What impact did a Paediatric Early Warning system have on emergency admissions to the paediatric intensive care unit? An observational cohort study

Summary The ideology underpinning Paediatric Early Warning systems (PEWs) is that earlier recognition of deteriorating in-patients would improve clinical outcomes. Objective To explore how the introduction of PEWs at a tertiary children's hospital affects emergency admissions to the Paediatric Intensive Care Unit (PICU) and the impact on service delivery. To compare ‘in-house’ emergency admissions to PICU with ‘external’ admissions transferred from District General Hospitals (without PEWs). Method A before-and-after observational study August 2005–July 2006 (pre), August 2006–July 2007 (post) implementation of PEWs at the tertiary children's hospital. Results The median Paediatric Index of Mortality (PIM2) reduced; 0.44 vs 0.60 (p < 0.001). Fewer admissions required invasive ventilation 62.7% vs 75.2% (p = 0.015) for a shorter median duration; four to two days. The median length of PICU stay reduced; five to three days (p = 0.002). There was a non-significant reduction in mortality (p = 0.47). There was no comparable improvement in outcome seen in external emergency admissions to PICU. A 39% reduction in emergency admission total beds days reduced cancellation of major elective surgical cases and refusal of external PICU referrals. Conclusions Following introduction of PEWs at a tertiary children's hospital PIM2 was reduced, patients required less PICU interventions and had a shorter length of stay. PICU service delivery improved

Tree composition and distribution in Federal University of Agriculturema Kurdi, Nigeria

Savannah ecosystem plays an important role in the welfare and economy of man. It is at the center of human activities which greatly influence the structure, composition and abundance of all plants life forms. In recent time, there is upsurge of interest in conservation of African Savannah; however, there is dearth of accurate data on conservation and distribution of tree species in many part of Africa, of which Federal University of Agriculture Makurdi is not left out. This study therefore assessed tree species composition  and distribution in Federal University of Agriculture Makurdi. Stratified and systematic sampling  technique were applied in the laying of transects and plots. Four transects of 2km were laid in four land  use types of Undisturbed area, Plantation, Wildlife Park and Residential Area. On each transects 4 plots of 50 50m were laid at regular interval of 500m. Species composition, species richness, evenness, diversity  and similarity were estimated across the land use types. Data were analyzed using descriptive  statistics. A total of 52 tree species in 48 genera and 22 families were recorded, with undisturbed area  having the highest number of species of 26. Forty five percent families were represented by only one  species. Species richness, evenness and diversity decreases from undisturbed area to residential area  (D= 6.091-2.695), ( J= 0.821-0.671), ( H1= 3.39-2.24). Undisturbed area and Wildlife Park were closely related. Even though, undisturbed area had the highest number of species, most of the species were  juvenile species. It was recommended that Federal University of Agriculture Makurdi authority  conservation effort be stepped up on the campus.Key words: Abundance, conservation, distribution, Species composition, Structure

Considerations for nutrition support in critically ill children with COVID-19 and paediatric inflammatory multisystem syndrome temporally associated with COVID-19

The aim of this editorial is to provide an adaptation of nutrition support recommendations for the overall population of critically ill children, to provide further refined recommendations for critically ill children presenting with COVID-19 or paediatric hyper-inflammatory syndrome temporally associated with COVID-19. They are based on the ESPNIC-MEN section recommendations published in January 2020 (6) and Surviving Sepsis Campaign recommendations from February 2020 (7). These recommendations cover the acute, stable and rehabilitation phases (Table 1, Table 2)

Optimising paediatric afferent component early warning systems : a hermeneutic systematic literature review and model development

Objective: To identify the core components of successful early warning systems for detecting and initiating action in response to clinical deterioration in paediatric inpatients. Methods: A hermeneutic systematic literature review informed by translational mobilisation theory and normalisation process theory was used to synthesise 82 studies of paediatric and adult early warning systems and interventions to support the detection of clinical deterioration and escalation of care. This method, which is designed to develop understanding, enabled the development of a propositional model of an optimal afferent component early warning system. Results: Detecting deterioration and initiating action in response to clinical deterioration in paediatric inpatients involves several challenges, and the potential failure points in early warning systems are well documented. Track and trigger tools (TTT) are commonly used and have value in supporting key mechanisms of action but depend on certain preconditions for successful integration into practice. Several supplementary interventions have been proposed to improve the effectiveness of early warning systems but there is limited evidence to recommend their wider use, due to the weight and quality of the evidence; the extent to which systems are conditioned by the local clinical context; and the need to attend to system component relationships, which do not work in isolation. While it was not possible to make empirical recommendations for practice, the review methodology generated theoretical inferences about the core components of an optimal system for early warning systems. These are presented as a propositional model conceptualised as three subsystems: detection, planning and action. Conclusions: There is a growing consensus of the need to think beyond TTTs in improving action to detect and respond to clinical deterioration. Clinical teams wishing to improve early warning systems can use the model to consider systematically the constellation of factors necessary to support detection, planning and action and consider how these arrangements can be implemented in their local context

The physical effects of wearing personal protective equipment: a scoping review

Background: The COVID-19 pandemic has required healthcare workers to wear personal protective equipment (PPE), and although there is increasing awareness of the physical effects of wearing PPE, the literature has yet to be synthesised around this topic. Methods: A scoping review was conducted to synthesise existing literature on the physical effects of wearing PPE and identify gaps in the literature. A comprehensive search strategy was undertaken using five databases from 1995 to July 2020. Results: A total of 375 relevant articles were identified and screened. Twenty-three studies were included in this review. Studies were conducted across 10 countries, spanning 16 years from 2004 to 2020. Half (13/23) were randomised controlled trials or quasi-experimental studies, five surveys, two qualitative studies, two observational or case series and one Delphi study. Most (82%, 19/23) studies involved the N95 mask (either valved or unvalved). None specifically studied the filtering facepiece 3 mask. The main physical effects relate to skin irritation, pressure ulcers, fatigue, increased breathing resistance, increased carbon dioxide rebreathing, heat around the face, impaired communication and wearer reported discomfort. Few studies examined the impact of prolonged wear (akin to real life practice) on the physical effects, and different types of PPE had different effects. Conclusions: The physical effects of wearing PPE are not insignificant. Few studies examined the physiological impact of wearing respiratory protective devices for prolonged periods whilst conducting usual nursing activity. No ideal respirators for healthcare workers exist, and the development of more ergonomic designs of PPE is required

Pilot Study Comparing Closed Versus Open Tracheal Suctioning in Postoperative Neonates and Infants With Complex Congenital Heart Disease

Objectives: To determine the hemodynamic effect of tracheal suction method in the first 36 hours after high-risk infant heart surgery on the PICU and to compare open and closed suctioning techniques. Design: Pilot randomized crossover study. Setting: Single PICU in United Kingdom. Participants: Infants undergoing surgical palliation with Norwood Sano, modified Blalock-Taussig shunt, or pulmonary artery banding in the first 36 hours postoperatively. Interventions: Infants were randomized to receive open or closed (in-line) tracheal suctioning either for their first or second study tracheal suction in the first 36 hours postoperatively. Measurements and Main Results: Twenty-four infants were enrolled over 18 months, 11 after modified Blalock-Taussig shunt, seven after Norwood Sano, and six after pulmonary artery banding. Thirteen patients received the open suction method first followed by the closed suction method second, and 11 patients received the closed suction method first followed by the open suction method second in the first 36 hours after their surgery. There were statistically significant larger changes in heart rate (p = 0.002), systolic blood pressure (p = 0.022), diastolic blood pressure (p = 0.009), mean blood pressure (p = 0.007), and arterial saturation (p = 0.040) using the open suction method, compared with closed suctioning, although none were clinically significant (defined as requiring any intervention). Conclusions: There were no clinically significant differences between closed and open tracheal suction methods; however, there were statistically significant greater changes in some hemodynamic variables with open tracheal suctioning, suggesting that closed technique may be safer in children with more precarious physiology. (Pediatr Crit Care Med 2017; XX:00–00

Planned peri-extubation fasting in critically ill children: an international survey of practice

Introduction: Cumulative energy/protein deficit is associated with impaired outcomes in pediatric intensive care Units (PICU). Enteral nutrition is the preferred mode, but its delivery may be compromised by periods of feeding interruptions around procedures, with peri-extubation fasting the most common procedure. Currently, there is no evidence to guide the duration of the peri-extubation fasting in PICU. Therefore, we aimed to explore current PICU fasting practices around the time of extubation and the rationales supporting them. Material and methods: A cross sectional electronic survey was disseminated via the European Paediatric Intensive Care Society (ESPNIC) membership. Experienced senior nurses, dieticians or doctors were invited to complete the survey on behalf of their unit, and to describe their practice on PICU fasting prior to and after extubation. Results: We received responses from 122 PICUs internationally, mostly from Europe. The survey confirmed that fasting practices are often extrapolated from guidelines for fasting prior to elective anaesthesia. However, there were striking differences in the duration of fasting times, with some units not fasting at all (in patients considered to be low risk), while others withheld feeding for all patients. Fasting following extubation also showed large variations in practice, with some units withholding nutrition for many hours, and others starting oral feeding based on child demand. The risk of vomiting/aspiration and reducing nutritional deficit were the main reasons for fasting children or reducing fasting times respectively. Discussion: This variability in practices suggests that shorter fasting times might be safe. Shortening the duration of unnecessary fasting, as well as accelerating the extubation process could potentially be achieved by using other methods of assessing gastric emptiness, such as gastric point of care ultrasonography (POCUS). Yet only half of the units were aware of this technique, and very few used it

Practical strategies to implement the ESPNIC nutrition clinical recommendations into PICU practice

Background: The European Society of Pediatric and Neonatal Intensive Care (ESPNIC) published 32 clinical recommendations around supporting nutrition in critically ill children following an extensive review of the literature online in January 2020. The challenge now is to engage with paediatric intensive care unit teams to implement these into their practice. Objective: This practical implementation guide uses a recognised implementation model to guide pediatric intensive care professionals to implement these evidence-based clinical recommendations into clinical practice. Results and conclusions: We use the Pronovost implementation of evidence into practice model to provide a practical framework with associated documents to facilitate PICU healthcare professional's implementation of these clinical recommendations into PICU practice. The paper is structured around the four steps in this model: summarising the evidence, identifying local barriers to implementation, measuring performance and ensuring all patients receive the intervention and useful checklists for implementation and compliance monitoring are provided, in addition to tables outlining key professional roles and responsibilities around nutrition in the paediatric intensive care unit

The implausibility of ‘usual care’ in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK)

Background: The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention. Methods: Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff. Results: Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision. Conclusions: We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes

Gastric point-of-care ultrasound in acutely and critically ill children (POCUS-ped): a scoping review

Point-of-care ultrasound (POCUS) use is increasing in pediatric clinical settings. However, gastric POCUS is rarely used, despite its potential value in optimizing the diagnosis and management in several clinical scenarios (i.e., assessing gastric emptying and gastric volume/content, gastric foreign bodies, confirming nasogastric tube placement, and hypertrophic pyloric stenosis). This review aimed to assess how gastric POCUS may be used in acute and critically ill children. An international expert group was established, composed of pediatricians, pediatric intensivists, anesthesiologists, radiologists, nurses, and a methodologist. A scoping review was conducted with an aim to describe the use of gastric POCUS in pediatrics in acute and critical care settings. A literature search was conducted in three databases, to identify studies published between 1998 and 2022. Abstracts and relevant full texts were screened for eligibility, and data were extracted, according to the JBI methodology (Johanna Briggs Institute). A total of 70 studies were included. Most studies ( = 47; 67%) were conducted to assess gastric emptying and gastric volume/contents. The studies assessed gastric volume, the impact of different feed types (breast milk, fortifiers, and thickeners) and feed administration modes on gastric emptying, and gastric volume/content prior to sedation or anesthesia or during surgery. Other studies described the use of gastric POCUS in foreign body ingestion ( = 6), nasogastric tube placement ( = 5), hypertrophic pyloric stenosis ( = 8), and gastric insufflation during mechanical ventilatory support ( = 4). POCUS was performed by neonatologists, anesthesiologists, emergency department physicians, and surgeons. Their learning curve was rapid, and the accuracy was high when compared to that of the ultrasound performed by radiologists (RADUS) or other gold standards (e.g., endoscopy, radiography, and MRI). No study conducted in critically ill children was found apart from that in neonatal intensive care in preterms. Gastric POCUS appears useful and reliable in a variety of pediatric clinical settings. It may help optimize induction in emergency sedation/anesthesia, diagnose foreign bodies and hypertrophic pyloric stenosis, and assist in confirming nasogastric tube placement, avoiding delays in obtaining confirmatory examinations (RADUS, x-rays, etc.) and reducing radiation exposure. It may be useful in pediatric intensive care but requires further investigation. [Abstract copyright: Copyright © 2022 Valla, Tume, Jotterand Chaparro, Arnold, Alrayashi, Morice, Nabialek, Rouchaud, Cercueil and Bouvet.