Chicago 2014

TFQO: Kee-Chong Ng (#COI = 113)EVREV 1: Gene Ong (#COI = 118)EVREV 2: Jos Bruinenberg (#COI = 19)Taskforce: Pediatric Taskforce

The Long Term Effects Of Atropine In Intubating Children

And Infants (Peds 821)

Chicago 2014COI Disclosure (SPECIFIC to this systematic review)

EVREV 1 COI#118Commercial/industry• Nil

Potential intellectual conflicts• Nil

EVREV 2 COI#19Commercial/industry• Nil

Potential intellectual conflicts• Nil

Chicago 20142010 Treatment Recommendation

“Topic not reviewed in 2010”.

Chicago 2014C2015 PICO

Population: Pediatrics & NeonatesIntervention: Use of Atropine as premedication in emergency intubationComparison: No atropine

OUTCOMES LEVEL OF IMPORTANCE

Likelihood/incidence of cardiac arrest CriticalSurvival with favorable neurological outcome at survival to hospital discharge 30 days follow up90 days follow up180 days follow up1 year follow up

Critical

Likelihood/Incidence of shockarrhythmias

Important

Chicago 2014Inclusion/Exclusion& Articles Found

List Inclusions/ExclusionsPubMed: ( Search Completed: April 06, 2014 ) PubMedDate Searched: March 27, 2014Number of Results: 260((((((((("Intubation, Intratracheal"[Mesh:NoExp]) OR intubat*[Title/Abstract])) AND ((Atropine[MeSH Terms]) OR atropine[Title/Abstract]))) AND ((((Infan* OR newborn* OR new-born* OR perinat* OR neonat* OR baby OR baby* OR babies OR toddler* OR minors OR minors* OR boy OR boys OR boyfriend OR boyhood OR girl* OR kid OR kids OR child OR child* OR children* OR schoolchild* OR schoolchild OR school child[tiab] OR school child*[tiab] OR adolescen* OR juvenil* OR youth* OR teen* OR under*age* OR pubescen* OR pediatrics[mh] OR pediatric* OR paediatric* OR peadiatric* OR school[tiab] OR school*[tiab] OR prematur* OR preterm*)))))) NOT (((animals[mh] NOT humans[mh]))))) NOT ((("letter"[pt] OR "comment"[pt] OR "editorial"[pt] or Case Reports[ptyp]))) Embase: ( Search Completed: April 06, 2014 ) EmbaseDate Searched: March 27, 2014Number of Results: 559'respiratory tract intubation'/exp OR intubat*:ab,ti AND ('atropine'/de OR atropine:ab,ti) AND (infan* OR newborn* OR (new NEXT/1 born*):ab,ti OR perinat* OR neonat* OR baby OR baby* OR babies OR toddler* OR minors OR minors* OR boy OR boys OR boyfriend OR boyhood OR girl*i OR kid OR kids OR child OR child* OR children* OR schoolchild OR schoolchild*:ab,ti OR (school NEXT/1 child):ab,ti OR (school NEXT/1 child*):ab,ti OR adolescen* OR juvenil* OR youth* OR teen* OR under*age* OR pubescen* OR 'pediatrics'/exp OR pediatric* OR paediatric* OR peadiatric* OR school:ab,ti OR school*:ab,ti OR prematur* OR preterm*) NOT ('animal'/exp NOT 'human'/exp) NOT ([editorial]/lim OR [letter]/lim OR 'case report'/de) AND [embase]/lim Cochrane: ( Search Completed: April 06, 2014 ) CochraneDate Searched: March 27, 2014Number of Results: 136([mh ^"Intubation, Intratracheal"] OR intubat*:ab,ti) AND ([mh Atropine] OR atropine:ab,ti) AND (Infan* OR newborn* OR “new-born*” OR perinat* OR neonat* OR baby OR baby* OR babies OR toddler* OR minors OR minors* OR boy OR boys OR boyfriend OR boyhood OR girl* OR kid OR kids OR child OR child* OR children* OR schoolchild* OR schoolchild OR “school child”:ab,ti OR “school child*”:ab,ti OR adolescen* OR juvenil* OR youth* OR teen* OR under*age* OR pubescen* OR [mh Pediatrics] OR pediatric* OR paediatric* OR peadiatric* OR school:ab,ti OR school*:ab,ti OR prematur* OR preterm*)

No Articles initially identified = 54No Finally Included in Evidence Profile tables = 3

RCTs = 0 Non-RCTs = 3

Chicago 20142015 Proposed Treatment Recommendations

Recommendations from SEERs

There is “Weak recommendation for the use of atropine as a premedication for emergent intubation for infants and children in relation to outcomes in mortality and/or incidence or likelihood of arrhythmias.”

Chicago 2014 Risk of Bias in studies

SURVIVAL IN PICU

Study Year DesignTotal

PatientsPopulation

Industry Funding

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

2013 Prospective cohort 264

Critically ill children (0-8 years) requiring

emergency RSI intubation; Setting: PICU and Intensive

Care Transport team of Hôpital Robert

Debré, Paris, 4 other PICUs and 5 NICUs in

the Paris Region, France from

September 2007-9

Nil Low Low Unclear Low

Non-RCT bias asssesment

Chicago 2014 Risk of Bias in studies

ARRHYTHYMIAS Arrhy

Study Year DesignTotal

PatientsPopulation

Industry Funding

Elig

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ty C

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Jones P et al. The effect of atropine on rhythm

and conduction disturbances during 322 critical care intubations.

Pediatr Crit Care Med

2013Non-RCT:

Prospective, cohort

322

Critically ill children (0-8 years) requiring emergency RSI

intubation; Setting: PICU and Intensive Care Transport team of

Hôpital Robert Debré, Paris, 4 other PICUs and

5 NICUs in the Paris Region, France.

Nil Low Low Low Low

Fastle RK et al. Pediatric rapid sequence

intubation: incidence of reflex bradycardia and

effects of pretreatment with atropine. Pediatr

Emerg Care

2004Non-RCT:

Retrospective, cohort

143

Critically ill paediatric patients (Day 3 - 19

years) requiring emergency RSI

intubation. Setting: ED at an urban children's hospital from January

1997 to March 2001

Nil Low Low High Low

Non-RCT bias asssesment

Chicago 2014Evidence profile table(s)

1) Author : Gene Ong / KC Ng

Date : 27 Oct 2014

Question : Should atropine be use as premedication in emergency intubation for infants and children?

Settings : Emergency Intubations

Bibliography (Non RCT trial): P Jones, MJ Peters, NP da Costa, T Kurth, C Alberti, K Kessous, N Lode, S Dauger. Atropine for critical care intubation in a cohort of 264 children and reduced mortality unrelated to effects on bradycardia. PLoS ONE 2013; 8 (2): e57478.

Chicago 2014

2) Author : Gene Ong / KC Ng

Date : 27 Oct 2014

Question : Should atropine be use as premedication in emergency intubation for infants and children?

Settings : Emergency intubations

Bibliography (Non-RCT Trials): (Combined analysis)

P Jones, S Dauger, I Denjoy, NP da Costa, C Alberti, R Boulkedid, MJ Peters.The effect of atropine on rhythm and conduction disturbances during 322 critical care intubations. Pediatr Crit Care Med Jul--2013; 14 (6): e289-97.

RK Fastle, MG Roback. Pediatric rapid sequence intubation: Incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr. Emerg. Care 2004; 20 (10): 651-655.

Quality Assessment

No of Patients

Effect

Quality

Importance No of Studies

Study Design

Risk of Bias

Inconsistency Indirectness Imprecisions Other Considerations

RR

(95% CI)

OR

(95% CI)

Incidence of Arrhythymias

2 Non RCT High High Not serious Substantial None 465 0.23 (0.12-0.45)

0.2

(0.1 -0.4)

IMPORTANT

Evidence profile table(s)

Chicago 2014Proposed Consensus on Science statements

Insert Summary statement(s) from SEERs* Critical Outcome : Survival (from PICU)There is only been 1 prospective 2 year observational study involving 264 patients (Yr - 2013).

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).

Relative Risk for unadjusted overall ICU crude mortality = 0.46, 95%CI (0.22-0.97), Absolute risk reduction = 0.09, 95% CI (0.06-0.16), NNT = 11, 95% CI (6-165)

Atropine use was associated with a significant difference in the ICU survival of children more than 28 days of life (p= 0.005) but not neonates (p = 0.57). The excess mortality appear to be associated with children more than 28 days of life with non-neonatal respiratory, cardiac and septic shock.

We did not identify any evidence to address the critical outcome of “neurologically intact survival”.Atropine for critical care intubation in a cohort of 264 children and reduced mortality unrelated to effects on bradycardia. P Jones, MJ Peters, NP da Costa, T Kurth, C Alberti, K Kessous, N Lode, S Dauger. PLoS ONE 2013; 8 (2): e57478.

Chicago 2014Proposed Consensus on Science statements

Insert Summary statement(s) from SEERs*

Important Outcome : Arrhythymias

There were 2 non-RCT trials involving a total of 465 patients. Combining both studies: (N=465), RR 0.23 95%CI (0.12-0.45); z=4.362 (p<0.0001); OR 0.1954 95%CI (0.0962 -0.3969), z=4.516 (p<0.0001).

It would appear that use of atropine is significantly associated with a decreased incidence of bradyarrythymias. However both studies suggest that there was no direct haemodynamic consequence of the arrhythmias.

• The effect of atropine on rhythm and conduction disturbances during 322 critical care intubations. P Jones, S Dauger, I Denjoy, NP da Costa, C Alberti, R Boulkedid, MJ Peters. Pediatr Crit Care Med Jul--2013; 14 (6): e289-97.

• Pediatric rapid sequence intubation: Incidence of reflex bradycardia and effects of pretreatment with atropine. RK Fastle, MG Roback. Pediatr. Emerg. Care 2004; 20 (10): 651-655.

Chicago 2014 Treatment Recommendations

Treatment Recommendations :

We suggest “for the use of atropine as a premedication for emergent intubation for infants and childrenin relation to outcomes in mortality and/or incidence or likelihood of arrhythmias. Weak recommendation - Very low quality of evidence”

Chicago 2014

Knowledge Gaps *DO NOT USE FOR PLENARY* - BREAKOUT ONLY

Other specific systematic review that would be helpful

NilSpecific research required

Survival with neurological outcomes RCTs on incidence of Arrhythymias