Research

On-going research

  1. Epidemiology of Pediatric Sepsis & septic shock in Asia: Clinical presentations, risk factors, management — collaboration with Pediatric Sepsis Asian collaboration (PEDSAC)
  2. Pediatric acute respiratory distress syndrome (PARDS) Ventilation Bundle [Pilot @ KK Women’s and Children’s Hospital] — ClinicalTrials.gov Identifier: NCT03504176
    PI: Dr Judith Wong, Department of Children’s Intensive Care, KK Women’s and Children’s Hospital
    Study Description: Mortality rates in children with pediatric acute respiratory distress syndrome (PARDS) are higher in Asia compared to other regions. Studies of ventilation practices in Asia showed that the majority of patients with PARDS were being ventilated with high tidal volume, high peak pressure and low PEEP, not in compliance with PALICC recommendations possibly accounting for the increased mortality.
    Aim: To determine if implementing a ventilation bundle comprising PALICC recommendations lowers pediatric intensive care unit (PICU) mortality rates.
    Study Design: The bundle contains a daily checklist for ventilation targets and reference tables listing targeted tidal volumes and end expiratory pressure-fraction of inspired oxygen titration. Applying a before-and-after study design, we will collect data over 18 months, and compare them with the 18 months prior to the implementation. The primary outcome is PARDS mortality, defined as number of deaths out of PARDS cases. Secondary outcomes are feasibility of ventilation bundle implementation, ventilator (VFD) and intensive care unit (IFD) free days and PICU mortality (number of deaths out of PICU admissions). Data from this study will inform if a multi-centre randomized controlled trial is feasible and justified.
  3. Does 3% hypertonic saline decrease mortality and improve long-term neurological outcomes among children with traumatic brain injury?
    PI: Dr Chong Shu Ling, Department of Emergency Medicine, KK Women’s and Children’s Hospital
    Aim: To compare 30-day mortality risk among children < 16 years with moderate to severe TBI treated 3% HTS, compared to mannitol. 
    Study Design: Prospective Observational Study
    Duration: July 2018 – June 2020 (Still OPEN to recruiting sites)
    Inclusion and Exclusion criteria: We will include all children < 16 years with moderate to severe TBI (Glasgow Coma Scale [GCS] ≤ 13) who undergo mechanical ventilation in the PICU of participating PACCMAN centres. 
    Data Collection: Variables defined a priori will be collected on a secure electronic data platform (Redcap) that is designed and maintained by the Singapore Clinical Research Institute (SCRI). Our team research will provide 2-monthly updates on the cases collected and clarify any missing data.
  4. Variation in intensive care practices for moderate to severe traumatic brain injury: A multi-national initiative.
    PI: Dr Chong Shu Ling, Department of Emergency Medicine, KK Women’s and Children’s Hospital
    Aim: To examine the injury epidemiology and outcomes of children presenting with head injuries; To study the variation in the clinical management of pediatric traumatic brain injury (TBI) in pediatric intensive care units (PICUs) across Asia.
    Study Design: Retrospective Observational Stud
    Duration: March 2018 – February 2019 (Still OPEN to recruiting sites)
    Inclusion and Exclusion criteria:
    We will include all children < 16 years old who present within 24 hours of head injury with Glasgow coma scale (GCS) ≤ 13 and admitted to the intensive care unit (ICU).
    We will exclude patients with known coagulopathies, prior neurosurgery, neurological deficits or developmental delay.
    We will also exclude trivial injuries in children whose symptoms resolved and who did not require monitoring or intervention in the ICU.
    Data Collection: Variables defined a priori will be collected on a secure electronic data platform (Redcap) that is designed and maintained by the Singapore Clinical Research Institute (SCRI). Our team research will provide 2-monthly updates on the cases collected and clarify any missing data.

Completed research

  • Risk Stratification in Pediatric Acute Respiratory Distress Syndrome: A Multicenter Observational Study

Study description: The Pediatric Acute Lung Injury Consensus Conference (PALICC) developed a pediatric specific definition for acute respiratory distress syndrome (PARDS). In this definition, severity of lung disease is stratified into mild, moderate and severe groups. We aim to describe the epidemiology of patients with PARDS across Asia and evaluate whether the PALICC risk stratification accurately predicts outcome in PARDS. This is a multicenter, retrospective, descriptive cohort study involving 10 multidisciplinary pediatric intensive care units in Asia.

Main findings: A total of 373 patients had mild [89(23.9%)], moderate [149 (39.9%)] and severe PARDS [135 (36.2%)]. Higher category of severity of PARDS was associated with lower ventilator free days [22 (17, 25), 16 (0, 23), 6 (0, 19); p<0.001 for mild, moderate and severe, respectively] and PICU free days [19 (11, 24), 15 (0, 22), 5 (0, 20); p<0.001 for mild, moderate and severe, respectively]. Overall PICU mortality for PARDS was 113/373 (30.3%), and 100-day mortality was 126/314 (39.7%).  After adjusting for site, presence of comorbidities and severity of illness in the multivariate Cox proportional hazard regression model, patients with moderate [hazard ratio (HR) 1.88, 95% confidence interval (CI): 1.03, 3.45; p=0.039] and severe PARDS [HR 3.18 (95% CI 1.68, 6.02); p<0.001] had higher risk of mortality compared to those with mild PARDS.

  • Differences Between Pulmonary and Extrapulmonary Pediatric Acute Respiratory Distress Syndrome: A Multicenter Analysis

Study description: Pediatric acute respiratory distress syndrome caused by extrapulmonary (PARDSexp) and pulmonary (PARDSp) etiologies is poorly described in the literature. We aimed to describe and compare the epidemiology, risk factors for mortality, and outcomes in PARDSexp and PARDSp. This is a secondary analysis of a multicenter, retrospective, cohort study. Patients were classified into two mutually exclusive groups (PARDSexp and PARDSp) based on etiologies. Primary outcome was pediatric intensive care unit mortality. Cox proportional hazard regression was used to identify risk factors for mortality.

Main findings: Children with PARDSexp had higher admission severity scores, and had a greater proportion of organ dysfunction compared to PARDSp group. Patients in the PARDSexp group had higher mortality (48.8% vs. 24.8%; p = 0.002) and reduced ventilator-free days [median 2.0 (interquartile range 0.0, 18.0) vs. 19.0 (0.5, 24.0) days; p = 0.001] compared to the PARDSp group. However, after adjusting for site, severity of illness, comorbidities, multiorgan dysfunction, and severity of acute respiratory distress syndrome, PARDSexp etiology was not associated with mortality [adjusted hazard ratio 1.56 (95% confidence interval 0.90, 2.71)].