49 research outputs found
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
Respiratory viruses in the pediatric intensive care unit: prevalence and clinical aspects
Hypothermia for encephalopathy in low and middle-income countries (HELIX): study protocol for a randomised controlled trial
Extracorporeal Membrane Oxygenation for Acute Pediatric Respiratory Failure
This article is made available for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.The use of extracorporeal membrane oxygenation (ECMO) to support children with acute respiratory failure has steadily increased over the past several decades, with major advancements having been made in the care of these children. There are, however, many controversies regarding indications for initiating ECMO in this setting and the appropriate management strategies thereafter. Broad indications for ECMO include hypoxia, hypercarbia, and severe air leak syndrome, with hypoxia being the most common. There are many disease-specific considerations when evaluating children for ECMO, but there are currently very few, if any, absolute contraindications. Venovenous rather than veno-arterial ECMO cannulation is the preferred configuration for ECMO support of acute respiratory failure due to its superior side-effect profile. The approach to lung management on ECMO is variable and should be individualized to the patient, with the main goal of reducing the risk of VILI. ECMO is a relatively rare intervention, and there are likely a minimum number of cases per year at a given center to maintain competency. Patients who have prolonged ECMO runs (i.e., greater than 21 days) are less likely to survive, though no absolute duration of ECMO that would mandate withdrawal of ECMO support can be currently recommended