Background

Background

The RTX^R respirator is an external ventilator that uses a plastic cuirass over the thorax and generates negative pressure ventilation. Acute flaccid myelitis (AFM) is characterized by rapid onset of flaccid weakness in one or more limbs, distinct abnormalities of the spinal cord gray matter on MRI and mostly caused by enterovirus-D68 infection.

Objectives

Describe the use of biphasic cuirass ventilation (BCV) to wean invasive ventilation in an infant with AFM.

Methods

Case study: a one-year-old girl presented with a paraparesis of the lower extremities and general weakness with absent cough strength. Based on electromyography, the neurologist diagnosed a subacute ascending tetraparesis, ascribed to enterovirus-D68, but not entirely typical as AFM.

Results

She was ventilated for six weeks with high oxygen demand. Extubation failed after four weeks, due to insufficient strength. Because CTA only showed atelectasis, we then suggested giving her a trachea cannula to facilitate weaning. The parents were opposed to this, however, and refused non-invasive ventilation with a mask. We then started training the respiratory muscles with negative pressure ventilation combined with invasive PressureSupport and CPAP. Oxygen demand decreased during BCV. After two weeks training she was extubated to high flow nasal cannula and BCV. She accepted the cuirass well. In addition, she was often put on a coughing assist machine to mobilize mucus. She was then weaned off from HFNC and BCV. 11 weeks after admission she no longer needed respiratory support.

Conclusion

BCV could be an alternative weaning strategy in neuromuscular disease and severe deconditioning after prolonged mechanical ventilation.

Background

Pulmonary interstitial emphysema (PIE) results from overdistention and rupture of the alveoli. PIE is a complication usually associated, although not exclusively, with mechanical ventilation in preterm newborns. Unilateral emphysema causes mediastinal shift and compression of the contralateral lung, which leads to higher ventilatory pressures, overdistension and a worsening cycle of events.

Objectives

The goal of this paper was to present a sucessful aproach of PIE by selective ventilation

Methods

The authors present a case report of a female preterm born at 28 weeks of gestation from caesarian delivery due to maternal pre-eclampsia.

Results

Female preterm with a birthweight of 875 grams (appropriate for gestational age). Due to respiratory distress syndrome nasal-biphasic positive airway pressure was initiated and two doses of surfactant were administered. On day two, she developed a left-sided hypertensive pneumothorax, which led to intubation and drainage with a chest tube. In the following days there was respiratory deterioration, with hyperinflation of the left lung and the need for multiple chest tubes.

On day 20 the chest x-ray showed severe PIE and compression of the right lung, confirmed by CT scan (image 1 and 2). Selective right bronchial intubation and right lung ventilation was decided with clinical improvement. Endotracheal tube was withdrawn to mid-tracheal position on day 34. She was successfully extubated on day 36, remaining clinically stable.

Conclusion

Selective intubation and ventilation of the contralateral lung has been described as a treatment option for unilateral pulmonary emphysema as it enables the affected lung to recover leading to lower risk for baro and volutrauma.

Background

Although uncommon, chylothorax is cause of pleural effusion in the newborn. It is defined as an accumulation of lymph in the pleural space.

It can be congenital or secondary to thoracic surgery, rarely associated with pulmonary lymphangiectasia or other lymphatic malformations.

It can be a cause of respiratory distress and death in the neonatal period due to pulmonary hypoplasia secondary to important pleural occupation.

Objectives

Description of the clinical, epidemiological and biochemical characteristics of the cases of chylothorax diagnosed in our neonatal unit

Methods

Retrospective descriptive study of patients diagnosed with neonatal chylothorax admitted to our unit between 2012-2018 through review of medical records

Results

We found 5 cases of chylothorax , 3 women and 2 men. Mean gestational age of 36 weeks. Average birth weight of 3197g. Prenatal diagnosis of bilateral pleural effusion in 4 patients. Apgar at birth to the minute of 5.2 and to the 5 minutes of 7.8.
The biochemical analysis showed a cellularity more than 90% of mononuclear cells. The mean protein concentration in pleural fluid was 3g/dl. All required mechanical ventilation.
Mean days of parenteral nutrition 19.4 days. Food was started with medium chain triglycerides (MCT) in all with good evolution except in a patient who needed start with octeotride and absolute diet again for reproduction of chylothorax .

Conclusion

Chylothorax in the neonatal period is rare but should always be suspected in pleural effusion. Biochemically checked chylothorax , conservative treatment with fluid evacuation and intravenous nutrition with subsequent initiation of feeding with medium chain triglycerides (MCT).

Background

Acute hypoxia induced by fiberoptic bronchoscopy (FBS) is a life-threatening complication and a limiting factor for the procedure requiring oxygen delivery systems for prevention and treatment.

Objectives

Assessing efficiency and safety of high flow nasal cannula (HFNC) compared to conventional nasal prongs (CNP) during FBS.

Methods

We conducted a prospective, controlled (non-blinded) clinical trial from 2015 to 2019 including 104 paediatric patients (n=104) from 0 to 16 years who were randomly allocated to two study groups (HFNC versus CNP) undergoing elective FBS. Oxygen administration through HFNC or CNP was given throughout the procedure and in case of hypoxia gas flow was increased. We performed a statistical analysis including demographic and clinical characteristics, number and severity of desaturations, adverse events, Ramsay Sedation Scale and bronchoscopic satisfaction score.

Results

Not included

Conclusion

Oxygen delivery through HFNC is safe and reduces number and severity of hypoxic events during FBS compared to CNP.

Background

Neonatal morbidity rates in bilateral renal agenesis are still estimated at 100 % because of respiratory failure. We present the case of an infant, which developed nearly normal pulmonary function despite of bilateral renal agenesis. To our knowledge this is only the second case in literature with similar findings.

Objectives

single patient

Methods

Case-Report

Results

Prenatal sonography at 19 weeks is strongly suspicious for bilateral renal agenesis with severe oligohydramnion. Abortion is discussed, which the parents decide against. At 31 weeks amniotic fluid (AF) is surprisingly presentable. At 34 weeks AF volume is at lower normal range, stomach and urinary bladder are not viewable. Because of PPROM at 35 weeks the child is delivered by cesarean-section. Respiratory stabilization is successful, short-term NO and Sildenafil administration lead to sufficient spontaneous breathing. Postnatal MRT confirms bilateral renal agenesis, but also shows duodenal atresia, small intestine stenosis and caudal regression syndrome, meeting clinical findings (e.g. anal atresia). A horseshoe-kidney obstruction described in fetal MRT equates to "double-bubble-sign". PD is successful.

In repeated multidisciplinary care conferences, however, palliative treatment is decided especially because of the limited prognosis of surgical repair during PD.

Conclusion

Maybe AF removal by swallowing was ineffective due to duodenal atresia and maintained an effectual AF volume. In literature, another theory describes a vascular accident of pelvic arterial supply later in pregnancy resulting in renal agenesis and atresia of pelvic organs – which also fits to our patient.

Our case could help to discuss generally poor fetal prognosis due to bilateral renal agenesis more individually.

Background

Both high specialty and complexity of care require a nursing staff highly qualified and continuously up-to-date. Clinical knowledge as well as policies and hospital procedures are more important than ever to guarantee quality and safety to patients. For this reason, many efforts should be done to offer equal opportunity training for the staff, to control quality in staff education and to monitor and evaluate levels of knowledge. E-learning technologies should offer this kind of opportunities.

Objectives

The main objective was to evaluate the opportunity to use on-line learning to support training and to monitor staff level of knowledge.

Methods

Moodle platform was used to offer ICU nurses a course about hospital procedures with short video-lessons and a final test. Anonymous on-line questionnaire was administered to nurses to evaluate the platform.

Results

Forty-one ICU nurses were involved (mean-age 34.12 years, SD±7.71), 37% males and 63 % females; 17% of the sample has already heard of Moodle platform and only 5% used it before but in academic context. Nurses’ satisfaction was generally high, about 9/10. In particular, Moodle was evaluated more than 8.50/10 as an easy tool to use both to manage educational materials and to organize an individual training. Both video-lessons (8/10) and final quiz (8.50/10) were positively evaluated as very useful.

Conclusion

Moodle experience was generally positive. It was only the first step to introduce e learning into the daily nursing practice but the positive feedback encourage exploring Moodle potentiality in order to support training and its quality.

Background

Shared decision making regarding direction and ‘place of care’ is key concept of realistic medicine. Admission to paediatric intensive care unit (PICU) usually aims at restorative therapy. For small cohort of patients however re-orientation of care becomes most appropriate. Practice of reorientation of care has evolved and involves close collaboration with a multidisciplinary team and parents.

Objectives

Review current literature regarding re-orientation of care at home for children at end of life, with an aim to develop a guideline for implementation in our local PICU.

Methods

A literature search performed to identify UK current practice. Retrospective analysis of deaths that occurred in our PICU from 2010-2017 and identification of those who may have been applicable for re-orientation of care out-with critical care. Development of a guideline and discharge checklist to implement in clinical practice.

Results

Between 2010-2017, within our unit, there were 76 deaths, 28 (37%) were identified as appropriate for re-orientation of care out-with critical care.

The guideline involves six steps. It identifies a patient, clarifies wishes and choice of place of care, and discusses with appropriate service to take over the patient’s care. Pre-transfer involves rationalising care for transfer and completion of CYPADM/ACP. Transfer would be performed by critical care team members, prior to compassionate re-orientation of care and handover to appropriate service.

Conclusion

Choice of home as final place of care around time of death should be considered for relevant patients in critical care and this guideline and discharge checklist will aid the medical team to offer this service.

Background

Mortality in paediatric critical care can be considered one of the factors of treatment efficiency. The relative decline of mortality can be related to the progress of intensive care. The trends in paediatric critical care mortality are not well described in Czech Republic.

Objectives

The primary aim was PICU mortality in two periods: 2008-2012 versus. 2013- 2017. The secondary outcome were demographics of the cohort and the diagnosis that led to death.

Methods

After Ethics committee approval authors retrospectively evaluated data of paediatric critical care patients who died in Department of paediatric anaesthesiology and intensive care, University hospital Brno. Pearson chi-square and Kolmogorov–Smirnov test were used to describe the mortality difference between groups.

Results

The overall mortality in study period was 11.44% (186/1625). The mean age of the patients (6.99 vs. 6.37 years, p=0.414) and the mean PICU length of stay (7,58 vs. 3.65 days, p=0.099) were not statistically different between the groups, also there was no detected difference according to the admission diagnosis between the groups: Post-resuscitation care/CPR in progress (38.9% vs. 52.1%, p=0.078), trauma (15.9% vs. 23.3%, p=0.20), sepsis (21.2% vs. 27.4%, p=0.33), respiratory failure (54.9% vs. 60.3%, p=0.46). Mortality in period 2008-2012 was 14.63% (113/772) versus 8.74% (73/835, p=0.00022) in period 2013-2017.

Conclusion

Mortality was significantly reduced in period 2013-2017 when compared to 2008-2012. The difference was independent of admission diagnosis.
Supported by MH CZ - DRO (FNBr, 65269705).

Background

Majority of in-hospital cardiac arrests in children happen on intensive care units which can result in significant mortality & morbidity. During 2015 and 2016, around 6% of admissions on our unit had an episode of cardiac arrest.

Objectives

A quality improvement project aimed to reduce cardiac arrests on PICU by 50% in 12 months.

Methods

We reviewed recent episodes of cardiac arrests, discussed with front-line healthcare professionals and conducted a safety climate survey to identify key areas for improvement.

ReCAP initiative utilizes quality improvement methodology and encourages staff to actively identify patients at risk of deterioration. This prompts a pre-brief which is a novel concept adapted from aviation industry to improve situational awareness and encourage a learning and supportive culture.

A senior clinician leads a structured bedside discussion about risk factors and early signs of deterioration, immediate plan to prevent a cardiac arrest, role allocation for possible resuscitation and addresses any knowledge-gaps among staff in a non-critical manner.

Other interventions in this project like simulations, reporting cardiac arrests on the Datix system and debriefs have been modified over time with staff feedback.7

Results

ReCAP was launched on 1^st January 2017. We saw a sustained reduction of 46% reduction in cardiac arrests during the first 12 months and this improvement has sustained over 2018. There has been a tangible improvement in safety culture and empowering junior staff to raise concerns and use pre-brief as learning opportunities.

Conclusion

Innovative strategies like pre-brief to improve situational awareness and team work can lead to significant improvement in patient safety.

Background

We developed and implemented a bespoke high dependency unit (HDU) service led by dedicated HDU trained paediatric medical consultants in our hospital in response to the UK Paediatric Royal College’s recommendations.

Objectives

We aim to assess the impact of implementing this dedicated day-time HDU trained senior medical team on patient care, efficiency of multi-disciplinary team (MDT) working practice and patient flow within the hospital.

Methods

A prospective mixed methodology study was conducted with data collected for comparisons between pre- and post-implementation of a bespoke dedicated HDU service led by specially trained paediatric consultants. Qualitative data (e.g. communication) was collected with a pre-designed hospital-wide staff questionnaire while quantitative data (e.g. duration of stay, efficiency of clinical tasks completion and adverse events) was collected using a pre-designed proforma. The bespoke HDU service was implemented over a 2 month period to provide day-time HDU trained consultant-led patient care with hospital outreach for potential admissions and critical care discharges follow-up. A weekly quality improvement cycle was used to continually enhance the service during implementation.

Results

Implementation of our bespoke HDU service enhanced staff communications, streamlining patient care and improved co-ordination of patient movement within the hospital for HDU patients requiring MDT care. It also reduced the median length of stay for acute medical patients by 33% compared to the same period of year prior to HDU service implementation.

Conclusion

Implementing a bespoke dedicated daytime HDU-trained consultant-led service benefits patient care. Impact with implementing a similar service to include out-of-hours cover warrants further investigation.

Background

Syringe drivers are the standard method of giving continuous infusions of important drugs to patients. Many of these drugs are critical for the maintenance of normal physiology. Anecdotal evidence abounds of severe patient instability on movements of syringe drivers.

Objectives

To define the variation in drug delivery seen in three syringe drivers, with changes in relative height between the syringe driver and the end of the giving set.

Methods

Three syringe drivers (Alaris CC, Braun, and Arcomed) were analysed for reliability of flow at 0.5, 1, 2, and 5ml/hr. A small air bubble was introduced in to the giving set, and the progression of this was documented before and after a vertical movement of the syringe driver by 25 or 50cm upwards or downwards.

Results

For all pumps, delivery was interrupted on movement of the pumps downwards, and a bolus was given with movement of the pump upwards. Delivery at lower pump speeds halted for longer than higher pump speeds. The maximum delivery interruption was 11.7 minutes. Boluses given on moving the pump up were calculated as the equivalent number of minutes needed to deliver the bolus at steady state. The maximum bolus given was 39 minutes. We were unable to eliminate the effect by slow movement of the pump.

Conclusion

Syringe drivers should not be moved vertically in relation to the patient. Patient critical drugs are interrupted for up to 11.7 minutes with relative downward movements, and significant boluses of drugs are given with relative upward movements.

Background

Previous studies have shown that WHO noise level guidelines are frequently exceeded on intensive care ward (1)

Objectives

To measure noise levels and acivity on a Paediatric High Dependency Unit.

Methods

Sound levels (in decibel) were measured over 4 x 2-hour periods (two mornings and two evenings) using the SLM24TK digital sound level meter. Ward activity was also documented.

Results

Noise levels shown in table. Conversation was the largest single contributor for frequency and noise level. Noise levels exceeded guidelines on all days

Conclusion

Average sound levels were above WHO guidelines and recommended sound levels for sleep on all days. Peak noise was always above 80dB, a workplace safety limitation. Although further research is necessary, simple interventions may already be appropriate. These would include cost-effective solutions such as staff education and use of headphones, as used in other studies.

Background

Oesophageal pressure (Poes) manometry allows assessment of respiratory mechanics, enabling individualized titration of respiratory support. Poes can be measured by specifically designed catheters, equipped with a small inflatable balloon. In adults, it has been recommended to perform an individual calibration procedure by creating a pressure volume loop of the balloon to determine the optimal filling volume. We sought to explore if this would also hold true for paediatric patients.

Objectives

To identify optimal balloon filling volume in mechanically ventilated children.

Methods

Mechanically ventilated sedated and/or paralyzed paediatric patients (<18years) with an oesophageal catheter (6Fr paediatric or 8Fr adult size) in situ were included. The oesophageal balloon was inflated incrementally by steps of 0.2mL, respectively with a maximum of 1.6mL and 2.6mL. Respiratory holds were performed at the end of each step. Pressure-volume loops were obtained to identify the minimal, maximal and optimal filling volume. The minimal and maximal filling volume were derived, visually, from the pressure-volume loops. The optimal filling volume was defined as the volume where the highest dPoes, between inspiratory and expiratory phase, was obtained within the range of the minimal and maximal filling volume.

Results

Thirty patients were eligible of whom 15 were excluded because of a confirmed malposition or a suspected malposition of the oesophageal catheter. Of the remaining 15 patients, median age 2 months [IQR 1, 25], optimal balloon volumes were obtained. The range of the obtained optimal filling volume was 0.2mL to 1.2mL.

Conclusion

The optimal filling volume of the oesophageal balloon varies considerably in the paediatric patient.