less than 24 hours, the intervention reduced the ventilation time by an average of seven hours. Overall, the chances of children having their breathing tube removed successfully was greater.

Professor Mark Peters, Consultant in Intensive Care at GOSH and Professor of Paediatric Intensive Care at UCL Great Ormond Street Institute of Child Health, a major partner in the research, said: “This is the largest randomised control trial ever undertaken in paediatric intensive care with more than 10,000 critically ill children taking part – almost 2,000 children at GOSH alone.

“To improve the care of the very sickest children in our hospitals, paediatric intensive care teams from across the UK have come together to put bedside nursing at the heart of decision making and introducing a more structured approach to reducing sedatives and ventilation.

“This trial redefines what is feasible in children’s intensive care research.”

The trial involved training more than 2,000 doctors and nurses in the new SANDWICH intervention. This resulted in a change in practice for two-thirds of the UK paediatric ICUs for the benefit of infants and children. The success of this quality improvement intervention in changing medical and nursing practice is far reaching for other paediatric ICUs world-wide.

Partners include: Alder Hey Hospital; Birmingham Children’s Hospital; Great Ormond Street Hospital; Royal Brompton Hospital; the University of Birmingham; University College London; University of Edinburgh; University of Leeds; University of Salford and the Northern Ireland Clinical Trials Unit.