Complex Paediatric Patients Research Articles

A multidisciplinary approach to managing a missing central incisor, impacted canines and complex medical history: a case report

Hypodontia of a maxillary central incisor is infrequent and can indicate Solitary median maxillary central incisor syndrome. We report on an 11-year-old child with medical comorbidities who presented with hypodontia of a maxillary central incisor, buccally impacted maxillary canines and root resorption of the maxillary lateral incisors. She had previously had dental extractions. Joint orthodontic–paediatric–oral surgery treatment included loss of the maxillary lateral incisors and fixed orthodontic appliances to idealize space for prosthetic replacement of a central incisor. The value of multidisciplinary planning is emphasized and the dental considerations for patients with complex medical histories explored. CPD/Clinical Relevance: The reader should have an understanding of the importance of a joint orthodontic-paediatric-oral surgery approach when managing complex paediatric dental patients.

Appendicitis-related acute referrals to Children’s Health Ireland from Non-Specialist Paediatric Surgical Centres

BackgroundAcute appendicitis is the most common surgical emergency in children. Eighty percent of paediatric appendicectomies are performed by adult general surgeons on an annual basis. The remaining 20% are performed at Children’s Health Ireland (CHI) centres. Occasionally patients are transferred from Non-Specialist Paediatric Surgical Centres (NSPSC) for specialised pre-operative or post-operative care.AimTo assess the rates of and characterise appendicitis-related referrals to CHI at Crumlin from NSPSC.MethodsA retrospective review of all appendicitis-related transfers to CHI at Crumlin between January 2020 and December 2021 was performed. Data relating to indications for transfer, referring hospital level, patient demographics, management, type of surgery, length of stay (LOS), and radiological studies were collected and analysed.ResultsSeventy-two patients were transferred to CHI at Crumlin over the 2-year period. A total of 60.9% were male, mean age 9 ± 4.3 years, mean LOS 6.0 ± 2.2 days (range 1–30 days). Nineteen percent were under 5 years of age. Seventy-three percent were transferred from level 4 centres. Ninety-seven percent were transferred pre-operatively, 25% of those transferred pre-operatively had imaging in CHI confirming appendicitis. Fifty-five percent (40/72) of patients had pre-operative imaging performed. A total of 37.5% (15/40) confirmed complicated appendicitis. Twenty percent (8/40) underwent both ultrasound and computerised tomography (CT) at the referring centre. A total of 2.7% (2/72) were transferred with known co-morbidities. Ninety-two percent (66/72) underwent appendicectomy. Eight percent (6/72) were managed non-operatively (NOM) — 2 failed NOM, 2 underwent interval appendicectomy. Of those managed operatively, 76% (50/66) underwent laparoscopic appendicectomy, and 24% (16/66) were performed open.ConclusionThe majority of paediatric appendicectomies are performed at Non-Specialist Paediatric Surgical Centres. It is vital to maintain this working relationship so that specialist paediatric centres are available to provide care to complex paediatric patients.

Combined otolaryngology and respiratory airway endoscopy for complex paediatric airway patients: A prospective qualitative review of 20 patients.

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Cracking a complex problem

This is the third instalment in a four-part series documenting my journey to better understand, and improve the care of, complex paediatric patients.

Intravesical gentamicin instillation for the treatment and prevention of urinary tract infections in complex paediatric urology patients: evidence for safety and efficacy

Little has been reported to date on the instillation of antimicrobials directly into the bladder in children. Children with complex urinary tract anomalies struggle frequently with recurrent urinary tract infections (UTI), with frequent emergence of antibiotic resistance. Gentamicin bladder instillation to treat and prevent UTI was described in children since 2006. We adopted gentamicin bladder instillation in 2016 and evaluate herein our intermediate-term experience with it. This study is a retrospective review of a prospectively initiated database and a clinical audit of our practice. The gentamicin bladder instillation was employed in 24 cases. A treatment regime was initiated for symptomatic documented UTI when resistance patterns precluded an oral alternative (14 cases), avoiding hospitalisation for parenteral antibiotics. A prophylaxis regime (19 cases-including 9 of the 14 who received an initial treatment regime) followed at least one breakthrough UTI while receiving oral prophylactic antibiotics. Two instillation volumes (8mg gentamicin in 20mL 0.9% NaCl or 20mg gentamicin in 50mL 0.9% NaCl) were used to suit different bladder capacities. The irrigation is given twice a day for 7 days in the treatment regime or once a day, every other day, in the prophylactic regime. Gentamicin serum levels (all cases) and audiology/audiometry testing (17/24 cases) were checked to assess the safety of this method. The median age when either the treatment course or prophylaxis regime was started was 3.8 years. The treatment regime was 86% successful (12/14) to suppress an acute UTI. The mean duration of prophylaxis was 252 days (median: 256 days). The percentage of patients on the prophylactic regime who had no breakthrough UTI was 58%. No serum gentamicin was detectable secondary to the intravesical instillation. No attributable cases of sensorineural hearing loss were detected. Gentamicin resistance emerged in one case (4.16%). Intravesical administration was feasible via various routes for a spectrum of complex lower urinary tract abnormalities (see Summary Figure). Concerns regarding systemic absorption, nephrotoxicity or ototoxicity were investigated and safety ensured. Limitations include being a small series of non-identical pathologies, albeit categorically similar and being a single-arm study, however, statistical significance was proven descriptively and analytically. In selected cases and with the appropriate specialist support and logistics, intravesical gentamicin instillation is well-tolerated and safe to treat and/or prevent urinary tract infections in pateints with complex bladder conditions and lower urinary tract pathologies.

Cracking a complex problem

This is the second instalment in a four-part series documenting my journey to better understand, and improve the care of, complex paediatric patients.

D-Mannose Reduces the Risk of UTI in Complex Paediatric Urology Patients

D-Mannose Reduces the Risk of UTI in Complex Paediatric Urology Patients

Cracking a complex problem

This is the first instalment in a four part series documenting my journey to better understand, and improve the care of, complex paediatric patients.

Tertiary hospital retrospective observational audit of tonsillectomy

ObjectivesTertiary hospitals see a wide array of complex paediatric patients requiring the procedure of tonsillectomy to alleviate airway symptoms. To investigate the implications of patient-specific factors on postoperative morbidities and hospital stay length, including the role of BMI and AH as predictors for airway complications following surgery. MethodsA retrospective chart review was performed for all patients presenting at The Children's Hospital at Westmead for routine tonsillectomy between July 2010 and July 2014. ResultsOf 500 charts, 420 patients met inclusion criteria. 155 (37%) patients had a pre-existing comorbidity. Polysomnogram (PSG) was conducted prior to surgery (n = 129). BMI results showed a mean BMI of 20.0, n = 25 were overweight, n = 70 were obese and n = 11 underweight. 84 patients (20%) experienced a postoperative complication/unexpected morbidity. There were no returns to theatre and no mortality. 24 patients had more than one complication. Complication rate was highest in the patients <2 years of age. There was a statistically significant difference in the number of desaturation related complications between obese and non-obese groups p = 0.00480. There was statistically significant difference in length of hospital stay between the two groups. 16% of children with co-morbidities stayed for >2 nights in hospital (25/155) compared to 7.5% of children without co-morbidities p = 0.00607. 9% of children with co-morbidities stayed for 3 nights in hospital (14/155) compared to patients without co-morbidities (6/256), p = 0.00167. ConclusionsThis audit confirms the impact of age, obesity and certain co-morbidities on the potential costs to the hospital in managing complications and length of stay after surgery.

Testing the Complex Child: CGH Array, WES, Clinical Exome, WGS

Purpose of Review The purpose of this review was to compare existing strategies for evaluation of complex paediatric patients with newer techniques. Comparative genomic hybridization (CGH) array is the currently accepted first tier genetic test in the evaluation of a pediatric patient with complex physical and developmental anomalies. CGH provides an answer in only 15–20 % cases, and further genetic testing is required in the majority of cases. This has previously involved sequential single-gene tests, with low yield, significant costs and delay in diagnosis.

A REVIEW OF THE USE OF THE TRUST'S STANDARD PARENTERAL NUTRITION BAGS FOR PAEDIATRIC PATIENTS

Standardised parenteral nutrition (PN) bags enable the provision of early nutrient supplies as well as having advantages by reducing microbiological contamination and compounding errors1 and their use is recommended by the Paediatric Chief Pharmacists Group.2 Aim To determine the uptake and suitability of the Trust9s current paediatric standard parenteral nutrition bags. Method Data was collected over a six month period from Jan-Jun 2013. Data on the number of bags ordered and wasted and the total volume and quantity of macronutrients was collected. Once the data was evaluated, patients prescribed an individualised bag where one of the current standard bags could have been used were highlighted. For patients who could not receive one of the current standard bags, details of bag volume and macronutrients were plotted on a scatter graph to compare the differences with the current standard bag compositions. Results There were 505 (78%) individualised and 148 (22%) standard bags ordered between Jan and Jun 2013. The high percentage of individualised bags leads to a higher cost to the Trust as the cost of an individualised bag is around £20 more expensive than the average standard bag as well as there being an increased work pressure on pharmacy resources and an increased risk of contamination. There were 54 out-of-date standard bags that were wasted over the data collection period leading to a cost of roughly £1,300. This is due to the poor uptake and the minimum order number for each of the current standard bags. The individualised bag compositions were reviewed and it was identified that only 16 (3%) patients could have received one of the current standard bags. The standard bags are already diluted to a pre-determined volume which was identified as a limiting factor for the complex surgical, gastroenterology and intensive care patients. The current standard bag compositions were based on the European Society for Clinical Nutrition and Metabolism (ESPEN) guidance. During the data collection it was noted that different members of the nutrition team were using either the Ball regimens or the ESPEN guidance, leading to different quantities of the macronutrients being ordered. Conclusion The current set of standard parenteral nutrition bags are not fit for purpose. The issues identified are that the current standard bag volumes limit their use in the more complex paediatric patients and there is no agreed Trust guidance available to assist with macronutrient ordering. The review has led to the development of a new set of standard bags being developed which will be more concentrated to allow for different volumes to be given and the development of Trust guidance on macro and micronutrient provision to enable a higher uptake of the new standard bags and reduce the cost in wastage.

The introduction of web-based video-consultation in a paediatric acute care setting

The Royal Children's Hospital (RCH) in Melbourne has been providing web-based video-consultations for a range of paediatric sub-specialties since 2011. There were 346 video-consultations in the first 16 months, from a total of 65 clinicians. Most teleconsultations were with the family at home. Generally, video-consultation was used for follow-up, after at least one face-to-face visit. A total of 132 users (specialist and regional clinicians, patients and families) responded to an online survey. The major reason for both clinicians and families participating in telehealth was the savings in families' travel time. Key factors for the successful implementation of telehealth at the RCH include: a clear organisational vision; simple web-based technology; clinician ownership; sustained support. The RCH experience suggests that telehealth is suitable for both simple and highly complex paediatric patients.

Teaching old dogs new tricks: A Paediatric Transition to Specialty Program (PTSP) for adult trained nurses in the intensive care unit

Monash Medical Centre is a 21 bed mixed adult and paediatric unit in the South Eastern Suburbs of Melbourne. The hospital caters for a wide range of specialties including cardiothoracic, neurosurgical, obstetrics, general adult and paediatric patients. The recent population growth has prompted the unit to upgrade and enhance the skills of the staff to accommodate the growing neds of the community. Skill mix has played a major role in the past as not all of nurses were trained to look after critically ill paediatric patients. The unit was already running a successful Adult Transition to Specialty Program (TSP) which added positively to skill mix and staff retention. With the pressing need of the unit to cope with the increasing numbers and acuity of paediatric patients that needed ICU management, a PTSP was launched. As a result, there are an increasing number of adult trained nurses who are now clinically competent with complex paediatric patients. The PTSP has created a positive result in terms of both skill and confidence amongst adult trained nurses in the ICU.

Early intervention in complex paediatric patients awaiting discharge with enteral feeding

Early intervention in complex paediatric patients awaiting discharge with enteral feeding

Do diagnosis related groups separate the case‐mix of a specialist children's hospital and a paediatric unit in a general hospital?

The ability of diagnosis related groups (DRG) and refinement diagnosis related groups (RDRG) to measure differences in case-mix was investigated using discharge data for patients < 18 years of age from three specialist children's hospitals and four district hospitals. While the three children's hospitals each had a greater percentage of RDRG for more complex patients, only one children's hospital had more complex patients based on DRG and RDRG cost weights and on the percentage of diagnoses per discharge. Cost weights based on USA practices may be inappropriate in Australia, and Australian weights will be necessary for firm conclusions. Refinement diagnosis related groups with appropriate cost weights may be acceptable measures of case-mix in specialist children's hospitals, but they have inherent limitations for paediatric patients in that many complex paediatric patients are ill very seriously with one disorder, whereas complex adult patients usually have secondary diagnoses and secondary procedures. Moreover, no DRG version developed in the US will be suitable for use in Australia unless it takes account of medical costs and transfer practice.