Background

The use of ultrasound (US) in placement of CVCs to raise success rate and to reduce complication rate. Simulation-based training for US-guided CVC access was known to improve CVC insertion skills for non-skilled physicians.

Objectives

We purposed to develop and validate a simple simulation model for ultrasound-guided central venous catheter insertion which can reproduce arterial and venous blood flow

Methods

The simulation model was constructed with chicken breast, two type of tubes, two type of motors and controller. A 4mm sized rubber tourniquet of high elasticity was connected to DWP-385 water pump which generated pulsatile water flow like physiologic flow rate of pediatric carotid artery. A 6mm sized silicon tube (HSUU Inc., Korea) was connected to DC peristaltic pump which generate continuous water flow like physiologic flow rate of pediatric jugular vein. Both tube were inserted into a piece of chicken breast and connected to controller part.

Then, we provided simulation program of ultrasound-guided central venous catheter insertion using our novel simulation model to resident physicians of emergency medicine.

Results

A total of 11 resident physicians are enrolled. All except one residents had no experience of pediatric central catheter insertion. The knowledge and confidence of discrimination of artery and vein using probe compression method and Doppler image were significantly improved after training with our simulation model (p = 0.003).

Conclusion

Our novel simulation model is very useful and realistic for ultrasound-guided central venous catheter insertion training. This controlled motor system can be applied to many simulation models which implement artery and vein circulation.

Background

RSI is an established method of inducing anaesthesia in patients who are at risk of aspiration of gastric contents. It traditionally included, pre-oxygenation, cricoid pressure, induction agent, suxamethonium, and then endotracheal intubation. However, in paediatric anaesthesia, RSI is a balance of theoretical risk vs real world practicalities.

Objectives

To assess variation in the practice of RSI among anaesthesiologists at the two major paediatric centres in Dublin, Ireland.

Methods

A one-page questionnaire was distributed throughout the anaesthesiology departments of the two paediatric hospitals in Dublin regarding two common scenarios. The first a 10 week old with bronchiolitis needing intubation post feed and the second a two year old with a neurovascular injury to the forearm following trauma that requires emergency reduction.

Results

There were 34 respondents to the questionnaire with even distribution between the two hospital sites, as well as between consultants and doctors in training. There was a significant difference in the use of standard RSI techniques between the two hospital sites (See Table 1). There was no significant difference between consultants and doctors in training. A naso-gastric tube was more likely to be placed in a 10 week old patient (62%) vs a 2 year old patient (6%) p < 0.0001.

Conclusion

Our results show that the practice of RSI varies widely, even between the two major paediatric sites in one city. RSI no longer represents a specific protocol, rather a broad range of techniques that may be safely used to minimise the risk of aspiration at intubation in high risk scenarios.

Background

The leading cause of preventable death in pediatrics is failure to manage the airway. Since specialized care nowadays is concentrated, NNI will mostly be performed by anesthetists or paediatric intensivists. Interns spend fewer hours in-hospital, and children in need of intubation decrease.

Objectives

NNI should be acquired by pediatricians according to the European Academy of Pediatrics (EAP). We argue this is a realistic or desirable goal.

Methods

A survey was sent to pediatricians about the importance of NNI, their competency, self-confidence and previous life-support-courses. Primary outcome was the importance to achieve competence, preparedness and self-confidence. Associations between demographics and importance/competence were assessed.

Results

The survey was sent to 806 pediatricians; 233 answers are analyzed. Forty % disagreed NNI is a skill a pediatrician should obtain (51% pediatricians, 30% residents with p <0.007). Self-confidence scored 3.4 (+/- 2.7) on a 0-10 scale. Seventy % did not feel confident in NNI, over eighty % felt confident in managing the airway. Seventy-five % did not intubate a child in the last five years.

Conclusion

Our survey showed low self-confidence in and very low exposure to NNI. Many residents will not develop competence in NNI, neither will pediatricians be able to maintain this skill. Refining of the list of skills required by the EAP could lead to a shift from being able to intubate, to being able to manage the airway of a child. If intubation is still perceived necessary, the best way to teach it should be examined: relying on clinical exposure is clearly not enough anymore.

Background

Managing and stabilising a critically ill child within a district general hospital prior to transfer to PICU can present communication challenges.

Objectives

Our study aims to identify ways in which teams can improve the delivery of family-centred care during this difficult time.

Methods

We reviewed the notes of 14 children who were transferred from the resuscitation area of a district general hospital to a tertiary PICU over a one-year period. We then conducted semi-structured telephone interviews with 14 parents focusing on the team’s communication with the family and how this could be improved.

Results

When reviewing patient notes documentation of clinician’s discussions with families was poor. Only 20% of notes had evidence of these discussions occurring. This is in stark contrast with the feedback from families themselves, with 100% of parents feeling they were adequately updated throughout. It is assumed the most senior clinician should update parents whereas the parental voice refutes this, with 80% preferring to have an update from a junior team-member to allow the most senior person to focus on their child. 75% of parents recall needing explanations repeated. Where available, 60% of parents were grateful to other allied healthcare professionals who offered one-to-one support (e.g. play specialists).

Conclusion

• Listening to parental voices allows teams to reflect on the true impact of their interaction with families

• Updates can come from any team member, not necessarily the most senior

• Documentation of communication is poorly done, not the communication itself

• Be prepared to re-explain things and re-check understanding

Background

Successful Intravenous (IV) catheter placement plays vital roles in the treatment of medical and traumatic patients in the pediatric emergency department (PED).

Objectives

We assessed PED-related factors associated with difficult IV catheter placement in PED.

Methods

We retrospectively reviewed electronic medical records of the patients younger than 18 years old who visited the PED with IV catheter placement attempt during PED stay. Difficult IV access was defined as placement of IV catheter by more than one attempts. Logistic regression analysis was used to evaluate factors associated with difficult IV access.

Results

A total of 925 patients were enrolled, and 77 (8.32%) cases were difficult IV access. The median age of patients was 3.0 [interquartile range 1-9], and male were 496 (53.6%). We found that age (OR 0.92, 95% CI [0.85-0.98], p=0.016), history of prematurity (OR 2.69, 95% CI [1.22-5.89], p=0.014), IV catheter insertion site (foot versus hand OR 5.6, 95% CI [2.91-10.79], p<0.001), high crowdedness of PED (OR 0.50, 95% CI [0.28-0.92], p=0.025) and the experience of provider (<6 months versus ≥12 months OR 4.21, 95% CI [1.74-10.15], p=0.001) were associated with the success rate of IV catheter insertion. However, sex, acuity of disease, vein visibility, vein palpability, IV catheter size, patients’ experience of IV access, and time of day did not show significant correlation with difficult IV access.

Conclusion

Early use of assist device or change of provider to the more skilled person should be considered when difficult IV access is anticipated by proposed factors.

Background

Minor head injuries usually cause no severe complications. The impact on the skull causes an opposite movement of the brain parenchyma, with stretching of the vessels because of the high moment of inertia. This leads to a traumatic endothelial intimal lesion, followed by fibrin accumulation and the formation of a white thrombus occluding the lumen [1].

Objectives

To detect lenticulostriate arteries pathology in children with basal ganglia stroke.

To compare sensitivity and specificity of MRI ant MDCT in identifying ischemic lesions.

Methods

CT and MRI of 31 pediatric patients with acute basal ganglia stroke were retrospectively evaluated. All patients had hemiparesis and underwent a comprehensive examination including CT, MRI and MRA. The control group consisted of 15 children without diagnostic findings. Student's t-test was used.

Results

Ischemic lesions were visualized in 31 patients using MRI and in 18 patient using CT. MRI sensitivity and specificity were 100% and 100%. CT sensitivity and specificity were 58% and 94%. Linear areas of hyperdensity in region of lenticulostriate arteries passage were detected in 22 patients and in 1 control group child. A statistically significant difference (p<0,05) was observed between measurements of mean density in group of patients (62,9±6,55 (p<0,5)) and control group (34,6±6,1 (p<0,5).

Conclusion

Linear areas of hyperdensity in region of lenticulostriate arteries passage in patients with acute basal ganglia stroke were regarded as blood clots that can play a major role in pathogenesis of basal ganglia stroke. MRI sensitivity in identifying ischemic lesions is twice as large as MDCT.

Background

Trauma related paediatric cardiopulmonary arrest (TRPCPA) is associated with high mortality and children that do survive often suffer from life changing morbidity. The decision of when to stop Cardiopulmonary Resuscitation (CPR) is always difficult and is often at the clinician’s discretion.

The European Resuscitation Council Guidelines for Resuscitation 2015 provides guidance on the cessation of CPR. The majority of these criteria are clear and objective. However, criterion 4 asks clinicians to define futility at a time when they may have limited clinical information and in what is often a time critical and highly emotive environment allowing for variation in practice.

Objectives

We aimed to review how objectively futility in TRPCPA is assessed and if it is defined well enough to aid clinician confidence in their decision making process.

Methods

We performed a systematic literature review of peer review articles published before January 2019. We identified articles that explored the futility or cessation of resuscitation in the context of TRPCPA.

Results

We reviewed 13 relevant articles identified from Embase, Medline, Pubmed, Cochrane and Google Scholar.

Conclusion

There is little evidence available to support clinicians in defining futility in the context of TRPCPA. The evidence that is available is generally of poor quality with studies containing low numbers, differing inclusion criteria and variable survival and morbidity outcomes. The only emerging objective marker of futility suggested is the presence or absence of fixed pupils but this requires significantly more robust research before it is implemented clinically.

Background

CoMET (Children’s Medical Emergency Transport) is a newly established standalone Paediatric Intensive Care transport service in the UK.

Bronchiolitis accounts for a significant number of intensive care transfers. Clinical features of bronchiolitis can mimic other life-threatening conditions. There are few studies reporting outcome of neonates initially referred as suspected bronchiolitis.

Objectives

To study the outcome of neonates requiring intensive care transfers with the referral diagnosis of bronchiolitis.

Methods

All referrals with diagnosis of bronchiolitis and in neonatal age group referred to CoMET from March 2017 till November 2018 were studied. The transport data log and discharge documents were reviewed.

Results

A total of 677 children requiring critical care support were retrieved by COMET. One hundred and fifty five (22.8%) were neonates. Seventy eight were initially referred as bronchiolitis.

A quarter of those, referred with diagnosis of severe bronchiolitis, were neonates [19/78].

All those who required transfers had to be intubated and mechanically ventilated. All received antibiotics. None received bronchodilators.

Eleven among nineteen (57.8%) neonates referred with bronchiolitis had an alternative final diagnosis - three (15.7%) had congenital heart disease and eight (42%) had non-viral infections. Of the 8 with a discharge diagnosis of bronchiolitis, 7 (87%) had a virus isolated from nasopharyngeal aspirate (NPA).

Conclusion

A significant number of neonates initially referred as bronchiolitis had an alternative diagnosis. When a virus cannot be isolated in NPA, another diagnostic possibility should be strongly considered.

Background

Early deaths due to severe sepsis in children occur even before reaching PICU's, thus not able to receive the management normally available in PICU's. Critical care transport services can bridge the gap in management of these children.

CoMET is a newly established stand-alone paediatric retrieval service based in the East Midlands, UK.

Objectives

To study the impact of CoMET on early stabilization and retrieval outcomes, of children referred with severe sepsis

Methods

The transport data logs of all acute unplanned referrals with referring diagnosis of severe sepsis, retrieved by CoMET from 15^th March 2017 to 14^th November 2018 were studied.

We assumed change in immediate PIM3 scores may reflect outcome, and analysed the PIM 3 scores at first contact and at handing over to accepting PICU’s.

Results

A total of 463 children were retrieved as acute unplanned including thirty [6.4%], referred as severe sepsis. Twenty nine [97%] were shocked at presentation. There were no deaths during transfer. Majority [83%] were under 5 years of age. Almost half [47%] had co-morbidities. Mechanical ventilation was required in 24 [77.45%] children. Twenty three [76.7%] were on ionotrope/s. The median stabilisation time was 145min. The stabilization time was proportional to the PIM3 score, at first contact. (p = 0.013, F=5.109, df=2). There was overall improvement in mean PIM3 score from 0.065(SD 0.154) to 0.0403(SD 0.074) (p =0.241, t = -1.200, 95% CI - 0.06727 to 0.01773).

Conclusion

The involvement of Paediatric Critical Care Retrieval service had a positive impact on immediate outcome of children referred with severe sepsis.

Background

Embrace, Yorkshire and Humber Infant and Children’s Transport Service, is a combined transport service. We previously used 3 types of ventilators to accommodate all our patients. In July 2017, we changed from BabyPac, that allows CMV+/-active PEEP, to Hamilton T1, with more ventilation modes including volume guarantee and monitoring of tidal/minute volumes and flow loops. We aim to avoid overventilation and underventilation in neonates since the neonatal brain is particularly susceptible to vasoconstriction, lower cerebral blood flow and increased neural excitability resulting from low pCO₂ levels which increases the brain damage risk.

Objectives

To compare over- and underventilation rates in neonates transferred using two ventilators. Overventilation is defined as a blood gas pCO₂ of < 4kPa and underventilation by a pCO₂ of > 7kPa and a pH of <7.2.

Methods

Retrospective notes review from January-June 2017 and 2018 for BabyPac and HamiltonT1 respectively, analysing referring unit predeparture and receiving unit arrival blood gases, end-tidal pCO₂ trends, journey length and patient diagnosis.

Results

Overventilations has decreased with the HamiltonT1 vs BabyPac but with a slight increase in underventilations.

Conclusion

Use of a new ventilator has decreased the number of overventilation but we still need to observe trends in tidal volumes, end–tidal CO₂ and eventually transcutaneous CO₂ to improve underventilation.