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 2014 COI Disclosure (SPECIFIC to this systematic review) EVREV 1 COI#118 Commercial/industry Nil Potential intellectual conflicts Nil EVREV 2 COI#19 Commercial/industry Nil Potential intellectual conflicts Nil

Chicago Treatment Recommendation “Topic not reviewed in 2010”.

Chicago 2014 C2015 PICO Population: Pediatrics & Neonates Intervention: Use of Atropine as premedication in emergency intubation Comparison: No atropine OUTCOMES LEVEL OF IMPORTANCE Likelihood/incidence of cardiac arrestCritical Survival with favorable neurological outcome at survival to  hospital discharge  30 days follow up  90 days follow up  180 days follow up  1 year follow up Critical Likelihood/Incidence of  shock  arrhythmias Important

Chicago 2014 Inclusion/Exclusion & Articles Found List Inclusions/Exclusions PubMed: ( 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 = 54 No Finally Included in Evidence Profile tables = 3 RCTs = 0 Non-RCTs = 3

Chicago 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

Chicago 2014 Risk of Bias in studies

Chicago 2014 Evidence profile table(s)

Chicago 2014 Evidence profile table(s)

Chicago 2014 Proposed 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 ). 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 ( ), Absolute risk reduction = 0.09, 95% CI ( ), 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 2014 Proposed 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 %CI ( ); z=4.362 (p<0.0001); OR %CI ( ), 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): e Pediatric rapid sequence intubation: Incidence of reflex bradycardia and effects of pretreatment with atropine. RK Fastle, MG Roback. Pediatr. Emerg. Care 2004; 20 (10):

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 Nil Specific research required Survival with neurological outcomes RCTs on incidence of Arrhythymias