Effect of hyperventilation on regional cerebral blood flow in head-injured children

Journal ArticleObjectives: To study cerebral blood flow and cerebral oxygen consumption in severe head-injured children and also to assess the effect of hyperventilation on regional cerebral blood flow. Design: Prospective cohort study. Setting: Pediatric intensive care unit at a tertiary-level university children's hospital. Patients: Twenty-three children with isolated severe brain injury, whose admission Glasgow Coma Scores were 35,25 to 35, and 4.7,3.3 to 4.7, and <3.3 kPa]) after allowing 15 mins for equilibrium. Measurements and Main Results: Thirty-eight studies (each study consisting of three sets of measurements at different levels of Paco2) were performed on 23 patients. At each level of Paco2, the following measurements were made: xenon-enhanced computed tomography scans; cerebral blood flow; intracranial pressure; jugular venous bulb oxygen saturation; mean arterial pressure; and arterial oxygen saturation. Derived variables included: cerebral oxygen consumption; cerebral perfusion pressure; and oxygen extraction ratio. Cerebral blood flow decreased below normal after head injury (mean 49.6 + 14.6 mL/min/100 g). Cerebral oxygen consumption decreased out of proportion to the decrease in cerebral blood flow; cerebral oxygen consumption was only a third of the normal range (mean 1.02 ? 0.59 mL/min/100 g). Neither cerebral blood flow nor cerebral oxygen consumption showed any relationship to time after injury, Glasgow Coma Score at the time of presentation, or intracranial pressure. The frequency of one or more regions of ischemia (defined as cerebral blood flow of <18 mL/min/ 100 g) was 28.9% during normocapnia. This value increased to 73.1% for Paco2 at <25 torr. Conclusions: Severe head injury in children produced a modest decrease in cerebral blood flow but a much larger decrease in cerebral oxygen consumption. Absolute hyperemia was uncommon at any time, but measured cerebral blood flow rates were still above the metabolic requirements of most children. The clear relationship between the frequency of cerebral ischemia and hypocarbia, combined with the rarity of hyperemia, suggests that hyperventilation should be used with caution and monitored carefully in children with severe head injuries. (Crit Care Med 1997; 25:1402-1409)

The Effect of Massage Therapy on Autonomic Activity in Critically Ill Children

Objectives. Our main objective was to describe the effect of foot and hand (F&H) massage on the autonomic nervous system (ANS) activity in children hospitalized in a pediatric intensive care unit (PICU); the secondary objectives were to assess the relationship between ANS function and the clinical severity and to explore the effects of repeated massage sessions on the ANS. Methods. Design was a descriptive experimental study. Intervention was single or six session(s) of F&H massage. ANS function was assessed through the frequency-domain analysis of heart rate variability. Main metrics included high and low frequency power (HF and LF), HF + LF, and LF/HF ratio. Results. Eighteen children participated in the study. A strong Spearman’s correlation (ρ=-0.77) was observed between HF + LF and clinical severity. During massage, the parasympathetic activity (measured by HF) increased significantly from baseline (P=0.04) with a mean percentage increase of 75% (95% CI: 20%∼130%). LF increased by 56% (95% CI: 20%∼92%) (P=0.026). Repeated sessions were associated with a persistent effect on HF and LF which peaked at the second session and remained stable thereafter. Conclusions. HF + LF is positively correlated with clinical severity. F&H massage can improve the ANS activity and the effect persists when repeated sessions are offered

Clinician-Driven Design of VitalPAD–An Intelligent Monitoring and Communication Device to Improve Patient Safety in the Intensive Care Unit

The pediatric intensive care unit (ICU) is a complex environment, in which a multidisciplinary team of clinicians (registered nurses, respiratory therapists, and physicians) continually observe and evaluate patient information. Data are provided by multiple, and often physically separated sources, cognitive workload is high, and team communication can be challenging. Our aim is to combine information from multiple monitoring and therapeutic devices in a mobile application, the VitalPAD, to improve the efficiency of clinical decision-making, communication, and thereby patient safety. We observed individual ICU clinicians, multidisciplinary rounds, and handover procedures for 54 h to identify data needs, workflow, and existing cognitive aid use and limitations. A prototype was developed using an iterative participatory design approach; usability testing, including general and task-specific feedback, was obtained from 15 clinicians. Features included map overviews of the ICU showing clinician assignment, patient status, and respiratory support; patient vital signs; a photo-documentation option for arterial blood gas results; and team communication and reminder functions. Clinicians reported the prototype to be an intuitive display of vital parameters and relevant alerts and reminders, as well as a user-friendly communication tool. Future work includes implementation of a prototype, which will be evaluated under simulation and real-world conditions, with the aim of providing ICU staff with a monitoring device that will improve their daily work, communication, and decision-making capacity. Mobile monitoring of vital signs and therapy parameters might help improve patient safety in wards with single-patient rooms and likely has applications in many acute and critical care settings.This work was supported by the Canadian Institutes of Health Research under Grant PJT-149042

ADP Ribosylation Factors 1 and 4 and Group VIA Phospholipase A2 Regulate Morphology and Intraorganellar Traffic in the Endoplasmic Reticulum–Golgi Intermediate Compartment

In search of morphological determinants for the endoplasmic reticulum-Golgi intermediate compartment (ERGIC), we found that a concerted action of Arf1, Arf4, and PLA2G6-A controls the architecture of the ERGIC by regulating tubular carriers. This is predicted to impact the rate of transport and destination of cargos in the ERGIC

Engaging Pediatric Intensive Care Unit (PICU) clinical staff to lead practice improvement: the PICU Participatory Action Research Project (PICU-PAR)

Background: Despite considerable efforts, engaging staff to lead quality improvement activities in practice settings is a persistent challenge. At British Columbia Children’s Hospital (BCCH), the pediatric intensive care unit (PICU) undertook a new phase of quality improvement actions based on the Community of Practice (CoP) model with Participatory Action Research (PAR). This approach aims to mobilize the PICU ‘community’ as a whole with a focus on practice; namely, to create a ‘community of practice’ to support reflection, learning, and innovation in everyday work. Methodology: An iterative two-stage PAR process using mixed methods has been developed among the PICU CoP to describe the environment (stage 1) and implement specific interventions (stage 2). Stage 1 is ethnographic description of the unit’s care practice. Surveys, interviews, focus groups, and direct observations describe the clinical staff’s experiences and perspectives around bedside care and quality endeavors in the PICU. Contrasts and comparisons across participants, time and activities help understanding the PICU culture and experience. Stage 2 is a succession of PAR spirals, using results from phase 1 to set up specific interventions aimed at building the staff’s capability to conduct QI projects while acquiring appropriate technical skills and leadership capacity (primary outcome). Team communication, information, and interaction will be enhanced through a knowledge exchange (KE) and a wireless network of iPADs. Relevance: Lack of leadership at the staff level in order to improve daily practice is a recognized challenge that faces many hospitals. We believe that the PAR approach within a highly motivated CoP is a sound method to create the social dynamic and cultural context within which clinical teams can grow, reflect, innovate and feel proud to better serve patients.Anthropology, Department ofArts, Faculty ofEmergency Medicine, Department ofMedicine, Faculty ofPediatrics, Department ofOther UBCNon UBCReviewedFacult

Hospital-acquired acute hyponatremia and reports of pediatric deaths

Abstract Information from four voluntary reports of hospital-acquired acute hyponatremia leading to the death of otherwise healthy children is highlighted. In this column, we present two cases and information from a recent ISMP Canada Safety Bulletin, as well as two cases reported to ISMP United States. Information is shared to enhance health care practitioners&apos; awareness of the potential for acute hyponatremia and to provide an overview of some of the potential underlying factors. Hospital-acquired acute hyponatremia and reports of pediatric deaths Four pediatric deaths due to acute hyponatremia associated with intravenous (IV) administration of hypotonic solutions, three in a postsurgical setting and the other in a medical setting were voluntarily reported (two to the Institute for Safe Medication Practices Canada [ISMP Canada] and two to the Institute for Safe Medication Practices [ISMP] in the United States). Acute hyponatremia is defined as a decline in serum sodium to less than 130 mmol/L within a 48-hour period. This abrupt change can lead to cerebral edema as a result of electrolyte-free water moving into the brain cells. Acute hyponatremia can be fatal for both children and adults. However, children are more vulnerable to the effects of fluid and electrolyte imbalance. The early signs of acute hyponatremia and rising intracranial pressure are often nonspecific and include nausea, vomiting, headache, and decreasing level of consciousness. Information from the voluntary incident reports is shared here to enhance health care practitioners&apos; awareness of the potential for acute hyponatremia and to provide an overview of some of the potential underlying factors. Incident reports received by ISMP Canad

Engagement and education: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND: Engagement and education of ICU clinicians in disaster preparedness is fragmented by time constraints and institutional barriers and frequently occurs during a disaster. We reviewed the existing literature from 2007 to April 2013 and expert opinions about clinician engagement and education for critical care during a pandemic or disaster and offer suggestions for integrating ICU clinicians into planning and response. The suggestions in this article are important for all of those involved in a pandemic or large-scale disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. METHODS: A systematic literature review was performed and suggestions formulated according to the American College of Chest Physicians (CHEST) Consensus Statement development methodology. We assessed articles, documents, reports, and gray literature reported since 2007. Following expert-informed sorting and review of the literature, key priority areas and questions were developed. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. RESULTS: Twenty-three suggestions were formulated based on literature-informed consensus opinion. These suggestions are grouped according to the following thematic elements: (1) situational awareness, (2) clinician roles and responsibilities, (3) education, and (4) community engagement. Together, these four elements are considered to form the basis for effective ICU clinician engagement for mass critical care. CONCLUSIONS: The optimal engagement of the ICU clinical team in caring for large numbers of critically ill patients due to a pandemic or disaster will require a departure from the routine independent systems operating in hospitals. An effective response will require robust information systems; coordination among clinicians, hospitals, and governmental organizations; pre-event engagement of relevant stakeholders; and standardized core competencies for the education and training of critical care clinicians