Background

The infusion of packed of red blood cells (RBC) in paediatric patients requires the use of a syringe infusion pumps (SIP) for accuracy. However, there is uncertainties regarding the effect of SIPs cause red cell damage and haemolysis of the RBC.

Objectives

To evaluate biochemical and haemolytic markers of RBC transfused in three different brands of SIP with two different infusion rates (10 and 100 ml/h), simulating clinical practice in paediatric and neonatal patients.

Methods

A lab-based experimental study with aliquots of 16 RBC bags. Haemolysis markers (total haemoglobin(g/dl), haematocrit(%), free haemoglobin(g/dl), potassium(mmol/L), lactate dehydrogenase(U/L), osmolality(mOms/kg), pH, degree of haemolysis(%)) were measured before and after RBC infusion. Three different SIP brands (A, B and C) were compared with two different infusion rates (10 and 100 ml/h).

Results

The total haemoglobin fell significantly in all RBC units during manipulation (p=0.026). The degree of haemolysis significantly increased (p=0.005) after manipulation of the RBC. One pump (SIP A) caused a threefold increase in potassium levels when compared to SIP B and C. (A: 3.78±6.10; B: -0.14±1.46; C: 1.63±1.98). SIP A also produced the worst changes, with an increase in free haemoglobin (0.05±0.05; p=0.038) and more haemolysis (0.08±0.07; p=0.033). No significant differences were found between the infusion rates.

Conclusion

SIPs cause significant RBC damage after infusion, and exposure of RBC in the infusion system with significant increases in free haemoglobin, potassium and the degree of haemolysis. One SIP caused significantly more damage compared to other pumps. Acknowledgment: CAPES (308281/2015-2); CNPq (474906/2013-2).

Background

The use of antimicrobial lock technique emerges as intervention to the prevention or treatment of central lines associated bloodstream infections in children undergoing bone marrow transplantation.

Objectives

To determine the stability of vancomycin hydrochloride solutions and vancomycin hydrochloride solutions with sodium heparin, according to the influence of time simulating the clinical practice of antimicrobial lock in central lines.

Methods

Experimental study performed in the Laboratory of Nursing Experiments–Federal University of São Paulo, Brazil. The sample consisted of 192 analyses of pH and concentration through the use of High Performance Liquid Chromatography (HPLC) monitored by peak area analysis, performed immediately, 3, 8 and 24 hours (h) after preparation of the solutions, under controlled environmental conditions (temperature of 22^oC and absence of light). Vancomycin hydrochloride (500mg) was reconstituted with 10mL of distilled water and diluted of 5mg/mL of saline solution. For heparin, the proposed concentrations were 100U/mL. The data are expressed as mean ± standard deviation.

Results

The mean pH for vancomycin hydrochloride 5mg/mL immediately after dilution was 3.76(±0.05), with 3h 3.73(±0.01), 8h 3.74(±0.01), and 24h 3.59(±0.03). The initial analytic peak area was 4953.43(±915.39), 3h 5053.61(±959.61), 8h 5084.91(±974.05) and 24h was 5349.54(±590.38). The pH values of association of vancomycin hydrochloride with heparin were 3.63(±0.03) immediately after preparation, 3.59(±0.02) after 3h, 3.64(±0.04) after 8h and 4.00(±0.02) after 24h. The HPLC peak area immediately, 3, 8 and 24h after preparation, respectively were 4615.98(±172.79), 4492.54(±70.65), 4418.41(±54.35) and 4371.33(±76.92).

Conclusion

Vancomycin solution remained acid; pH in association solution increased overtime. For peak area decreases occurred in solutions with heparin.

Background

Immobility negatively affects muscle weakness, circadian rhythm, and potentially increases the risk of delirium. Providing early mobilization (EM) during the Intensive Care Unit (ICU) stay has shown effective in adults.

Objectives

We determined the feasibility and safety of the implementation of an EM program in a Pediatric ICU (PICU).

Methods

A prospective pre-posttest implementation study was conducted in patients admitted on a PICU for at least 3 days. This quality improvement project involved a usual care baseline phase, followed by a quality improvement phase implementing a multicomponent, multidisciplinary protocol for early mobilization of critically ill children. Primary outcome was the number of mobilization activities. Secondary outcomes were prevalence of delirium, consumption in sedatives, and mobilization related adverse events.

Results

In total, 61 children (pretest) and 56 children (posttest) were included, with a median age of 28 months (IQR 10-103) and 38.5 months (IQR 7-152), respectively. The median number of mobilization activities increased from 5 (IQR 3-7) to 6 (IQR 4-8) (p<0.0001). Among children who were ventilated, there was an increase in the proportion who participated in sitting in a chair: 27% vs. 54% (p<0.029). The delirium rate was not different between the pretest and posttest (15.3% vs. 14.0%; p=0.842). Further, there were no differences in median midazolam day doses (2.8 vs. 2.9 mg/kg; p=0.799) and morphine doses (0.18 vs. 0.22 mg/kg; p=0.797). No mobilization related adverse events were documented after implementation of the EM program.

Conclusion

Implementation of a structured EM program in PICU patients is feasible and resulted in no adverse events.

Background

Reviewing sedation is a key component of care for mechanically ventilated PICU patients. However, there is also evidence that assessment and management of sedation is an important component in patient mobilisation¹.

Objectives

To conduct a service evaluation (SE) of a single-site 30-bed PICU of how ‘sedation’ (including scores, level, medication requirement) and mobilisation were discussed during medical ward-rounds.

Methods

A data collection tool informed by literature and multi-disciplinary PICU staff was developed and piloted. Data collection was conducted by an independent, trained observer and included a review of documented sedation scores and verbal discussion. Observations occurred during medical ward-rounds; morning (08:30) and afternoon (16:30).

Results

14 ward-rounds were attended (July-August 2018); 08.30(n=9) and 16.00(n=6). 120 complete patient discussions were observed; 71 patients were intubated and ventilated (59%); all of whom had their sedation discussed. Sedation was also well reviewed in patients receiving sedation (71/81; 88%). However sedation scores were recorded only 19% (21/109) of the time and never referred to within ward-round discussions. Mobilisation was mentioned in only 11/120 observations (9%); commonly when the patient was not receiving sedation (n=7) and not intubated (n=6).

Conclusion

Although review of sedation is common during PICU ward-rounds, there is a lack of consistency in discussions, with sedation scores poorly documented and used. Sedation is rarely referred to in relation to mobilisation and planning to mobilise is not a core component of ward-round discussions. Further work is required to promote the use of sedation scores, optimise sedation levels and promote consideration of mobilisation.

Background

Achieving adequate nutrition in preterm or very sick infants is vital but equally challenging for different reasons.

Objectives

Objective

To describe practices around gastric residual volume (GRV) measurement in UK neonatal units (NNUs) as part of a feasibility study.

Methods

Methods

Cross-sectional electronic survey of all UK neonatal units, in October 2018. A doctor, nurse and dietician triad were asked to complete the survey collaboratively.

Results

Results

95/183 (52%) NNUs completed the survey, a mixture of neonatal intensive care units (71%), local neonatal units (47%) and special care baby units (33%). 85% (81/95) NNUs had written guidance around enteral feeding. Most (94.7% 90/95) units fed by bolus feed with only 5% feeding continuously. 42% NNUs provided guidance around GRV measurement. 29% (5/17) NNUs that admitted both medical and surgical babies reported having different guidance for these different babies. NNUs reported variable frequency of GRV measurement from before every feed (22%) to only when clinically indicated 30% with a range of ‘other’ responses. Decision-making around GRV aspirate was made predominantly by the bedside nurse (62.2%) or nurse in charge (28.9%).

Conclusion

Conclusions

The routine measurement of GRV remains a common practice in UK NNUs, further work will explore in more detail clinicians and parental views around this practice.

Funding acknowledgement
This study was funded by the NIHR HTA ref 16/94/02

Department of Health and Social Care disclaimer
The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.