Sick babies at risk due to lack of monitoring of breathing tubes

Foy, K. E. et al. |  2018|  Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC‐NIC survey|  Anaesthesia| doi:10.1111/anae.14359

A new article that appears in the current issue of Anaesthesia finds that some special care baby unit may be putting babies health at risk due to breathing tubes not being monitored.

The study reports major gaps in optimal airway management provision in both pediatric intensive care, but particularly in UK neonatal  intensive care units. Wider implementation of waveform capnography is necessary to ensure compliance with the new ‘Never Event’ and has the potential to improve airway management.

The researchers used telephone surveys  from paediatric and neonatal intensive care units across England,  finding that less than half of specialist baby units had the equipment to measure carbon dioxide (capnography) coming from the lungs.

 

Summary

In 2011, the Fourth National Audit Project (NAP4) reported high rates of airway complications in adult intensive care units (ICUs), including death or brain injury, and recommended preparation for airway difficulty, immediately available difficult airway equipment and routine use of waveform capnography monitoring. More than 80% of UK adult intensive care units have subsequently changed practice. Undetected oesophageal intubation has recently been listed as a ‘Never Event’ in UK practice, with capnography mandated. We investigated whether the NAP4 recommendations have been embedded into paediatric and neonatal intensive care practice by conducting a telephone survey of senior medical or nursing staff in UK paediatric intensive care units (PICUs) and neonatal intensive care units (NICUs). Response rates were 100% for paediatric intensive care units and 90% for neonatal intensive care units. A difficult airway policy existed in 67% of paediatric intensive care units and in 40% of neonatal intensive care units; a pre‐intubation checklist was used in 70% of paediatric intensive care units and in 42% of neonatal intensive care units; a difficult intubation trolley was present in 96% of paediatric intensive care units and in 50% of neonatal intensive care units; a videolaryngoscope was available in 55% of paediatric intensive care units and in 29% of neonatal intensive care units; capnography was ‘available’ in 100% of paediatric intensive care units and in 46% of neonatal intensive care units, and ‘always available’ in 100% of paediatric intensive care units and in 18% of neonatal intensive care units. Death or serious harm occurring secondary to complications of airway management in the last 5 years was reported in 19% of paediatric intensive care units and in 26% of neonatal intensive care units. We conclude that major gaps in optimal airway management provision exist in UK paediatric intensive care units and especially in UK neonatal intensive care units. Wider implementation of waveform capnography is necessary to ensure compliance with the new ‘Never Event’ and has the potential to improve airway management.

The full article can be read at Anaesthesia 

In the news:

BBC News Sick babies at risk from lack of breathing tube monitoring

Increasing admissions to paediatric intensive care units in England and Wales: more than just rising a birth rate

Davis P, Stutchfield C, Evans TA, et al. Increasing admissions to paediatric intensive care units in England and Wales: more than just rising a birth rate. Archives of Disease in Childhood Published Online First: 30 October 2017. doi: 10.1136/archdischild-2017-313915

Study noted increasing numbers of admissions to PICUs in England/Wales between 2004 and 2013 is not explained by rising child population and there was no evidence of decrease in admission criteria. Continued increases would present challenging prospect for providers/commissioners

Risk Stratification in Pediatric Acute Respiratory Distress Syndrome

This study aims to describe the epidemiology of patients with PARDS across Asia and evaluate whether the Pediatric Acute Lung Injury Consensus Conference risk stratification accurately predicts outcome in PARDS | Critical Care Medicine

Objectives: The Pediatric Acute Lung Injury Consensus Conference 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 Pediatric Acute Lung Injury Consensus Conference risk stratification accurately predicts outcome in PARDS.

Measurements and Main Results: Data on epidemiology, ventilation, adjunct therapies, and clinical outcomes were collected. Patients were followed for 100 days post diagnosis of PARDS. A total of 373 patients were included. There were 89 (23.9%), 149 (39.9%), and 135 (36.2%) patients with mild, moderate, and severe PARDS, respectively. The most common risk factor for PARDS was pneumonia/lower respiratory tract infection (309 [82.8%]). 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 of 373 (30.3%), and 100-day mortality was 126 of 317 (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, 1.88 [95% CI, 1.03-3.45]; p = 0.039) and severe PARDS (hazard ratio, 3.18 [95% CI, 1.68, 6.02]; p < 0.001) had higher risk of mortality compared with those with mild PARDS.

Conclusions: Mortality from PARDS is high in Asia. The Pediatric Acute Lung Injury Consensus Conference definition of PARDS is a useful tool for risk stratification.

Full reference: Wong, J, J-M. et al. (2017) Risk Stratification in Pediatric Acute Respiratory Distress Syndrome: A Multicenter Observational Study. Critical Care Medicine. Published online: July 26 2017

 

Retrospective cohort study of all deaths among infants born between 22 and 27 completed weeks of gestation

The aim of this research is to assess causes and circumstances of deaths in extremely low gestational age neonates (ELGANs) born in Switzerland over a 3-year period | BMJ Open

Design: Population-based, retrospective cohort study.

Setting: All nine level III perinatal centres (neonatal intensive care units (NICUs) and affiliated obstetrical services) in Switzerland.

Patients: ELGANs with a gestational age (GA) <28 weeks who died between 1 July 2012 and 30 June 2015.

Results: A total of 594 deaths were recorded with 280 (47%) stillbirths and 314 (53%) deaths after live birth. Of the latter, 185 (59%) occurred in the delivery room and 129 (41%) following admission to an NICU. Most liveborn infants dying in the delivery room had a GA ≤24 weeks and died following primary non-intervention. In contrast, NICU deaths occurred following unrestricted life support regardless of GA. End-of-life decision-making and redirection of care were based on medical futility and anticipated poor quality of life in 69% and 28% of patients, respectively. Most infants were extubated before death (87%).

Conclusions: In Switzerland, most deaths among infants born at less than 24 weeks of gestation occurred in the delivery room. In contrast, most deaths of ELGANs with a GA ≥24 weeks were observed following unrestricted provisional intensive care, end-of-life decision-making and redirection of care in the NICU regardless of the degree of immaturity.

Full reference: Berger, T.M. et al. (2017) Retrospective cohort study of all deaths among infants born between 22 and 27 completed weeks of gestation in Switzerland over a 3-year period. BMJ Open. 7:e015179

Transport of the critically ill child

Sarfatti, A. & Ramnarayan, P. Paediatrics and Child Health | Published online: 5 March 2017

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With the centralization of specialist services into a limited number of hospitals across the UK, an increasing number of children require an inter-hospital transfer. In 2014, 6000 critically ill or injured children were transferred between hospitals in the UK. While most of the transfers are done by specialist teams, as many as 23% are done by non-specialist teams.

These patients are some of the sickest children. It is while in transit that these patients are most at risk, and the transferring team is most exposed. To achieve a smooth and safe transfer it is important that the appropriate team with the relevant skills undertakes such transfers. The patient’s condition should be optimised before transfer and any likely difficulties are anticipated, and that the transferring team is prepared to act to resolve any complications swiftly and effectively. In this review we will attempt to offer our approach to the safe transfer of the critically ill child.

Read the abstract here

New blood draw protocol could minimize risk for critically ill children

Checklist-style guidelines decreased unnecessary blood culture collection by nearly half in study

C0009206 Test tubes for collecting blood
Image source: Wellcome Library // CC BY-NC-ND 4.0

Investigators say that safely reducing the frequency of blood draws in hospitalized children with fevers has historically not been a hospital priority despite the stress, pain and high rate of false positives associated with the procedure.

The researchers found that fostering cross-departmental collaboration and offering guidelines to clinicians helped reduce the number of unnecessary blood draws on some of the smallest and most vulnerable patients at the Johns Hopkins Children’s Center. Clinicians were able to accomplish an immediate reduction in unnecessary blood draws using the newly designed checklist protocols, and they were able to sustain the reduction over time.

Read the full overview here

Read the original research abstract here

Supporting Siblings of Neonatal Intensive Care Unit Patients

Morrison, A. & Gullón-Riveraemail, A.L. Journal of Pediatric Nursing. Published online: December 12 2016

life-862967_960_720.jpgHighlights:

  • The article discusses the benefit of a Social Story™ to support siblings as an intervention approach within the NICU.
  • The Social Story™ approach is unique and differs from the formats of current children’s books about NICU.
  • This article provides an example of a NICU Social Story™ ready to implement with siblings of NICU patients.
  • Child Life Specialists can utilize Social Stories™ as educational tool to provide sibling and family support.

Read the abstract here