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

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

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

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

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.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.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.ACTRN12617000609358; Pre-results

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 < 0.001) and the occurrence of an AE (aOR: 2.76; 95% CI: 1.74–4.37; p < 0.001). Presuction increases in fraction of inspired oxygen (FiO) 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 FiO. 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

Normal saline and lung recruitment with paediatric endotracheal suction (NARES): A pilot, factorial, randomised controlled trial

Background/objective: Endotracheal suction is one of the most common and harmful procuedres performed on mechanically ventilated children. The aim of the study was to establish the feasibility of a randomised controlled trial (RCT) examining the effectiveness of normal saline instillation (NSI) and a positive end-expiratory pressure recruitment manoeuvre (RM) with endotracheal suction in the paediatric intensive care unit. Methods: Pilot 2 × 2 factorial RCT. The study was conducted at a 36-bed tertiary paediatric intensive care unit in Australia. Fifty-eight children aged less than 16 years undergoing tracheal intubation and invasive mechanical ventilation. (i) NSI or no NSI and (ii) RM or no RM with endotracheal suction. The primary outcome was feasibility; secondary outcomes were ventilator-associated pneumonia (VAP), change in end-expiratory lung volume assessed by electrical impedance tomography, dynamic compliance, and oxygen saturation-to-fraction of inspired oxygen (SpO2/FiO2) ratio. Results/Findings: Recruitment, retention, and missing data feasibility criteria were achieved. Eligibility and protocol adherence criteria were not achieved, with 818 patients eligible and 58 enrolled; cardiac surgery was the primary reason for exclusion. Approximately 30% of patients had at least one episode of nonadherence. Children who received NSI had a reduced incidence of VAP; however, this did not reach statistical significance (incidence rate ratio = 0.12, 95% confidence interval = 0.01–1.10; p = 0.06). NSI was associated with a significantly reduced SpO2/FiO2 ratio up to 10 min after suction. RMs were not associated with a reduced VAP incidence (incidence rate ratio = 0.31, 95% confidence interval = 0.05–1.88), but did significantly improve end-expiratory lung volume at 2 and 5 min after suction, dynamic compliance, and SpO2/FiO2 ratio. Conclusion: RMs provided short-term improvements in end-expiratory lung volume and oxygenation. NSI with suction led to a reduced incidence of VAP; however, a definitive RCT is needed to test statistical differences. A RCT of study interventions is worthwhile and may be feasible with protocol modifications including the widening of participant eligibility.</p

Insertion, management, and complications associated with arterial catheters in paediatric intensive care: A clinical audit

Introduction: Peripheral arterial catheters (PAC) are used for haemodynamic monitoring and blood sampling in paediatric critical care. Limited data are available regarding PAC insertion and management practices, and how they relate to device function and failure. This information is necessary to inform future interventional research. Objectives: The primary objective of this study was to describe PAC insertion and management practices, and associated complications. Secondary objectives were to determine patient and clinical characteristics associated with risk of PAC successful insertion and failure. Methods: A prospective, observational study was conducted in the anaesthetic department and paediatric intensive care unit of a tertiary paediatric facility. Data were collected on PAC insertion, PAC management and PAC removal. Standard incidence and prevalence were calculated per 1,000 device days. Risk factors for multiple insertions and PAC failure were identified using Cox regression. Results: A total of 100 catheters in 89 children were examined capturing 472 device days. PACs were primarily inserted for blood sampling (78%) in the radial artery (78%) using ultrasound guidance (67%), with 31% inserted on first attempt. Heparin saline solution was used in 82% of devices. Median catheter dwell was 50.6 hours (IQR 24.0 – 158.0), with PAC failure occurring in 19 devices (20%), at a rate of 40.2 per 1000 catheter days (95% CI 25.7 - 63.1). Arm board immobilisation (HR 2.9; 95% CI 1.02-8.02; p = 0.05), higher PIM3 score (HR 1.06; 95% CI 1.03-1.09; p < 0.01) was associated with an increased the risk of PAC failure, and non-2% chlorhexidine antisepsis was associated with a decrease in PAC failure (HR 0.32; 95% CI 0.11-0.96; p = 0.04), in univariate analysis. Conclusions: PAC insertion is challenging, and failure is common. Prospective clinical trial data is needed to identify high risk patient groups and to develop interventions which optimise practices, thereby reducing failure

Ventilator weaning and extubation practices in critically ill children : An Australian and New Zealand survey of practice

Objectives: We aimed to (i) describe current weaning and extubation practices in children (protocols to identify weaning candidates, spontaneous breathing trials, and other aspects of care such as sedation weaning) and (ii) understand responsibilities for ventilation weaning decisions across Australia and New Zealand (ANZ). Methods: A cross-sectional survey of ANZ intensive care units who routinely intubate and ventilate children (<18 years) was conducted. We worked with the Australian and New Zealand Intensive Care Society Paediatric Study Group to identify units and potential respondents (senior nurse representative per unit) and to administer questionnaires. Survey questions (n = 35) examined current protocols, practices, unit staffing, and decision-making responsibilities for ventilation weaning and extubation. Open-ended questions examined respondents' experiences of weaning and extubation. Results: A senior nursing respondent from 18/22 intensive care units (82%) completed the survey. Across units, most used sedation assessment tools (88%), and less often, sedation weaning tools (55%). Spontaneous awakening protocols were not used; one unit (5%) reported the use of a spontaneous breathing protocol. Two respondents reported that ventilation weaning protocols (11%) were in use, with 44% of units reporting the use of extubation protocols. Weaning and extubation practices were largely perceived as medically driven, with qualitative data demonstrating a desire from most respondents for greater shared decision-making. Conclusion: In ANZ, ventilation weaning and extubation practices are largely medically driven with variation in the use of protocols to support mechanical ventilation weaning and extubation in children. Our findings highlight the importance of future research to determine the impact of greater collaboration of the multidisciplinary team on weaning practices.</p