Children's Intensive Care Research Articles

Evaluation of multidisciplinary simulation training on clinical performance and team behavior during tracheal intubation procedures in a pediatric intensive care unit

Tracheal intubation in the pediatric intensive care unit is often performed in emergency situations with high risks. Simulation has been recognized as an effective methodology to train both technical and teamwork skills. Our objectives were to develop a feasible tool to evaluate team performance during tracheal intubation in the pediatric intensive care unit and to apply the tool in the clinical setting to determine whether multidisciplinary teams with a higher number of simulation-trained providers exhibit more proficient performance. Prospective, observational pilot study. Single tertiary children's hospital pediatric intensive care unit. Pediatric and emergency medicine residents, pediatric intensive care unit nurses, and respiratory therapists from October 2007 to June 2008. A pediatric intensive care unit on-call resident, a pediatric intensive care unit nurse, and a respiratory therapist received simulation-based multidisciplinary airway management training every morning. An assessment tool for team technical and behavioral skills was developed. Independent trained observers rated actual intubations in the pediatric intensive care unit by using this tool. For observer training, two independent raters (research assistants 1 and 2) evaluated a total of 53 training sessions (research assistant 1, 16; research assistant 2, 37). The correlation coefficient with the facilitator expert (surrogate standard) was .73 for research assistant 1 and .88 for research assistant 2 (p ≤ .001 for both) in the total score, .84 for research assistant 1 and .77 for research assistant 2 (p < .001 for both) in the technical domain, and .63 for research assistant 1 (p = .009) and .84 for research assistant 2 (p < .001) in the behavioral domain. The correlation coefficient was lower in video-based observation (.62 vs. .88, on-site). For clinical observation, 15 intubations were observed in real time by raters. The performance by a team with two or more simulation-trained members was rated higher compared with the team with fewer than two trained members (total score: 127 ± 6 vs. 116 ± 9, p = .012, mean ± sd). It is feasible to rate the technical and behavioral performance of multidisciplinary airway management teams during real intensive care unit intubation events by using our assessment tool. The presence of two or more multidisciplinary simulation-trained providers is associated with improved performance during real events.

Factors influencing sleep for parents of critically ill hospitalised children: A qualitative analysis

The aim of this study was to describe factors affecting the sleep of parents of critically ill children and to determine strategies used to improve their sleep. One hundred and eighteen parents of 91 children recruited during their child's paediatric intensive care unit stay responded in writing to open-ended questions assessing their experiences with sleep and eliciting ideas for strategies to promote sleep to be used by parents and provided by hospital staff. Patterns and concepts were coded and organised into themes using a qualitative descriptive approach. Seven themes emerged related to influences on and strategies to improve sleep: (1) the child's condition; (2) being at the bedside or not; (3) difficult thoughts and feelings; (4) changes to usual sleep; (5) caring for self and family; (6) the hospital environment and (7) access to sleep locations. Parents described multiple, often competing, demands that affected their ability to achieve sleep, regardless of location. Many more factors that influenced sleep were described than strategies to improve sleep, highlighting the need for nurses to explore with parents the unique barriers and facilitators to sleep they encounter and to develop and rigorously test interventions to improve sleep.

Successful drainage of a traumatic haemopericardium with pericardiocentesis through an intercostal approach

A case of traumatic haemopericardium, sustained after blunt thoracic trauma, is described in a paediatric patient that was successfully drained by needle pericardiocentesis under 2D-echocardiographic guidance, via an intercostal approach, in the Children's Intensive Care Unit. The patient was haemodynamically unstable with obvious signs of cardiac tamponade. Drainage of the haemopericardium resulted in immediate improvement in haemodynamics. There was no re-accumulation of the haemopericardium. There were no complications as a result of the pericardiocentesis. No further surgical intervention was required.

1445 Introduction of New Children's Intensive Care Ambulances: The Change Process in Action

In February 2010 the South Thames Retrieval service finally took delivery of three new retrieval ambulances. This was the culmination of over 12 months work. We are fortunate to have had an ambulance contract which enables us to have control over the type and internal layout of the vehicles we use for retrievals. In 2008 the ambulance contract once again went out to tender. We seized this opportunity to redesign our ambulance layout looking at new ways of working. We were keen to ensure all parties that used the vehicle were involved in the new design and understood the benefits of the change. Potential new designs were disseminated to all staff and opportunities given for feeding back ideas and suggestions. Following several meetings with the designer our teams agreed on the final internal layout. The vehicles were ready to view in the WAS factory in Germany in November 2009. Two team members went to oversee the vehicles and discussions were had with the design team and engineers relating to some minor adjustments. The ambulances arrived with us in February 2010. They were packed and equipped. Technicians were trained and assessed in driving the new vehicles. Medical and nursing teams were orientated to the ambulances with the aim of smoothing out the transition. The vehicles were launched on the 18th February 2010. Initial feedback was positive. A questionnaire was designed and sent out to all members of the team to formally assess the impact of this change.

Dual-Frequency Active RFID Solution for Tracking Patients in a Children's Hospital. Design Method, Test Procedure, Risk Analysis, and Technical Solution

This work addresses the problem of reliable identification and tracking of children in an intensive care unit in a children's hospital. Tracking and identification of patients are critical for the clinical risk management process, particularly for a children's hospital intensive care unit where patients' identities can easily be confused. This work offers a multilayer approach to the design of the process of identification and tracking; it gives an active radio-frequency identification (RFID) solution that best fits all the given constraints. The paper is divided in the following sections: design (where a multilayer method is provided, including project aims, functional requirements, and technical constraints); risk analysis [a failure modes and effects analysis (FMEA) method is used to assess the risks of each stage of the process of patient management]; technical solution with a specific test phase and a review of the risk analysis results. As a result of the proposed approach, we got a strong coherence between the initial aims and the technical solution, improving patient safety and reducing the clinical risk in the process of tracking and identifying patients.

Continuous hydrocortisone infusion in severe pediatric community‐acquired pneumonia (CAP)

Pediatrics InternationalVolume 52, Issue 3 p. e125-e127 Continuous hydrocortisone infusion in severe pediatric community-acquired pneumonia (CAP) Jan Hau Lee, Corresponding Author Jan Hau Lee Department of Paediatric Subspecialties andJan Hau Lee, MBBS, MRCPCH (UK), 100, Bukit Timah Road, Singapore 229899. Email: [email protected]Search for more papers by this authorTsee Foong Loh, Tsee Foong Loh Children's Intensive Care Unit, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, SingaporeSearch for more papers by this author Jan Hau Lee, Corresponding Author Jan Hau Lee Department of Paediatric Subspecialties andJan Hau Lee, MBBS, MRCPCH (UK), 100, Bukit Timah Road, Singapore 229899. Email: [email protected]Search for more papers by this authorTsee Foong Loh, Tsee Foong Loh Children's Intensive Care Unit, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, SingaporeSearch for more papers by this author First published: 14 June 2010 https://doi.org/10.1111/j.1442-200X.2010.03060.xCitations: 2 Role of authors: Jan Hau Lee, first author of case report and discussion; Tsee Foong Loh, helped write the discussion and review of the case report. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume52, Issue3June 2010Pages e125-e127 RelatedInformation

Parent Stress Levels During Children’s Hospital Recovery After Congenital Heart Surgery

The hospitalization of a child for cardiac surgery is known to be a stressful experience for parents. However, little is known about the time course or the relationships between parental stress and the child's actual or perceived recovery. This research aimed to investigate pre- and postoperative parental stress and to examine some of the influencing factors during the postoperative period for children undergoing elective cardiac surgery. Parents of 211 children completed questionnaires and structured interviews preoperatively and on postoperative days 3, 5, 8, and 15. The stress of the parents remained moderate to high throughout their children's hospitalization regardless of the severity of illness. Parents' perceptions of their children's level of illness correlated with an objective measure of postoperative morbidity. There were few differences between mothers' and fathers' stress or their perceptions of their children's illness. Parents in more deprived communities and mothers born outside the UK had higher stress levels. These findings indicate the negative impact of children's surgery and intensive care hospitalization on parents. Better identification of parents at risk for high stress and specific interventions to improve parental support and coping are needed.

Fatherhood and medicine

Having children will inevitably, to a greater or lesser degree, have a negative impact on a woman doctor's career progression. It is a major challenge to create a working environment which optimises her career progression, and at the same time enables optimal parental care for her children. This is a multi-faceted issue, but the quality of childcare is rarely discussed, except in terms of nursery places and tax deductions. The perspective of the father, and his potential contribution to the sustenance of his wife's career and the welfare of his children, are rarely considered. The woman doctor's perspective as a mother is also put to one side. The major burden of childcare for the foreseeable future will fall on the mother, but the key issue (for parents and administrators) is that the period of intensive childcare is limited and, once complete, both careers can proceed at full pace.

Iatrogenic perinatal pharyngoesophageal injury: A disease of prematurity

Objective Perinatal pharyngoesophageal instrumentation, including endotracheal intubation, oral suctioning, and feeding tube placement, is often necessary but risks tissue damage. Our objective was to estimate the incidence of iatrogenic perinatal pharyngoesophageal injury (IPPI) in preterm versus term infants in a children's hospital neonatal intensive care unit (NICU). A secondary goal was to explore the clinical characteristics and outcomes associated with these complications. Methods All NICU discharge summaries from 2004 to 2008 were searched for IPPI-related keywords. Highlighted records were reviewed and the incidence of complications calculated by gestational age and weight. Results Of 5910 total NICU discharges, 6 cases of IPPI were identified, for an overall incidence of 0.10%. All injuries occurred in infants less than 33 weeks gestational age and 1500 g, with a trend towards higher incidence with increasing prematurity. The incidence of IPPI rose to 4/1321 (0.30%) at 27–32 weeks and 2/521 (0.38%) at less than 27 weeks gestation. Similarly, IPPI occurred in 3/675 (0.44%) babies born at 1000–1500 g and 3/642 (0.47%) babies below 1000 g. All affected infants survived with conservative management. Conclusions IPPI is a rare but serious complication of perinatal airway instrumentation and is primarily a disease of prematurity. In this sizeable cohort, no complications occurred in term infants, and the incidence of injury increased with decreasing gestational age and weight. This increased propensity towards injury should prompt special care when performing even routine airway procedures on premature neonates.

Development of a Quality Measure for the Child Care Service in Regional Level

This paper is to develop a quality measure to evaluate the quality level of child care service in the regional level. By utilizing the biannual intensive child care statistical reports, ten variables are integrated and summarized as a quality measure for child care service in regional level by employing Principal Component Analysis (PCA). Conclusively, it is possible to get a comprehensive measure and the measure obtained from data between 2003 and 2008 illustrates the difference in child care service quality among regions over years. With the measure developed by this research, each region can also get very good insight into what kinds of factors of child care service should be paid more attention to in order to improve the quality of its child care service. Moreover, the measure obtained in this paper is proven reliable and robust in that it reflects the quality of child care service in each region and gives us statistically uniform quality scores with a different data set.

The influence over a period of 8 years of patterns of prescribing palizivumab for patients with and without congenitally malformed hearts, and in admissions to paediatric intensive care

To describe the pattern of prescribing for palivizumab in the Glasgow area over the period 1999 through 2007, and to compare recent prescribing to the current recommendations by the Joint Committee on Vaccination and Immunisation of the United Kingdom Department of Health. Our secondary objective was to describe admissions to paediatric intensive care in patients with respiratory syncytial virus receiving palivizumab. Tertiary children's hospital out-patient immunisation clinic and paediatric intensive care unit. Prospective analysis of prescribing and admissions data for the period 1999 through 2007. Number of prescriptions and admissions to the paediatric intensive care unit. The number of children receiving palivizumab annually initially rose more than 5-fold, from 17 in the season of 1999 and 2000 versus 115 in 2004 and 2005, although it has declined in the past 2 years, to 63 in 2006 and 2007, following publication of the recommendations of the Joint Committee on Vaccination and Immunisation established by the United Kingdom Department of Health. There has been no significant change in demographics of patients during this period. Prior to publication of these recommendations, 35 of 44 (80%) patients with congenitally malformed hearts who received palivizumab in the season of 2005 and 2006 deviated from the current recommendations, compared to 5 of 51 (10%) who received palivizumab for non-cardiac indications. No patients who received palivizumab required admission to the paediatric intensive care unit with proven respiratory syncytial virus infection over the 8 year period. The number of children receiving palivizumab initially increased significantly, although it has now fallen following implementation of national recommendations. Much prescribing, particularly for children with congenitally malformed hearts, did not fulfil current recommendations. The absence of admissions to paediatric intensive care reflects the success of targeted immunisation in our population.

Healthcare assistants in the children’s intensive care unit

Recruiting and retaining qualified nurses for children's intensive care units is becoming more difficult because of falling numbers of recruits into the child branch and inadequate educational planning and provision. Meeting the staffing challenge and maintaining the quality of children's intensive care services requires flexible and creative approaches, including considered evolution of the role of healthcare assistants. Evidence from adult services indicates that the addition of healthcare assistants to the intensive care team can benefit patient care. The evolution of the healthcare assistant role to support provision of safe, effective care in the children's intensive care setting requires a comprehensive strategy to ensure that appropriate education, training and supervision are in place. Career development pathways need to be in place and role accountability clearly defined at the different stages of the pathway. Experience in one unit in Glasgow suggests that healthcare assistants make a valuable contribution to the care of critically ill children and young people.

Immediate and 5‐year cumulative outcome after paediatric intensive care in Sweden

Little has been reported about intensive care of children in Sweden. The aims of this study are to (I) assess the number of admissions, types of diagnoses and length-of-stay (LOS) for all Swedish children admitted to intensive care during the years 1998-2001, and compare paediatric intensive care units (PICUs) with other intensive care units (adult ICUs) (II) assess immediate (ICU) and cumulative 5-year mortality and (III) determine the actual consumption of paediatric intensive care for the defined age group in Sweden. Children between 6 months and 16 years of age admitted to intensive care in Sweden were included in a national multicentre, ambidirectional cohort study. In PICUs, data were also collected for infants aged 1-6 months. Survival data were retrieved from the National Files of Registration, 5 years after admission. Eight-thousand sixty-three admissions for a total of 6661 patients were identified, corresponding to an admission rate of 1.59/1000 children per year. Median LOS was 1 day. ICU mortality was 2.1% and cumulative 5-year mortality rate was 5.6%. Forty-four per cent of all admissions were to a PICU. This study has shown that Sweden has a low immediate ICU mortality, similar in adult ICU and PICU. Patients discharged alive from an ICU had a 20-fold increased mortality risk, compared with a control cohort for the 5-year period. Less than half of the paediatric patients admitted for intensive care in Sweden were cared for in a PICU. Studies are needed to evaluate whether a centralization of paediatric intensive care in Sweden would be beneficial to the paediatric population.

Newborn resuscitation: should we oxygenate or not?

how should we oxygenate newborn and infants suffering from hypoxia and ischemia? Is it harmful to use 100% O2? It may seem odd to question a practice that has been carried out for so long, seemingly without any adverse effects. The case is, however, that after the practice of routinely using 100% O2

Alterations in glucose homeostasis in the pediatric intensive care unit: Hyperglycemia and glucose variability are associated with increased mortality and morbidity*

Critically ill patients with alterations in glucose equilibrium may experience adverse outcomes. We sought to describe the distribution of blood glucose values in the absence of insulin therapy and to evaluate the association of hyperglycemia, hypoglycemia, and glucose variability with mortality and morbidity of critically ill children. Retrospective cohort analysis. University-affiliated children's hospital pediatric intensive care unit (PICU). All children admitted to the PICU for >24 hrs with at least one blood glucose level recorded from a 1-yr period. Patients were excluded if >18 yrs of age, if insulin was administered during their PICU stay, and if the PICU admitting diagnosis included diabetes mellitus or hypoglycemia. None. Patients were categorized with isolated hyperglycemia (blood glucose >or=150 mg/dL, [>or=8.3 mmol/L]), isolated hypoglycemia (blood glucose <or=60 mg/dL, [<or=3.3 mmol/L]), and glucose variability (both hyper- and hypoglycemia), and the associations with mortality, hospital length of stay, and nosocomial infections were assessed. Fisher's exact test, Kruskal-Wallis test, and logistic and linear regression were used to test for associations. Hyperglycemic and hypoglycemic measurements occurred in 56.1% and 9.7% of all patients, respectively. Glucose variability occurred in 6.8% of all patients. Glucose variability (odds ratio 63.6; 95% confidence interval, 7.8-512) and hyperglycemia (odds ratio 11.1; 95% confidence interval, 1.5-85.6) in the univariate analysis were associated with increased mortality. There were no deaths among patients with isolated hypoglycemia. Hyperglycemia and glucose variability were also associated with nosocomial infections (p = .01) and increased hospital length of stay (p < .001). Hypoglycemia and glucose variability occurred more commonly in younger patients (p < .001). We found a relationship between blood glucose level and PICU patient outcomes. The relationship is similar to that found in adults and raises the question whether attention to control of blood glucose will improve outcomes in critically ill children.

Type B lactic acidosis and insulin-resistant hyperglycemia in an adolescent following cardiac surgery

To report the presence of type B lactic acidosis and insulin-resistant hyperglycemia following cardiopulmonary bypass in a pediatric patient. Case report. Tertiary referral children's hospital pediatric intensive care unit. Fourteen-year-old child with hyperlactatemia and hyperglycemia following cardiac surgery. We report a patient who following cardiopulmonary bypass for repair of his congenital heart disease developed type B lactic acidosis and hyperglycemia resistant to insulin therapy. Resolution of his hyperlactatemia and hyperglycemia occurred approximately 24 hrs postoperatively without apparent ill effect. Type B lactic acidosis is a phenomenon that may occur in the pediatric population in conjunction with insulin-resistant hyperglycemia. We observed that its resolution corresponded to improvement in the patient's hyperglycemia.

Predictors of mortality and length of stay for neonates admitted to children's hospital neonatal intensive care units

Current scoring systems, which adjust prediction for severity of illness, do not account for higher observed mortality in neonatal intensive care units (NICUs) of children's hospitals than that of perinatal centers. We hypothesized that three potential predictors, (a) admission from another NICU, (b) presence of congenital anomalies and (c) need for surgery, would modify expected mortality and/or length of stay for infants admitted to NICUs in children's hospitals. We reviewed consecutive admissions to two NICUs in children's hospitals in Canada. We performed regression analyses to evaluate these potential predictors and severity-of-illness indices for the outcomes of mortality and length of stay. Of 625 neonatal admissions, transfer from another NICU, congenital anomalies requiring admission and surgery were identified in 371 (59%). Using logistic regression, mortality was predicted based on admission from another NICU (odds ratio (OR) 1.92; 95% confidence interval (CI) 1.04, 3.57), congenital anomalies (OR 7.28; 95% CI 3.69, 14.36) and a validated severity-of-illness score, the Score for Neonatal Acute Physiology Perinatal Extension Version II (SNAPPE-II; OR 1.07; 95% CI 1.05, 1.09 per point). By contrast, surgical intervention was predictive of survival (OR 0.35; 95% CI 0.18, 0.67). Length of stay >or=21 days was predicted by SNAPPE-II (OR 1.02; 95% CI 1.01, 1.03 per point), congenital anomalies (OR 2.47; 95% CI 1.60, 3.79) and surgery (OR 2.73; 95% CI 1.77, 4.21). Fair performance comparisons of NICUs with different case-mixes, such as children's hospital and perinatal NICUs, in addition to severity-of-illness indices, should account for admissions from another NICU, congenital anomalies and surgery.

The nursing management of children with severe traumatic brain injury and raised ICP

Traumatic brain injury remains the greatest cause of death and disability in children worldwide. The children's intensive care nurse plays a key role in the prevention of secondary injury in these children, which can ultimately affect patient outcome. This article discusses the pathophysiology of paediatric brain injury and provides a framework for the intensive care nursing of these children. The pragmatic approach taken highlights the neurophysiological rationale and evidence base (where available) for key nursing interventions. A clear understanding of the neurophysiology is crucial for nurses working with children with traumatic brain injuries so that effective care can be given.

Parents’ Perspectives Regarding a Physician-Parent Conference after Their Child’s Death in the Pediatric Intensive Care Unit

To investigate parents' perspectives on the desirability, content, and conditions of a physician-parent conference after their child's death in the pediatric intensive care unit (PICU). Audio-recorded telephone interviews were conducted with 56 parents of 48 children. All children died in the PICU of one of six children's hospitals in the National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN) 3 to 12 months before the study. Only seven (13%) parents had a scheduled meeting with any physician to discuss their child's death; 33 (59%) wanted to meet with their child's intensive care physician. Of these, 27 (82%) were willing to return to the hospital to meet. Topics that parents wanted to discuss included the chronology of events leading to PICU admission and death, cause of death, treatment, autopsy, genetic risk, medical documents, withdrawal of life support, ways to help others, bereavement support, and what to tell family. Parents sought reassurance and the opportunity to voice complaints and express gratitude. Many bereaved parents want to meet with the intensive care physician after their child's death. Parents seek to gain information and emotional support, and to give feedback about their PICU experience.

Perioperative feasibility of imaging the heart and pleura in patients with aortic stenosis undergoing aortic valve replacement

Significant start-up delays are inherent to syringe infusion pumps, particularly at low infusion rates, as routinely used in children's anaesthesia and intensive care. Such delays are mainly the result of engagement of gears in the mechanical drive or compliance of the syringe assembly. The purpose of the present study was to determine the effect of flow rate, syringe size and syringe architecture on fluid delivery during infusion start-up. Elapsed time from infusion start to achievement of steady-state flow was gravimetrically determined for various infusion rates (0.1, 0.5, 1 mL h-1), different syringe sizes (10-, 20-, 30-, 50-mL) and syringes of two different brands (BD and Codan). Four measurements for each condition were performed with two identical Alaris Asena GH syringe infusion pumps (total of eight experiments). Statistical analysis was done by two-way ANOVA with Bonferroni's post-test; P < 0.05 was considered significant. Start-up time was from 3.6 +/- 0.9 min (BD 10-mL syringe, 1.0 mL h-1) to 74.5 +/- 26.6 min (BD 50-mL syringe, 0.1 mL h-1). Overall, the start-up time markedly increased with lower flow rate (0.1 mL h-1 vs. 1 mL h-1; P < 0.0001), larger syringe size (50 mL vs. 10 mL; P < 0.01), and the BD brand in comparison with the Codan syringes (P < 0.01). Highest possible flow rate, smaller sized syringes and syringe plungers with reduced compressibility should be preferred in order to avoid significant start-up delays in fluid delivery.