Management of tetralogy of Fallot in the pediatric intensive care unit

Tetralogy of Fallot (ToF) is one of the most common congenital cyanotic heart lesions and can present to a variety of health care professionals, including teams working in pediatric intensive care. Pediatric intensive care teams may care for a child with ToF pre-operatively, peri-operatively, and post-operatively. Each stage of management presents its own unique challenges. In this paper we discuss the role of pediatric intensive care in each stage of management

Transport of critically ill children to paediatric intensive care units in the UK and Ireland: 2013–2022

Objective: To explore the trends and changes in the transport of children to paediatric intensive care units (PICUs) between 2013 and 2022. Design: Retrospective analysis of routinely collected data. Patients: Children transported for care in a PICU in the UK and Ireland aged<16 years. Interventions: None. Measurements and main results: There were 43 058 transports to a PICU involving 36 438 children from 2013 to 2022 with the majority of children requiring only one transport. The number of transports increased from 4131 (2013) to 4792 (2022). Over the study period the percentage of children aged under 1 year who were transported decreased from 50.2% to 45.2% and similarly, the percentage who were invasively ventilated also decreased from 81.1% to 70.2%. Conversely, the use of non-invasive ventilation during transports increased slightly from 4.0% to 7.0%. The percentage of transports where a parent was able to accompany the child increased over time (2013: 66.2% to 2019: 74.9%), although there were reductions due to the COVID-19 pandemic and requirements for social distancing (2020: 52.4%). Conclusions: We have demonstrated an increased use of specialist paediatric transport services and changes in the PICU population over time. Routine data collection from the transport services provide a means to measure improvements and changes over time in the service provided to critically ill children and young people who need transport to the PICU

Psychological impact of working in paediatric intensive care. A UK-wide prevalence study

OBJECTIVE: To determine the prevalence of work-related psychological distress in staff working in UK paediatric intensive care units (PICU). DESIGN: Online (Qualtrics) staff questionnaire, conducted April to May 2018. SETTING: Staff working in 29 PICUs and 10 PICU transport services were invited to participate. PARTICIPANTS: 1656 staff completed the survey: 1194 nurses, 270 physicians and 192 others. 234 (14%) respondents were male. Median age was 35 (IQR 28-44). MAIN OUTCOME MEASURES: The Moral Distress Scale-Revised (MDS-R) was used to look at moral distress, the abbreviated Maslach Burnout Inventory to examine the depersonalisation and emotional exhaustion domains of burnout, and the Trauma Screening Questionnaire (TSQ) to assess risk of post-traumatic stress disorder (PTSD). RESULTS: 435/1194 (36%) nurses, 48/270 (18%) physicians and 19/192 (10%) other staff scored above the study threshold for moral distress (≥90 on MDS-R) (χ2 test, p<0.00001). 594/1194 (50%) nurses, 99/270 (37%) physicians and 86/192 (45%) other staff had high burnout scores (χ2 test, p=0.0004). 366/1194 (31%) nurses, 42/270 (16%) physicians and 21/192 (11%) other staff scored at risk for PTSD (χ2 test, p<0.00001). Junior nurses were at highest risk of moral distress and PTSD, and junior doctors of burnout. Larger unit size was associated with higher MDS-R, burnout and TSQ scores. CONCLUSIONS: These results suggest that UK PICU staff are experiencing work-related distress. Further studies are needed to understand causation and to develop strategies for prevention and treatment

Ultrasound and cadaveric prosections as methods for teaching cardiac anatomy: a comparative study.

This study compared the efficacy of two cardiac anatomy teaching modalities, ultrasound imaging and cadaveric prosections, for learning cardiac gross anatomy. One hundred and eight first-year medical students participated. Two weeks prior to the teaching intervention, students completed a pretest to assess their prior knowledge and to ensure that groups were equally randomized. Students, divided into pre-existing teaching groups, were assigned to one of two conditions; "cadaver" or "ultrasound." Those in the cadaver group received teaching on the heart using prosections, whereas the ultrasound group received teaching using live ultrasound images of the heart. Immediately after teaching, students sat a post-test. Both teaching modalities increased students' test scores by similar amounts but no significant difference was found between the two conditions, suggesting that both prosections and ultrasound are equally effective methods for teaching gross anatomy of the heart. Our data support the inclusion of either cadaveric teaching or living anatomy using ultrasound within the undergraduate anatomy curriculum, and further work is needed to compare the additive effect of the two modalities

Preoperative bioelectrical impedance predicts intensive care length of stay in children following cardiac surgery

We have previously shown that children with a bioelectrical impedance spectroscopy phase angle at 50° (PA 50°) of &lt;2.7 on postoperative day 2 had a four-fold increase in the risk of prolonged paediatric intensive care length of stay. In this study, we demonstrate a relationship between a baseline measure of phase angle 200/5° and postoperative length of stay.</p

Impact of child death on paediatric trainees

ObjectiveTo assess the prevalence of symptoms of acute stress reactions (ASR) and post-traumatic stress disorder (PTSD) in paediatric trainees following their involvement in child death.DesignA survey designed to identify trainees’ previous experiences of child death combined with questions to identify features of PTSD. Quantitative interpretation was used alongside a χ2 test. A p value of &lt;0.05 was considered significant.Setting604 surveys were distributed across 13 UK health education deaneries.Participants303/604 (50%) of trainees completed the surveys.Results251/280 (90%) of trainees had been involved with the death of a child, although 190/284 (67%) had no training in child death. 118/248 (48%) of trainees were given a formal debrief session following their most recent experience. 203/251 (81%) of trainees reported one or more symptoms or behaviours that could contribute to a diagnosis of ASR/PTSD. 23/251 (9%) of trainees met the complete criteria for ASR and 13/251 (5%) for PTSD. Attending a formal debrief and reporting feelings of guilt were associated with an increase in diagnostic criteria for ASR/PTSD (p=0.036 and p&lt;0.001, respectively).ConclusionsPaediatric trainees are at risk of developing ASR and PTSD following the death of a child. The feeling of guilt should be identified and acknowledged to allow prompt signposting to further support, including psychological assessment or intervention if required. Clear recommendations need to be made about the safety of debriefing sessions as, in keeping with existing evidence, our data suggest that debrief after the death of a child may be associated with the development of symptoms suggestive of ASR/PTSD.</jats:sec

Acute kidney injury and short-term renal support in the post-operative management of neonates following repair of transposition of the great arteries

Neonates requiring congenital cardiac surgery are at risk of acute kidney injury, associated with significant morbidity, mortality, and increased hospital length of stay; treatment may require renal replacement therapy. Data for single cardiac defect cohorts is important to stratify risk, but is lacking for transposition of the great arteries. Our study aimed at collecting data for this single lesion. A single-centre, retrospective analysis of 71 cases of arterial switch operation in neonates with isolated transposition of the great arteries, or transposition of the great arteries with ventricular septal defect, including length of stay, renal function and need for renal replacement therapy was performed. Acute kidney injury developed in 50.7%, and was associated with longer paediatric intensive care and hospital stays (p &lt; 0.05). Paediatric intensive care unit length of stay correlated with higher peak creatinine and urea (p &lt; 0.05) and also with higher lactate levels at paediatric intensive care unit admission and 1 and 6 h post-admission (p &lt; 0.05). Renal replacement therapy via peritoneal dialysis was delivered to 11.1%, but this was not found to prolong paediatric intensive care unit length of stay. Initiation of renal replacement therapy was associated with a positive fluid balance at 1 and 6 h (p &lt; 0.05). This study analyses renal outcomes in a cohort of neonates with transposition of the great arteries undergoing an arterial switch operation. Acute kidney injury is a significant complication, with accompanying need for renal replacement therapy. Development of acute kidney injury and a positive fluid balance were associated with increased length of stay. Initiation of renal replacement therapy was not associated with increased length of stay, and with some evidence from the literature that early or prophylactic peritoneal dialysis catheter insertion improves outcomes, these data report minimal complication rates which may be important when deciding to utilise peritoneal dialysis