The effect of intensive care nursing interventions on the intracranial pressure in children with moderate to severe traumatic brain injury

Objective The aim of this study was to examine the effects of selected routine nursing interventions - endotracheal suctioning and manual ventilation (ETSMV), log-rolling, eye care, mouth care and washing - on the intracranial pressure (ICP) in children with traumatic brain injury. Design Prospective observational study over three years. Setting Single tertiary paediatric intensive care unit in the North West of England. Patients Twenty five children with moderate to severe closed traumatic brain injury and intraparenchymal intracranial pressure monitoring in intensive care (2 -17 years of age). Interventions Routine nursing care interventions. Measurements and main results ICP measured one minute before the procedure, at the maximal value during the procedure and five minutes after the procedure was recorded for the purpose of this study. Time to recovery was also recorded, in minutes. A total of 25 measurements (the first one in each child) in the first 36 hours of the child's PICU admission were analysed. Both ETSMV and log-rolling were associated with clinically and statistically significant changes in ICP from baseline to maximal ICP (p=0.005) and maximal to 5-minute post ICP (p=0.001) for ETSMV and (p15mmHg) showed higher maximal ICPs (but not ICP rise), suggesting a linear relationship between baseline and maximal ICP, although this was more pronounced during turning. One third of the children had not returned to their baseline ICP by 5 minutes after ETSMV, compared with 60% children after log-rolling. Neither eye care nor mouth care showed any clinically significant effects on ICP in these children, suggesting these procedures are not noxious and are tolerated very well. However, there was only a small number of washing episodes reported in this study therefore the observations are not conclusive. Conclusions Endotracheal suctioning and log-rolling in moderate to severe traumatic brain injured children can cause significant intracranial instability and should only be performed as required and with careful planning and execution. Eye and mouth care and washing appear to be well tolerated interventions and could be performed when necessary

A roadmap for paediatric and neonatal critical care nursing science in Europe: Engage, action and impact

Guest editoria

Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals

Background: This position statement provides clinical recommendations for the assessment of pain, level of sedation, iatrogenic withdrawal syndrome and delirium in critically ill infants and children. Admission to a neonatal or paediatric intensive care unit (NICU, PICU) exposes a child to a series of painful and stressful events. Accurate assessment of the presence of pain and non-pain related distress (adequacy of sedation, iatrogenic withdrawal syndrome, and delirium) is essential to good clinical management and to monitoring the effectiveness of interventions to relieve or prevent pain and distress in the individual patient. Methods: A multidisciplinary group of experts was recruited from the members of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). The group formulated clinical questions regarding assessment of pain and non-pain related distress in critically ill and non-verbal children, and searched the PubMed/Medline, Cinahl, and Embase databases for studies describing the psychometric properties of assessment instruments. Further, level of evidence of selected studies was assigned and recommendations were formulated, and grade or recommendations were added based on the level of evidence. Results: An ESPNIC Position Statement was drafted which provides clinical recommendations on assessment of pain (n=5), distress and/or level of sedation (n=4), iatrogenic withdrawal syndrome (n=3), and delirium (n=3). These recommendations were based on the available evidence and consensus amongst the experts and other members of the ESPNIC society. Conclusions: This multidisciplinary ESPNIC Position Statement guides professionals in the assessment and re-assessment of the effectiveness of treatment interventions for pain, distress, inadequate sedation, withdrawal syndrome and delirium

Parent's experiences of their child's withdrawal syndrome: A driver for reciprocal nurse-parent partnership in withdrawal syndrome.

Withdrawal assessment in critically ill children is complicated by the reliance on non-specific behaviours and compounded when the child's typical behaviours are unknown. The existing approach to withdrawal assessment assumes that nurses elicit the parents' view of the child's behaviours. OBJECTIVE AND RESEARCH METHODOLOGY: This qualitative study explored parents' perspectives of their child's withdrawal and preferences for involvement and participation in withdrawal assessment. Parents of eleven children were interviewed after their child had completed sedation weaning during recovery from critical illness. Data were analysed using thematic analysis. SETTING: A large children's hospital in the Northwest of England. FINDINGS: Parents experienced varying degrees of partnership in the context of withdrawal assessment and identified information deficits which contributed to their distress of parenting a child with withdrawal syndrome. Most parents were eager to participate in withdrawal assessment and reported instances where their knowledge enabled a personalised interpretation of their child's behaviours. Reflecting on the reciprocal nature of the information deficits resulted in the development of a model for nurse-parent collaboration in withdrawal assessment. CONCLUSION: Facilitating nurse-parent collaboration in withdrawal assessment may have reciprocal benefits by moderating parental stress and aiding the assessment and management of withdrawal syndrome

Considerations for nutrition support in critically ill children with COVID-19 and paediatric inflammatory multisystem syndrome temporally associated with COVID-19

The aim of this editorial is to provide an adaptation of nutrition support recommendations for the overall population of critically ill children, to provide further refined recommendations for critically ill children presenting with COVID-19 or paediatric hyper-inflammatory syndrome temporally associated with COVID-19. They are based on the ESPNIC-MEN section recommendations published in January 2020 (6) and Surviving Sepsis Campaign recommendations from February 2020 (7). These recommendations cover the acute, stable and rehabilitation phases (Table 1, Table 2)

Impact of different syringe pumps on red cells during paediatric simulated transfusion

Background: Critically ill patients frequently need blood transfusions. For safety, blood must be delivered via syringe infusion pumps, yet this can cause red cell damage and increase the rate of haemolysis. Aims and objectives: To evaluate biochemical and haemolytic markers of red blood cells transfused in three different, common type of syringe infusion pumps with two different infusion rates (10 and 100 ml/h). Methods: A lab-based study using aliquots of 16 red blood cells bags was undertaken. Haemolysis markers (total haemoglobin(g/dl), haematocrit(%), free haemoglobin(g/dl), potassium(mmol/L), lactate dehydrogenase(U/L), osmolality(mOsm/kg), pH, degree of haemolysis(%)) were measured before and after red blood cells infusion and exposure. Three different syringe infusion pumps brands (A, B and C) were compared with two different infusion rates (10 and 100 ml/h). Results: The total haemoglobin fell significantly in all red blood cells units during manipulation (Pre-infusion: 26.44±5.74; Post-exposure: 22.62±4.00; p=0.026). The degree of haemolysis significantly increased by 40% after manipulation of the red blood cells. Syringe infusion pump A caused a threefold increase in potassium levels (3.78±6.10) when compared to B (-0.14±1.46) and C (1.63± 1.98) (p=0.015). This pump also produced the worst changes, with an increase in free haemoglobin (0.05±0.05; p=0.038) and more haemolysis (0.08±0.07; p=0.033). There were significant differences and an increase in the degree of haemolysis (p=0.004) in the infusion rate of 100 mL/h. Conclusions: Syringe infusion pumps may cause significant red blood cell damage during infusion, with increases in free haemoglobin, potassium and the degree of haemolysis. Some pumps types, with a cassette mechanism, caused more damage. Relevance to clinical practice: In many ICUs, bedside nurses are able to consider infusion pump choice and understanding the impact of different pump types on RBC during a transfusion provides the nurses with more information to enhance decision-making and improve the quality of the transfusion

Establishing and augmenting acceptability of the Fever trial: a mixed methods feasibility study

Introduction: Paediatric clinical trials in critical care settings are challenging to conduct. Establishing trial acceptability can help inform trial design and avoid research waste. This paper reports on how research with parents and staff established and augmented perspectives and the design of a trial investigating temperature thresholds in critically ill children with fever and infection (Fever trial). // Methods: We used a mixed methods approach to explore perspectives at three time points: 1) before, 2) during and 3) after a pilot trial. This included: 1) pre-trial focus groups with staff and interviews with parents; 2) questionnaires with parents of randomised children following trial recruitment; 3) post-trial interviews with parents and focus groups and a survey with staff. Data analysis drew on Sekhon et al (2017) theoretical framework of acceptability. // Results: 1) 25 parents were interviewed and 56 staff took part focus groups, 2) 60 parents of 57 randomised children took part in questionnaires, 3) 19 parents were interviewed and 50 staff took part in focus group and 48 in a survey. There was initial support for the trial, although both groups raised concerns regarding proposed thresholds and not using paracetamol for pain or discomfort. Pre-trial findings informed pilot trial protocol changes and training, which assisted practitioner ‘buy in’. However, concerns about children being in pain or discomfort when weaned from ventilation led to cases of withdrawal and protocol non-adherence. Nevertheless, 95% of parents provided consent and all supported the trial. Those trained by the Fever team found the trial more acceptable than those trained by colleagues. Trusting parent and staff relationships were linked to trial acceptability. // Conclusions: Pre-trial findings and pilot trial experience augmented perspectives, providing insight into how challenges may be overcome. The proposed trial was deemed feasible. We present an adapted theoretical framework of acceptability to inform the design of future trial feasibility studies

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

Planned peri-extubation fasting in critically ill children: an international survey of practice

Introduction: Cumulative energy/protein deficit is associated with impaired outcomes in pediatric intensive care Units (PICU). Enteral nutrition is the preferred mode, but its delivery may be compromised by periods of feeding interruptions around procedures, with peri-extubation fasting the most common procedure. Currently, there is no evidence to guide the duration of the peri-extubation fasting in PICU. Therefore, we aimed to explore current PICU fasting practices around the time of extubation and the rationales supporting them. Material and methods: A cross sectional electronic survey was disseminated via the European Paediatric Intensive Care Society (ESPNIC) membership. Experienced senior nurses, dieticians or doctors were invited to complete the survey on behalf of their unit, and to describe their practice on PICU fasting prior to and after extubation. Results: We received responses from 122 PICUs internationally, mostly from Europe. The survey confirmed that fasting practices are often extrapolated from guidelines for fasting prior to elective anaesthesia. However, there were striking differences in the duration of fasting times, with some units not fasting at all (in patients considered to be low risk), while others withheld feeding for all patients. Fasting following extubation also showed large variations in practice, with some units withholding nutrition for many hours, and others starting oral feeding based on child demand. The risk of vomiting/aspiration and reducing nutritional deficit were the main reasons for fasting children or reducing fasting times respectively. Discussion: This variability in practices suggests that shorter fasting times might be safe. Shortening the duration of unnecessary fasting, as well as accelerating the extubation process could potentially be achieved by using other methods of assessing gastric emptiness, such as gastric point of care ultrasonography (POCUS). Yet only half of the units were aware of this technique, and very few used it