Background: The optimal management of CSF drainage in acute hydrocephalus, in particular when to initiate drain weaning, remains uncertain. This study aimed to evaluate the impact of timing and method of drain weaning on patient outcomes. Methods: This prospective observational study in a large-volume tertiary neuroscience centre included all adult patients who required temporary CSF drainage for acute hydrocephalus of any cause between January 2020 and March 2021. Contemporaneous data collection was conducted, including patient demographics, time to clamp, weaning methods, and clinical outcomes of hospital length of stay (LOS), rate of shunt insertion, drain-related infections, and mechanical complications. Univariate and multivariate statistical analyses were performed to identify the independent associations of timing-related factors. Results: A total of 69 patients were included (mean age = 59.4 years). A total of 59% had CSF diversion for aneurysmal subarachnoid haemorrhage, and 88% had EVD drainage. The length of drainage prior to the first clamp was significantly associated with the overall length of drainage (p < 0.0001), LOS (p = 0.004), and time to shunt (p = 0.02) following multivariate adjustment. For each day delayed in initiating the drain challenge, the overall LOS increased by an additional 1.25 days. There was no association between the weaning method and LOS, the rate of shunting, or CNS infection; however, those in the gradually weaned group had more mechanical complications, such as drain blockage or CSF leakage, than those rapidly weaned (p = 0.03) after adjustment. Discussion: This study recommends challenging the drain early via a rapid wean to reduce LOS, mechanical complications, and possibly infections. The consequences of temporary CSF diversion have significant implications at financial and patient levels, but the quality of evidence regarding weaning remains poor. Further randomised multicentre studies and national databases of practice are required to allow definitive conclusions to be drawn.

Introduction Childhood mortality in the emergency setting is disproportionately high in low-income and middle-income countries (LMIC), with limited research dedicated to improving timely interventions, especially for critically ill children during transport. To perform essential prehospital paediatric research, there is a need for a tailored consent process, which reflects the specific needs and concerns of participants in this challenging research context. Objective The objective is to prospectively investigate stakeholder perceptions and preferences regarding consent processes for a specific paediatric ambulance-based telemedicine trial. Methods Exploratory qualitative study design using face-to-face semistructured interviews and focus group discussions. Data were analysed using thematic analysis. Participants included healthcare providers (paediatric telemedicine physicians and emergency medical technicians) and parents of children who required emergency transportation in Karachi, Pakistan. Results 47 participants, ranging from 19 to 47 years old, were involved in in-depth interviews or focus group discussions. The participants comprised 29 healthcare workers and 18 parents. Among them, 9 were women and 38 were men. Expressing diverse attitudes towards different consent methods, the majority recommended a prospective written informed consent approach to build trust and provide legal protection. Participants understood the situational incapacity that occurs in emergency settings, emphasised the importance of keeping the consent brief and recommended a subsequent contact in 2–3 days after the emergency transport to reconfirm consent and answer any questions. Conclusion Our interpretation of the findings revealed that participants preferred a staged consent process for telemedicine trials in LMIC paediatric emergency settings.

Introduction: Globally, half of all 6.2 million deaths in children are caused by acute illnesses which can be prevented if diagnosed and treated in time. We hypothesise that long elapsed travel time and delay in care can be tackled using telemedicine. The objective of this study is to determine the acceptability of linking ambulances that transport acutely ill children to a remote paediatric emergency physician using a simple audiovisual device. Methods: We conducted a qualitative study to determine the acceptability of ambulance-based teleconsultation for the emergency care of acutely ill children informed by the Theoretical Framework of Acceptability. We developed semistructured guides using this framework and conducted five interviews with telemedicine physicians (TMPs), 18 interviews with parents of children who recently needed an ambulance and four focused groups with emergency medical technicians (EMTs) who transport children. Results: All participants were supportive of using the telemedicine consultation during ambulance transport in the proposed trial as they felt that having access to a video-based physician would offer prompt intervention, particularly for critically ill children in crowded cities and remote regions with scarce resources. Parents believed that ambulance-based telemedicine would enhance their trust in EMTs and reduce their stress. The concerns related to the intervention included parental reluctance in using video cameras due to privacy issues, doubts about doctors’ treatment reliability, risk of miscommunication and inadequate parental education. To address these challenges, the groups proposed solutions such as joint training for EMTs and TMPs, educating parents about intervention processes, improving telecommunication infrastructure and promoting public awareness. Conclusion: Parents, EMTs and TMPs mutually agreed that the use of telemedicine during ambulance transport can be successfully implemented through proper training and is acceptable in our population. All participants agreed that this intervention holds great potential to improve the survival of critically ill children.