The current state of knowledge and research required around nutrition in pediatric critical illness

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Guest editorial : introduction to the WHO year of the nurse and midwife: the impact of critical care nurses and meet the new editors

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What's in this issue (Volume 25, Issue 1)

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Enteral feeding in post-operative cardiac surgical infants – how fast should we go?

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European neonatal intensive care nursing research priorities: an e-Delphi study.

OBJECTIVE: This study aimed to identify and prioritise neonatal intensive care nursing research topics across Europe using an e-Delphi technique. DESIGN: An e-Delphi technique with three questionnaire rounds was performed. Qualitative responses of round one were analysed by content analysis and research statements were generated to be ranged on importance on a scale of 1-6 (not important to most important). SETTING: Neonatal intensive care units (NICUs) in 17 European countries. POPULATION: NICU clinical nurses, managers, educators and researchers (n=75). INTERVENTION: None. MAIN OUTCOME MEASURES: A list of 43 research statements in eight domains. RESULTS: The six highest ranking statements (≥5.0 mean score) were related to prevention and reduction of pain (mean 5.49; SD 1.07), medication errors (mean 5.20; SD 1.13), end-of-life care (mean 5.05; SD 1.18), needs of parents and family (mean 5.04; SD 1.23), implementing evidence into nursing practice (mean 5.02; SD 1.03), and pain assessment (mean 5.02; SD 1.11). The research domains were prioritised and ranked: (1) pain and stress; (2) family centred care; (3) clinical nursing care practices; (4) quality and safety; (5) ethics; (6) respiratory and ventilation; (7) infection and inflammation; and (8) professional issues in neonatal intensive care nursing. CONCLUSIONS: The results of this study might support developing a nursing research strategy for the nursing section of the European Society of Paediatric and Neonatal Intensive Care. In addition, this may promote more European researcher collaboratives for neonatal nursing research

Review of outcomes used in nutritional trials in Pediatric Critical Care

Background: Generating robust evidence within Pediatric Intensive Care (PIC) can be challenging because of low patient numbers and patient heterogeneity. Systematic reviews may overcome small study biases but are limited by lack of standardisation in outcome measures and their definition. Trials of nutritional interventions in PIC are increasing, thus we wanted to examine the outcome measures being used in these trials. Objective: To systematically describe outcome measures used when a nutritional intervention has been evaluated in a PIC randomized controlled trial. Methods: A systematic literature review of all studies involving a PIC trial of a nutritional intervention was undertaken from 1 January 1996 until 20 February 2018. Results: Thirty-one trials met the criteria and were reviewed. They included a total of 3346 patients across all trials. Thirty-nine primary outcomes and 93 secondary outcomes were found. These were categorized into PIC-related outcomes (infection, intensive care dependency, organ dysfunction / long-term functional and mortality) and nutritional outcomes (energy targets, nutritional parameters and feeding tolerance). We found large variation in the outcome measures used. Outcome domains of energy targets, feeding tolerance and infection were not adequately defined. Conclusions: Large variations in the outcome measures chosen and their definitions exist within PIC nutritional trials. Optimal nutritional outcomes for PIC must be agreed and defined, specifically domains of nutrition efficiency, nutrition tolerance and non-nutritional PIC outcomes. The next step is to conduct an International Delphi study to gain expert consensus and develop a core outcome set to be reported in future pediatric nutrition trials

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

The physical effects of wearing personal protective equipment: a scoping review

Background: The COVID-19 pandemic has required healthcare workers to wear personal protective equipment (PPE), and although there is increasing awareness of the physical effects of wearing PPE, the literature has yet to be synthesised around this topic. Methods: A scoping review was conducted to synthesise existing literature on the physical effects of wearing PPE and identify gaps in the literature. A comprehensive search strategy was undertaken using five databases from 1995 to July 2020. Results: A total of 375 relevant articles were identified and screened. Twenty-three studies were included in this review. Studies were conducted across 10 countries, spanning 16 years from 2004 to 2020. Half (13/23) were randomised controlled trials or quasi-experimental studies, five surveys, two qualitative studies, two observational or case series and one Delphi study. Most (82%, 19/23) studies involved the N95 mask (either valved or unvalved). None specifically studied the filtering facepiece 3 mask. The main physical effects relate to skin irritation, pressure ulcers, fatigue, increased breathing resistance, increased carbon dioxide rebreathing, heat around the face, impaired communication and wearer reported discomfort. Few studies examined the impact of prolonged wear (akin to real life practice) on the physical effects, and different types of PPE had different effects. Conclusions: The physical effects of wearing PPE are not insignificant. Few studies examined the physiological impact of wearing respiratory protective devices for prolonged periods whilst conducting usual nursing activity. No ideal respirators for healthcare workers exist, and the development of more ergonomic designs of PPE is required

Optimising paediatric afferent component early warning systems : a hermeneutic systematic literature review and model development

Objective: To identify the core components of successful early warning systems for detecting and initiating action in response to clinical deterioration in paediatric inpatients. Methods: A hermeneutic systematic literature review informed by translational mobilisation theory and normalisation process theory was used to synthesise 82 studies of paediatric and adult early warning systems and interventions to support the detection of clinical deterioration and escalation of care. This method, which is designed to develop understanding, enabled the development of a propositional model of an optimal afferent component early warning system. Results: Detecting deterioration and initiating action in response to clinical deterioration in paediatric inpatients involves several challenges, and the potential failure points in early warning systems are well documented. Track and trigger tools (TTT) are commonly used and have value in supporting key mechanisms of action but depend on certain preconditions for successful integration into practice. Several supplementary interventions have been proposed to improve the effectiveness of early warning systems but there is limited evidence to recommend their wider use, due to the weight and quality of the evidence; the extent to which systems are conditioned by the local clinical context; and the need to attend to system component relationships, which do not work in isolation. While it was not possible to make empirical recommendations for practice, the review methodology generated theoretical inferences about the core components of an optimal system for early warning systems. These are presented as a propositional model conceptualised as three subsystems: detection, planning and action. Conclusions: There is a growing consensus of the need to think beyond TTTs in improving action to detect and respond to clinical deterioration. Clinical teams wishing to improve early warning systems can use the model to consider systematically the constellation of factors necessary to support detection, planning and action and consider how these arrangements can be implemented in their local context