Accuracy of enteral syringes with commonly prescribed paediatric liquid medicines

OBJECTIVE: Oral syringes are the preferred method for delivering paediatric enteral drugs; however, little is known about factors affecting accuracy, particularly at volumes <5 mL. We investigated volumetric accuracy for enteral syringes, using commercially available liquid drug formulations with various physicochemical properties at clinically relevant volumes. DESIGN: In vitro experiment. INTERVENTIONS: Ten drugs were tested using two syringe brands (Baxa, Medicina) across a range of formulation volumes (0.05-5 mL) and syringe sizes (1-5 mL). Syringe weights (empty and filled) were converted into volume, using known formulation densities. Ten replications were performed for each drug/syringe/volume combination. MAIN OUTCOME MEASURES: Delivered volume accuracy was expressed as a percentage of intended volume, with the desired range being within ±10%. RESULTS: Baxa demonstrated a slight positive bias (excess average volumes delivered) at the smallest volumes for each syringe size, while Medicina had poorer precision (greater variability, analysis of variance-interactions all p<0.005). From these results, we identified the limit for volume accuracy for each syringe size and brand. Of note, the 1 mL syringe for both brands was inaccurate for delivering volumes ≤0.1 mL. The physicochemical properties of pH (range 2.82-7.45), surface tension (30.2-86.7 mN/m) and viscosity (2-299 mPaS) did not influence error in a discernible pattern. CONCLUSIONS: Dosing was inaccurate when small volumes were used across all syringe sizes and brands. These reflect volumes used in clinical practice. Administration error could potentially be reduced by (1) clinicians using syringes appropriate to dosing volumes and (2) manufacturers revising formulation concentrations for drugs

Establishing and augmenting views on the acceptability of a paediatric critical care randomised controlled trial (the FEVER trial): a mixed methods study

OBJECTIVE: To explore parent and staff views on the acceptability of a randomised controlled trial investigating temperature thresholds for antipyretic intervention in critically ill children with fever and infection (the FEVER trial) during a multi-phase pilot study. DESIGN: Mixed methods study with data collected at three time points: (1) before, (2) during and (3) after a pilot trial. SETTING: English, Paediatric Intensive Care Units (PICUs). PARTICIPANTS: (1) Pre-pilot trial focus groups with pilot site staff (n=56) and interviews with parents (n=25) whose child had been admitted to PICU in the last 3 years with a fever and suspected infection, (2) Questionnaires with parents of randomised children following pilot trial recruitment (n=48 from 47 families) and (3) post-pilot trial interviews with parents (n=19), focus groups (n=50) and a survey (n=48) with site staff. Analysis drew on Sekhon et al's theoretical framework of acceptability. RESULTS: There was initial support for the trial, yet some held concerns regarding the proposed temperature thresholds and not using paracetamol for pain or discomfort. Pre-trial findings informed protocol changes and training, which influenced views on trial acceptability. Staff trained by the FEVER team found the trial more acceptable than those trained by colleagues. Parents and staff found the trial acceptable. Some concerns about pain or discomfort during weaning from ventilation remained. CONCLUSIONS: Pre-trial findings and pilot trial experience influenced acceptability, providing insight into how challenges may be overcome. We present an adapted theoretical framework of acceptability to inform future trial feasibility studies. TRIAL REGISTRATION NUMBERS: ISRCTN16022198 and NCT03028818