Airway management during a respiratory arrest in a clinical simulation scenario. Experience at a pediatric residency program

Introduction. Respiratory failure is the most common cause of cardiac arrest in pediatrics. Recognizing and managing it adequately is critical. Simulation is used to improve medical skills. The objective of this study was to establish the proportion of pediatric residents who recognized a respiratory arrest in a child at a simulation center. Methods. This was an observational study in 77 residents. A simulation of a patient with respiratory distress that progressed to respiratory arrest was used. Results. Among the 77 participants, 48 recognized respiratory arrest (62.3%). The mean time to recognize respiratory arrest was 38.16 seconds. Conclusion. Respiratory arrest was recognized by 62.3% of participants. Among those who did so, the average time was 38.16 seconds. Severe failures were noted in some of the expected interventions.

Communication of medical errors in a simulated clinical scenario. Experience with a pediatric residency group

OBJECTIVE

To determine the performance of groups of pediatric residents from a Buenos Aires hospital, in terms of correct recognition and communication of a medical error (ME), in a high-fidelity simulation scenario. To describe the reactions and communication attempts following the ME and the self-perception by the trainees before and after a debriefing.

METHODS

Quasi-experimental uncontrolled study conducted in a simulation center. First- and third-year pediatric residents participated. We designed a simulation case in which an ME occurred and the patient deteriorated. During the simulation, participants had to provide information on communicating the ME to the patient's father. We assessed communication performance and, additionally, participants completed a self-perception survey about ME management before and after a debriefing.

RESULTS

Eleven groups of residents participated. Ten (90.9%) identified the ME correctly, but only 27.3% (n=3) of them reported that a ME had occurred. None of the groups told the father they were going to give him important news concerning his son's health. All 18 residents who actively participated in this communication completed the self-perception survey, with an average score before and after debriefing of 5.00 and 5.05 (out of 10) (p=0.88).

CONCLUSIONS

We observed a high number of groups that recognized the presence of a ME, but the communication action was substantially low. Communication skills were insufficient and residents' self-perception of error management was regular and not modified by the debriefing.

Assessment of emergency trolley drugs in a children's hospital. Before and after study on an educational intervention

INTRODUCTION

The approach to pediatric emergencies requires specialized resources, and medication errors are common.

OBJECTIVES

To describe the contents of emergency trolleys (ETs) in a children's hospital and compare them after an educational intervention.

METHODS

The ETs from 9 hospitalization wards were included. A checklist of 30 drugs was developed. ETs were assessed by determining whether drugs were present or absent and their amount. An educational intervention was conducted and assessments were repeated 30 and 90 days after the intervention.

RESULTS

The baseline measurement indicated an overall ratio of adequate drugs of 43.9 % (95 % confidence interval [Cl]: 38.4-49.4) with a variation among ETs from 29 % to 54.8 %, and from 15 % to 85 % among drug groups. At 30 days, the adequate ratio reached 70.3 % (95 % CI: 65.275.4), with a wide variation among the different ETs and drug groups (from 51.6 % to 93.5 % and from 50 % to 95 %, respectively). At 90 days, the percentages were similar. The comparison between the first and second measurement showed an improvement in all ETs (range: 3.2 %-45.1 %), odds ratio: 3.73 (95 % CI: 2.5-5.6), p < 0.001. Results were similar between the second and third measurement.

CONCLUSIONS

The baseline measurement showed a low level of adequate ET drugs. After the intervention, this improved significantly and was maintained during the studied period.

[Epidemiologic study of birth weight from birth certificates]

INTRODUCTION

Based on the fact that there is evidence of an association between low birth weight and neonatal and infant morbi-mortality, the World Health Organization considered birth weight as the main isolated factor associated with infant's survival. A study was undertaken to identify risk factors associated with low birth weight, using epidemiological and demographic variables present on the Birth Certificates, the source of data for the System of Information on Newborn Infants of the Brazilian Ministry of Health, for the purpose of motivating the use and the analysis of data currently generated in hospitals.

METHOD

The distribution, by birth weight, of 14,784 single hospital newborn infants from five cities of the State of S. Paulo, Brazil, in an observation period of six months (1992), was analysed. Statistical analysis was based on point estimates (average, median and standard deviation) measures of association and confidence intervals (95%) of the prevalence ratios.

RESULTS AND CONCLUSIONS

The highest proportion (10.4%) of low birth weight infants (weight less than 2,500 g) occurred in Itararé, the city with the highest infant mortality rate in the State, the overall proportion being 7.5%. Significant statistical associations between low birth weight and sex (female), gestational age (less than 37 weeks), mother's age (adolescent and 35 or more years of age) and parity were detected. The use of Birth Certificates in epidemiological and public health studies is highly recommended because of their validity, great importance and high coverage.

Cytokines and dysregulation of the immune response in human malaria

The dysregulation of the immune response by malaria parasite has been considered as a possible constraint to the effectiveness of malaria vaccination. In spite of the important role interleukin-1 (IL-1) plays on the immunoregulation, and its ability to mimic various features of clinical malaria, reports on IL-1 in malaria are lacking. We found that only 2 out of 35 subjects with acute malaria showed increased levels of serum IL-1 alpha by enzyme immunoassay. To assess whether IL-1 could interfere with T-lymphocyte responses, blood mononuclear cells from patients infected with Plasmodium falciparum, P. vivax, or healthy subjects were cultured with phytohemagglutinin, and lymphocyte proliferation measured 72 h later by 3H-thymidine incorporation. Our data showed that T-lymphocyte responses are depressed both in P. falciparum (10,500 +/- 2,900) and P. vivax malaria (13,000 +/- 3,300), as compared to that of healthy individuals (27,000 +/- 3,000). Addition of IL-1 partially reversed depression of malaria lymphocytes, but had no effect on normal cells. On the other hand, T-lymphocytes from malaria infected-subjects presented a minimal decrease in proliferation, when cultured in the presence of exogenous PGE2. These data indicate the occurrence of two defects of immunoregulation in malaria: a deficiency of IL-1 production by monocytes/macrophages, and an increased resistance of lymphocytes to the antiproliferative effect of PGE2.