Author Of 4 Presentations
ENTEROVIRUS D68 ASSOCIATED ACUTE FLACCID PARALYSIS IN UK CHILDREN - DO WE HAVE A PROBLEM?
Abstract
Background
Enterovirus D68 is a non-poliovirus, spread by respiratory droplets, which in rare circumstances has been associated with an acute flaccid paralysis (AFP). In 2014 there was an outbreak of this strain in the USA and Northern Europe, leading to five cases of AFP in Colorado and two cases in Norway.
Objectives
Following two recent cases of children admitted to PICU in Nottingham with AFP secondary to Enterovirus D68, it was decided to survey all of the UK Paediatric Intensive Care Units, to identify whether these were isolated incidents.
Methods
A survey was conducted amongst 24 PICUs in the UK confirming cases of AFP associated with Enterovirus D68 during 2018. They were asked about the patient’s age and whether or not the patient required tracheostomy ventilation long term.
Results
Of the 24 PICUs contacted, 21 responded to the survey. There were 10 cases of confirmed D68 AFP in 2018, with ages ranging from 8 months to 6 years. 40% of cases were located in the East Midlands and South Yorkshire, with 70% requiring long-term ventilation, and at least 50% of patients requiring tracheostomy.
Conclusion
Our experience in Nottingham has been reflected in other parts of the UK, and is suggestive of a possible outbreak of AFP associated with Enterovirus D68. This emerging problem is concerning, with significant long term implications for health and resource utilisation.
LOW RATES OF ADMINISTRATION OF PNEUMOCOCCAL VACCINATION IN OPEN HEAD TRAUMA DESPITE NATIONAL GUIDANCE
Abstract
Background
Invasive pneumococcal disease is a major cause of morbidity and mortality and is significantly more common in patients with open head trauma than the general population. Public Health England recommends that all such patients receive pneumococcal vaccination.
Objectives
Our aim was to assess whether patients presenting with open head trauma were immunised during their admission.
Methods
Analysis of digital health records, hospital reporting systems, and pharmacy dispensing for patients admitted to PICU between 01/01/2012–01/06/2018 identified 94 patients with major head trauma. 46 were excluded as their skull fracture was closed or notes were unavailable.
Results
48 patients had open head trauma. 15 (31%) received pneumococcal immunisation during their admission. 33 (69%) did not. 1 child presented 18 months post injury with devastating pneumococcal meningitis (albeit a strain not covered by the vaccination). Another received a prolonged course of antibiotics during her initial presentation for assumed meningitis (although all cultures were negative). Neither of these were immunised.
Conclusion
Our administration record was well below expected standards. We have contacted patients who did not receive pneumococcal vaccination and are arranging community administration. We are adding safeguards to ensure eligible patients are immunised at initial presentation. We plan to re-audit our performance 2 years after making these changes.
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THE USE OF ELECTRICAL IMPEDANCE TOMOGRAPHY (EIT) FOR THE QUANTIFICATION OF IDEAL PEEP IN PATIENTS WITH BRONCHIOLITIS
Abstract
Background
Establishing the ideal PEEP (PEEPid) is a challenge; the balance between collapse and over distension is difficult to assess. Electrical Impedance Tomography (EIT) can be used to evaluate the regional compliance changes at different PEEP levels, measuring areas of collapse and over distention.
Objectives
Evaluate the PEEPid in patients with bronchiolitis.
Methods
Patients with bronchiolitis ventilated on PICU were included. We used a Pulmovista 500 (Draeger) electrical impedance tomography monitor and a 16 electrode belt; a decremental PEEP (14/12/10/8/6/4 cmH2O) was applied over 10 minutes. Data was collected prior and 2, 4, and 6 hours after the trial. PEEPid was defined as the point of best compliance.
Results
38 PEEP trials were done in 27 children with no adverse events. Mean age was 8.5 months (1-27) and weight 6.6 kg (12.5-4). Initial mean satO2 was 94% with a mean FiO2 of 0.45 and a PEEP of 7.9 (5-10) cmH2O. PEEPid was more broadly distributed: 6/37 patients were at the PEEPid, with 14 patients starting at below and 10 above the PEEPid.There was no association between PEEPid and age. Patients varying from PEEPid had increasing compliance loss with increasing distance from PEEPid+ or – 2cmH2O meant a compliance loss of 14.2 or 12.9%, with over 30% for variations of 6cm H2O.
Conclusion
PEEP trials are feasible and practicable in children with bronchiolitis. PEEP levels prior to PEEP trials were different to PEEPid in 31/37 patients. Population predictions of PEEPid cannot be made. Compliance loss increases rapidly the further from the PEEPid the patient is set.
CONTINUOUS DRUG DELIVERY IS SIGNIFICANTLY AFFECTED BY CHANGES OF RELATIVE HEIGHT BETWEEN PATIENT AND SYRINGE DRIVER
Abstract
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.