Background

Introduction: Seizures are the most common manifestation of neurologic compromise in the newborn period and often portend serious neurologic injury or dysfunction. Understandably, movements that mimic seizures during this period cause significant concern for parents and physicians alike and often prompt extensive diagnostic evaluation.

Objectives

Here we reported a newborn patient admitted to NICU with mistaken for refractory seizures.

Methods

Case: A term 15 days female neonate presented to NICU suggestive of abnormal movements of limbs noted over the preceding 2 days. She was born by spontaneous vaginal delivery with uneventful antenatal period. The baby was admitted with a diagnosis of refractory neonatal seizures in another hospital and was treated with oral phenobarbital unsuccesfully.

Ictal and interictal EEG and cranial USG did not reveal any abnormality. These findings helped us in establishing a diagnosis of benign neonatal sleep myoclonus. The baby continued to be active in the hospital. Anticonvulsants therapy was tapered gradually and baby was sent home. On follow up, the jerks steadily reduced in frequency and disappeared by 4 weeks of life.

Results

Discussion: Benign neonatal sleep myoclonus, a benign movement disorder that typically starts within the first 15 days of life, occurs during NREM sleep, and consists of intermittent repetitive jerks of the limbs at 2 to 3 per second.

Conclusion

Conclusion: Benign sleep myoclonus of infancy can be mistaken for neonatal seizures or even neonatal status epilepticus; the recognition of diagnosis is imperative to avoid unnecessary diagnostic studies and treatments.

Background

The Children’s Hospital in Edinburgh is one of only two tertiary paediatric hospitals in Scotland with a dedicated Paediatric Intensive Care Unit (PICU) staffed by paediatric intensivists. Children admitted to the High Dependency Unit (HDU), however, were looked after by the critical care (PICU and HDU) nursing team with their medical care provided by their primary general or specialist team. The UK’s Royal College of Paediatrics and Child Health (RCPCH) recently published recommendation for dedicated HDU services to be led by HDU trained paediatricians given the increasing complexity of patients.

Objectives

We aim to create an HDU service led by a dedicated team of HDU trained consultants within our paediatric critical care unit.

Methods

A cross-sectional nationwide survey of UK hospitals providing paediatric critical care was carried out. Visits to selected units with dedicated HDU Paediatricians were undertaken to collect elements of good practice. All HDU stakeholders within our hospital were consulted and focus groups set up to gain multi-specialty and multidisciplinary input to tailor the design of a potential model for a dedicated HDU trained consultants.

Results

Wide variance in the medical cover for UK Paediatric HDU was identified. The consensus from our HDU stakeholders supported development of a dedicated HDU service to enhance patient care. A bespoke dedicated HDU service was designed and implemented to provide coordinated care for these patients.

Conclusion

A bespoke dedicated HDU service was designed and implemented successfully. Its benefits to patient care and outcome warrants further investigations.

Background

There are many pediatric patients with chronic and complicated diseases in tertiary care hospital. These patients require long-term vascular access for fluid and medication administration. The use of Peripherally Inserted Central Catheters (PICCs) has been increasing globally since 1976; however, the adoption of PICCs in Thailand has been initiated less than a decade ago. There is no data regarding prevalence and risk factors for Peripherally Inserted Central Catheters (PICCs) complications in pediatric patients in Thailand.

Objectives

To identify prevalence, incidence of complications and risks related to PICCs used in hospital- and ambulatory- based patients.

Methods

We retrospectively reviewed pediatric patients with PICC line insertion by in-training pediatric pulmonology and critical care fellows to assess the prevalence of complications and their risk factors for two years in a tertiary referral center. Moreover, we compared the complications between hospital-based patients and discharge-to-home patients.

Results

A total of 200 PICCs were inserted in 176 children with 7,817 total catheter day. The overall complications were 6.9 per 1000 catheter day. The most common complications were occlusion and CRBSI with 1.6 per 1000 catheter day. The ambulatory-based patients have longer PICC dwell time (61.9 days, p value<0.001) and less complications compared to hospital-based patients (p value=0.008). Smaller catheter and repeated PICC insertion were associated with complications (p-value=0.013 and <0.001, respectively).

Conclusion

The larger sized PICC catheter had less complication than the smaller sized. The Ambulatory-based PICC is possible. A thorough maintenance, care plan and care team of PICC should be initiated for ambulatory options.

Background

There are approximately 16,000 transfers of premature and sick babies each year according to the UK Neonatal Transport Group. Neonatal transfers using ambulance vehicles in some cases have resulted in the crash of the ambulance vehicle.

A custom designed Impact Reduction Interface System (IRIS) for use on ambulance trolley’s has being developed by Birmingham City University and Evac+Chair International to reduce the acceleration and deceleration forces acting on a neonate in emergency ambulance transportation and in the event of a crash at speeds of up to 40MPH (65KPH).

Objectives

To reduce the g-Forces caused by excessive braking and acceleration of an ambulance.

To reduce the probability of significant neonatal organ damage caused by an ambulance crash of up to 40MPH/65KPH.

Methods

g-Force data acquisition (emergency ambulance transport): Configured accelerometers to record peak acceleration (g-Forces) exerted on a neonate dummy during normal ambulance transfers were fitted to a standard neonatal National Health Service (NHS) trolley.

g-Forces data acquisition (crash): A crash test at 40MPH/65KMP of a neonate dummy in an incubator was undertaken to record g-Forces and motion of the neonate dummy using high speed film recording.

A custom designed Impact Reduction Interface System (IRIS) was physically built and tested against the simulation and real data obtained in emergency ambulance transfers for correlation in g-Force reduction.

Results

Significant reduction of g-Forces experienced by a neonate in emergency transport compared to without using IRIS.

New ambulance trolleys for NHS built with IRIS.

Conclusion

Reduction in post care neonatal costs to the NHS following an ambulance crash.

Background

Medication errors during paediatric resuscitation are thought to be common. However, there is little evidence about the individual process steps that contribute to such medication errors in this context.

Objectives

Todescribe the incidence, nature and severity of medication errors in simulated paediatric resuscitations, and to employ human reliability analysis to understand the contributory role of individual process step discrepancies to these errors.

Methods

We conducted a prospective observational study of simulated resuscitations subject to video micro-analysis, identification of medication errors, severity assessment and human reliability analysis in a large English teaching hospital. Fifteen resuscitation teams of two doctors and two nurses each conducted one of two simulated paediatric resuscitation scenarios.

Results

At least one medication error was observed in every simulated case, and a large magnitude or clinically significant error in 11 of 15 cases. Medication errors were observed in 29% of 180 simulated medication administrations, 40% of which considered to be moderate or severe. These errors were the result of 884 observed discrepancies at a number of steps in the drug ordering, preparation and administration stages of medication use, 8% of which made a major contribution to a resultant medication error.Most errors were introduced by discrepancies during drug preparation and administration.

Conclusion

Medication errors were common with a considerable proportion likely to result in patient harm. There is an urgent need to optimise existing systems and to commission research into new approaches to increase the reliability of human interactions during administration of medication in the paediatric emergency setting.

Background

Progressive scoliosis often requires deformity correction. Intraoperative neuromonitoring (IONM) using motor evoked potentials (MEP) and sensory evoked potentials (SEP) is the method of standard to evaluate the integrity of the spinal cord during the procedure. Thus, IONM may detect iatrogenic spinal cord injuries with excellent sensitivity. But there are multiple factors that influence the IONM results.

Objectives

Aim of the study was to identify origins of occurring IONM alarms.

Methods

A total of 54 operative procedures from 2014 to 2017 in 34 children and 18 adults (m:w = 17:35, age 16 +/- 5) were analyzed retrospectively. All patients suffered from scoliosis, underwent spinal deformity surgery and were monitored by MEP and SEP performance intraoperatively.

Anesthesia was generated with propofol, sufentanil and remifentanil. MEP alarms were defined as an amplitudal decrement > 90%. SEP alarms were defined as any extension of latency. According to our algorithm, alarms were categorized in 3 different origins: anestetical, surgical and technical.

Results

In 48 (88,9%) out of 54 procedures reliable MEP and SEP could be generated. 17 alarms were detected. 15 alarms (88,2%) were associated with anesthetic agents. 2 alarms (11,8%) had technical causes. None could be assigned to the surgical procedure.

Conclusion

IONM is state of the art to evaluate spinal cord integrity changes during deformity correction. Dosage and selection of anesthetic agents are the major causes of IONM alarms during scoliosis surgery.

Background

After kidney transplantation (NTX) in children high intraabdominal pressure may impair graft perfusion and graft function.

Objectives

We analysed whether longitudinal intraabdominal pressure (IAP) measurement is feasible and safe postoperatively in these patients and if IAP affects graft function after kidney transplantation in the pediatric intensive care setting.

Methods

We longitudinally measured IAP values using an Unometer™Abdo-Pressure™device connected to a Foley urinary catheter in eight children who underwent kidney transplantation (mean (SD) age: 9.6 (6.1) years) and in 18 controls (mean (SD) age: 5.9 (6.0) years) for 96 hours postoperatively. Vital signs and clinical parameters were documented in both groups. Graft function was evaluated using serum creatinine and urea nitrogen. Correlations were calculated using the Spearman rank correlation method.

Results

We analysed 29 measurements of IAP in children after NTX and 71 IAP measurements in control patients. Mean (SD) IAP were similar in both groups (NTX: 7.4 (4.2) mmHg, Controls: 7.4 (3.4) mmHg; p=0.74). IAP values exceeded the threshold of 10 mmHg indicating intraabdominal hypertension in 20% vs. 22% of the cases in NTX patients vs. in controls. The IAP was not correlated with diuresis, fluid balance, abdominal perfusion pressure (=mean arterial pressure – IAP) or graft function. IAP measurements did not cause complications in particular no urinary tract infection occurred in both groups.

Conclusion

Perioperative intraabdominal pressure monitoring is safe and feasible after pediatric kidney transplantation. IAP values were similar in NTX patients and controls. No correlation between intraabdominal pressure, graft function, diuresis or fluid balance were detected.

Background

The hemostasis system in neonates and infants is characterized by functional immaturity due to age-specific differences in proteins.

Objectives

The aim of this study was to identify clinical significance age specificity in pediatric coagulation profile.

Methods

We assessed the coagulation tests (aPPT, PT, fibrinogen level, INR) in 850 patients admitted into PICU. All patients received heparin therapy to prevent thromboembolic events (UFH) infusion consisting of the washing solution (3 IU/ml). 8 pts with v-a ECMO were excluded. We compared 3 age groups: neonates, n=132; infants, n=367; and children, n=343. We assessed the row data and during preventive heparin therapy ones. For statistics we used nonparametric computations

Results

We found that PT 11.83±1.118, 11.75±1.302, and 12.25±1.071, respectively. PT in infants was significantly less than in children group, p<0.05. We not found any differences in aPPT between age groups; aPPT was 35.37±5.55, 34.15±5.51, and 34.99±5.52, respectively, p>0.05. INR before preventive heparin therapy among infants was significantly high than in children, p<0.05. And, than we compared fibrinogen levels in these groups, we’ve found that infants have significantly low fibrinogen levels than patients in children group. The lowest fibrinogen was in neonate group. Fibrinogen (m ±SD) was 2.58±0.45, 2.66±0.74, and 2.92±0.62, respectively. Fibrinogen level in infants was significantly less than in children group, p<0.05.The preventive therapy was effective and there were not any thromboembolic events during treatment.

Conclusion

The hemostasis system in children has dynamic development and before any preventive or treatment intervention we should assess initial coagulation profile with regard to age-dependent specificity.