Dressings and securement devices to prevent complications for peripheral arterial catheters

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To compare the effectiveness of dressings and securement devices for peripheral arterial catheters

Implementing paediatric appropriate use criteria for endotracheal suction to reduce complications in mechanically ventilated children with respiratory infections

BackgroundEndotracheal suction is used to maintain endotracheal tube patency. There is limited guidance to inform clinical practice for children with respiratory infections.ObjectiveThe objective of this study was to determine whether implementation of a paediatric endotracheal suction appropriate use guideline Paediatric AirWay Suction (PAWS) is associated with an increased use of appropriate and decreased use of inappropriate suction interventions.MethodsA mixed-method, pre-implementation–post-implementation study was conducted between September 2021 and April 2022. Suction episodes in mechanically ventilated children with a respiratory infection were eligible. Using a structured approach, we implemented the PAWS guideline in a single paediatric intensive care unit. Evaluation included clinical (e.g., suction intervention appropriateness), implementation (e.g., acceptability), and cost outcomes (implementation costs). Associations between implementation of the PAWS guideline and appropriateness of endotracheal suction intervention use were investigated using generalised linear models.ResultsData from 439 eligible suctions were included in the analysis. Following PAWS implementation, inappropriate endotracheal tube intervention use reduced from 99% to 58%, an absolute reduction (AR) of 41% (95% confidence interval [CI]: 25%, 56%). Reductions were most notable for open suction systems (AR: 48%; 95% CI: 30%, 65%), 0.9% sodium chloride use (AR: 23%; 95% CI: 8%, 38%) and presuction and postsuction manual bagging (38%; 95% CI: 16%, 60%, and 86%; 95% CI: 73%, 99%), respectively. Clinicians perceived PAWS as acceptable and suitable for use.ConclusionsImplementation of endotracheal tube suction appropriate use guidelines in a mixed paediatric intensive care unit was associated with a large reduction in inappropriate suction intervention use in paediatric patients with respiratory infections

“When no-one's looking,” the application of lung recruitment and normal saline instillation with paediatric endotracheal suction: An exploratory study of nursing practice

BackgroundThe complex nature of the Paediatric Intensive Care Unit (PICU) patient requires the bedside nurse to make rapid, complex decisions regarding endotracheal suction (ETS) interventions. It is not understood what influences nurses’ decision making in the context of ETS, however, the actions of the clinician have a direct impact on the efficacy of the ETS event and patient outcomes.ObjectivesTo explore and describe the use of normal saline instillation and lung recruitment with paediatric ETS in a cohort of Australian nurses, and to identify factors that influence normal saline use with ETS.MethodsA descriptive, exploratory study. An evidence-based practice model formed the conceptual basis for the study. Semi-structured interviews were conducted with 12 nurses from an Australian tertiary referral paediatric intensive care unit. Audiotaped interviews were transcribed. Inductive thematic analysis was used to code and analyse the interview data and identify themes.FindingsData analysis revealed three themes: patient’s clinical presentation, clinician judgement and unit practice norms.ConclusionsVariability in nurses ETS practice was marked. In the absence of evidence based clinical guidelines, nurses relied on knowledge derived from clinical experience and the local setting to guide NSI and LR intervention decisions. Participants reported uncertainty regarding ETS best practice and perceived the lack of research evidence as a barrier to making informed clinical decisions at the bedside. Rigorous research evaluating the safety and efficacy of NSI and LR with ETS is urgently required for patient care; however PICU nurses rely on multiple sources of evidence to inform ETS practice decision

Normal Saline and Lung Recruitment With Paediatric Endotracheal Suction:A Review and Critical Appraisal of Practice Recommendations

Background: Normal saline instillation (NSI) and lung recruitment manoeuvres (RMs) are used in conjunction with endotracheal suction (ETS) in mechanically ventilated children. Practice is varied, and it is not currently understoodwhat clinical practice guidelines (CPGs) are available to inform practice decisions. Objective: The aimof this studywas to identify and systematically reviewthe quality of existing ETS CPGs, specifically in the context of NSI and RM use. Methods: A systematic search for ETS CPGs in children (<18 years old) was conducted in Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PubMed, EMBASE, and Google Scholar. Two independent assessors evaluated CPGs using the Appraisal of Guidelines for Research and Evaluation II instrument. Standardised scores were calculated for individual CPGs, and scale domain scores were calculated. Results: Four CPGs and practice recommendations from 2 literature reviews were identified and evaluated. The routine use of NSI and RMs with paediatric ETS was not recommended. Recommendations reflected the low quality and limited availability of evidence to inform NSI and RM application. Collectively, the highest scoring domain was clarity of presentation, followed by scope and purpose (78). Overall assessments ranged from 8 to 100 from a possible 100 points. Four ETS CPGs (100%) were recommended for use with modification. Conclusions: Clinical practice guidelines and practice recommendations pertaining to NSI and RM were consistent but, however, limited by the quality and volume of available evidence. Clinical practice guideline developers should focus on improving the applicability and rigour in development processes. Further consensus work and rigorous trials are needed to inform future CPGs. </p

Adverse events and practice variability associated with paediatric endotracheal suction: An observational study

Objective: The objective of this study was to determine the incidence of endotracheal tube (ETT) suction–related adverse events (AEs) and to examine associations between AEs and patient and suction characteristics. Secondary objectives were to describe ETT suction practices in an Australian paediatric intensive care unit (PICU). Methods: A prospective, observational study was undertaken in a mixed cardiac and general PICU. Children were eligible for inclusion if they were intubated and mechanically ventilated. Data on patient and suction variables (indication for ETT suction, number of suction episodes per mechanical ventilation episode, indication for normal saline instillation [NSI] and NSI dose) including potential predictive variables (age, Paediatric Index of Mortality 3 [PIM3], NSI, positive end-expiratory pressure, and hyperoxygenation) were collected. The main outcome variable was a composite measure of any AE. Main results: A total of 955 suction episodes were recorded in 100 children. AEs occurred in 211 (22%) ETT suctions. Suction-related AEs were not associated with age, diagnostic category, or index of mortality score. Desaturation was the most common AE (180 suctions; 19%), with 69% of desaturation events requiring clinician intervention. Univariate logistic regression showed the odds of desaturation decreased as the internal diameter of the ETT increased (odds ratio [OR]: 0.59; 95% confidence interval [CI]: 0.37–0.95; p = 0.028). Multivariable modelling revealed NSI was significantly associated with an increased risk of desaturation (adjusted OR [aOR]: 3.23; 95% CI: 1.99–5.40; p 2) was significantly associated with an increased risk of experiencing an AE (aOR: 2.0; 95% CI: 1.27–3.15; p = 0.003). Conclusions: ETT suction–related AEs are common and associated with NSI and the requirement for pre-suction increases in FiO2. Clinical trial data are needed to identify high-risk patient groups and to develop interventions which optimise practice and reduce the occurrence of ETT suction–related AEs.</p

mHealth Applications for Children and Young People With Persistent Pain: A Scoping Review

Persistent pain is a global health care issue affecting more than 30% of children and young people. mHealth applications delivered using smartphones, are an innovative method to engage children in pain self-management. This article outlines the evidence concerning the development, implementation, and evaluation of mHealth apps for these children in terms of feasibility, acceptability, and impact on important pain outcomes such as quality of life and health care utilization

Flushing of peripheral intravenous catheters: A pilot, factorial, randomised controlled trial of high versus low frequency and volume in paediatrics

Aim: To test the feasibility of an efficacy trial comparing different flushing frequencies and volumes to reduce peripheral intravenous cannula (PIVC) failure in paediatric inpatients. Methods: Pilot, 2 × 2 factorial, randomised controlled trial comparing PIVC flushing techniques in intervention pairs: (i) low volume (3 mL) versus high volume (10 mL); and (ii) low frequency (24 hourly) versus high frequency (6 hourly). Patients were excluded if: fluids were restricted, weight 24 h or continuous infusion. The primary end-point was feasibility (eligibility, recruitment, retention, protocol adherence, missing data and sample size estimates) of a large trial. Secondary end-points were PIVC failure (composite and individual), bloodstream infection and mortality. Results: A total of 919 children were screened from April to November 2015, with 55 enrolled. Screening feasibility criteria were not met, mainly due to continuous infusions and PIVCs in situ >24 h or planned for imminent removal. However, 80% of eligible participants consented, 2% withdrew, protocol adherence was 100%, and there was no missing primary end-point data. PIVC failure was significantly higher (hazard ratio = 2.90, 95% confidence interval: 1.11–7.54) in the 3 mL compared to the 10 mL group. There was no difference in failure between frequency groups (hazard ratio = 0.91, 95% confidence interval: 0.36–2.33). There was no interaction effect (P = 0.22). Conclusion: Trial feasibility proved challenging due to eligibility criteria, which could be improved with additional recruiting staff. Firm conclusions cannot be made based on this small sample, but flush volume may impact PIVC failure

Normal saline instillation versus no normal saline instillation And lung Recruitment versus no lung recruitment with paediatric Endotracheal Suction: the NARES trial. A study protocol for a pilot, factorial randomised controlled trial

Introduction: Endotracheal suction (ETS) is a frequent and necessary airway intervention for the intubated child. The aim of ETS is to clear the endotracheal tube and airways of respiratory secretions; however, the methods of performing ETS are varied. Internationally a number of ETS treatments are in use. Many have not been rigorously evaluated in a randomised controlled trial setting, and it is uncertain whether any are associated with better outcomes for the critically ill child. With approximately 50% of paediatric intensive care admissions requiring intubation, ETS interventions that maximise the efficacy and minimise the complications of ETS could translate to improved health for substantial numbers of critically ill children, and significant cost savings. The primary aim of the study is to examine two ETS interventions, normal saline instillation and lung recruitment, to determine if it is feasible to conduct a full efficacy trial.Methods and analysis: NARES (Normal saline instillation versus no normal saline instillation And lung Recruitment versus no lung recruitment with paediatric Endotracheal Suction) is a single-centre, pilot, factorial randomised controlled trial conducted in a tertiary referral paediatric centre in Brisbane, Australia. Children (aged 0–16 years) are eligible if they are intubated with an endotracheal tube and mechanically ventilated. Two intervention pairs will be compared using a 2×2 factorial design: (1) normal saline instillation versus no normal saline instillation; and (2) lung recruitment versus no lung recruitment. The primary outcome is study feasibility measured by a composite analysis of eligibility, recruitment, retention, protocol adherence and missing data. Secondary outcomes are ventilator-associated pneumonia, SpO2/FiO2 ratio, lung compliance, end expiratory level and regional tidal volume.Ethics and dissemination: Ethical approval to conduct the research has been obtained. Dissemination of the research findings will be untaken, guided by the Consolidated Standards of Reporting Trials statement recommendations. Protocol content was guided by the Standard Protocol Items: Recommendations for Interventional Trials 2013 statement.Trial registration number: ACTRN12617000609358; Pre-results

Endotracheal suction interventions in mechanically ventilated children: an integrative review to inform evidence-based practice

Objective: The objective of this study was to review and critically appraise the evidence for paediatric endotracheal suction interventions. Data sources: A systematic search for studies was undertaken in the electronic databases CENTRAL, Medline, EMBASE, and EBSCO CINAHL from 2003. Study selection: Included studies assessed suction interventions in children (≤18 ys old) receiving mechanical ventilation. The primary outcome was defined a priori as duration of mechanical ventilation. Secondary outcomes included adverse events and measures of gas exchange and lung mechanics. Data extraction: Data extraction were performed independently by two reviewers. Study methodological quality was assessed using Cochrane's risk of bias tool for randomised trials or the Newcastle–Ottawa Scale for observational studies. Overall assessment of the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations criteria. Results: Overall 17 studies involving 1618 children and more than 21,834 suction episodes were included in the review. The most common intervention theme was suction system (five studies; 29%). All included trials were at unclear or high risk of performance bias due to the inability to blind interventionists. Current evidence suggests that closed suction may maintain arterial saturations, normal saline leads to significant transient desaturation, and lung recruitment applied after suction offers short-term oxygenation benefit. Limitations: Lack of randomised controlled trials, inconsistencies in populations and interventions across studies, and imprecision and risk of bias in included studies precluded data pooling to provide an estimate of interventions effect. Conclusions: Based on the results of this integrative review, there is insufficient high-quality evidence to guide practice around suction interventions in mechanically ventilated children