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Mwale D, Manda-Taylor L, Langton J, Likumbo A, van Hensbroek MB, Calis J, Janssens W, Pell C. The role of healthcare providers and caregivers in monitoring critically ill children: a qualitative study in a tertiary hospital, southern Malawi. BMC Health Serv Res 2024; 24:595. [PMID: 38714998 PMCID: PMC11077805 DOI: 10.1186/s12913-024-11050-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Critically ill children require close monitoring to facilitate timely interventions throughout their hospitalisation. In low- and middle-income countries with a high disease burden, scarce paediatric critical care resources complicates effective monitoring. This study describes the monitoring practices for critically ill children in a paediatric high-dependency unit (HDU) in Malawi and examines factors affecting this vital process. METHODS A formative qualitative study based on 21 in-depth interviews of healthcare providers (n = 12) and caregivers of critically ill children (n = 9) in the HDU along with structured observations of the monitoring process. Interviews were transcribed and translated for thematic content analysis. RESULTS The monitoring of critically ill children admitted to the HDU was intermittent, using devices and through clinical observations. Healthcare providers prioritised the most critically ill children for more frequent monitoring. The ward layout, power outages, lack of human resources and limited familiarity with available monitoring devices, affected monitoring. Caregivers, who were present throughout admission, were involved informally in monitoring and flagging possible deterioration of their child to the healthcare staff. CONCLUSION Barriers to the monitoring of critically ill children in the HDU were related to ward layout and infrastructure, availability of accurate monitoring devices and limited human resources. Potential interventions include training healthcare providers to prioritise the most critically ill children, allocate and effectively employ available devices, and supporting caregivers to play a more formal role in escalation.
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Affiliation(s)
- Daniel Mwale
- Kamuzu University of Health Sciences, Blantyre, Malawi.
- Training Research Unit of Excellence, Blantyre, Malawi.
| | - Lucinda Manda-Taylor
- Kamuzu University of Health Sciences, Blantyre, Malawi
- Training Research Unit of Excellence, Blantyre, Malawi
| | | | - Alice Likumbo
- Training Research Unit of Excellence, Blantyre, Malawi
| | - Michael Boele van Hensbroek
- Department of Paediatric Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Meibergdreef, NL, the Netherlands
| | - Job Calis
- Department of Paediatric Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Meibergdreef, NL, the Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciencies, Blantyre, Malawi
| | - Wendy Janssens
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Economics, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Global Health Amsterdam, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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Morabito LA, Corica D, Pepe G, Li Pomi A, Aversa T, Wasniewska MG. Critical illness-related corticosteroid insufficiency (CIRCI) in paediatric patients: a diagnostic and therapeutic challenge. Ital J Pediatr 2024; 50:46. [PMID: 38462639 PMCID: PMC10926569 DOI: 10.1186/s13052-024-01616-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/24/2024] [Indexed: 03/12/2024] Open
Abstract
Critical illness-related corticosteroid insufficiency or CIRCI is characterized by acute and life-threatening disfunction of hypothalamic-pituitary-adrenal (HPA) axis observed among intensive care unit- staying patients.It is associated with increased circulating levels of biological markers of inflammation and coagulation, morbidity, length of ICU stay, and mortality.Several mechanisms are involved in CIRCI pathogenesis: reduced CRH-stimulated ACTH release, peripheral resistance to glucocorticoids, altered cortisol synthesis, impaired cortisol-free fraction and bioavailability.Diagnostic and therapeutic management of this condition in children is still debated, probably because of the lack of agreement among intensive care specialists and endocrinologists regarding diagnostic criteria and prevalence of CIRCI in paediatric age.In the present narrative review, we focused on definition of CIRCI in paediatric age and we advise on how to diagnose and treat this poorly understood condition, based on current literature data.
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Affiliation(s)
- Letteria Anna Morabito
- Pediatric Unit, Maternal Infant Department, "Gaetano Martino" University Hospital, Via Consolare Valeria, 98122, Messina, Italy.
| | - Domenico Corica
- Pediatric Unit, Maternal Infant Department, "Gaetano Martino" University Hospital, Via Consolare Valeria, 98122, Messina, Italy
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Giorgia Pepe
- Pediatric Unit, Maternal Infant Department, "Gaetano Martino" University Hospital, Via Consolare Valeria, 98122, Messina, Italy
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Alessandra Li Pomi
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Tommaso Aversa
- Pediatric Unit, Maternal Infant Department, "Gaetano Martino" University Hospital, Via Consolare Valeria, 98122, Messina, Italy
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Malgorzata Gabriela Wasniewska
- Pediatric Unit, Maternal Infant Department, "Gaetano Martino" University Hospital, Via Consolare Valeria, 98122, Messina, Italy
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
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de Oliveira JK, Schaan CW, Silva CK, Piva TC, Sousa ITE, Bruno F, Lukrafka JL. Reliability of ultrasound in the assessment of muscle thickness in critically ill children. An Pediatr (Barc) 2023:S2341-2879(23)00100-X. [PMID: 37198052 DOI: 10.1016/j.anpede.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/16/2023] [Indexed: 05/19/2023] Open
Abstract
INTRODUCTION Ultrasound has been used to quantify and qualify muscle morphology in critically ill children and can detect changes in muscle thickness. The aim of this study was to assess the reliability of ultrasound measurement of muscle thickness in critically ill children and to compare the assessments made by an expert with those made by inexperienced sonographers. MATERIAL AND METHODS Cross-sectional observational study conducted in the paediatric intensive care unit of a tertiary care university hospital in Brazil. The sample included patients aged 1 month to 12 years who received invasive mechanical ventilation for at least 24 h. Ultrasound images of the biceps brachii/brachialis and quadriceps femoris were obtained by one experienced sonographer and several inexperienced sonographers. We assessed intrarater and inter-rater reliability by means of the intraclass correlation coefficient (ICC) and Bland-Altman plot analysis. RESULTS Muscle thickness was measured in 10 children with a mean age of 15.5 months. The mean thickness of the assessed muscles as 1.14 cm for the biceps brachii/brachialis (standard deviation [SD], 0.27) and 1.85 cm for the quadriceps femoris (SD, 0.61). The intrarater and inter-rater reliability were good for all sonographers (ICC > 0.81). The differences were small, there was no significant bias in the Bland-Altman plots and all measurements were within the limits of agreement, except for 1 measurement of biceps and quadriceps. CONCLUSION Sonography can be used in critically ill children to accurately assess changes in muscle thickness, even by different evaluators. More studies are needed to establish a standardised approach to the use of ultrasound for monitoring muscle loss in order to incorporate it in clinical practice.
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Affiliation(s)
- Jéssica Knisspell de Oliveira
- Programa de Posgrado en Pediatría, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS), Brasil.
| | | | | | | | - Ian Teixeira E Sousa
- Programa de Posgrado en Salud Infantil y Adolescente, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS), Brasil
| | - Francisco Bruno
- Hospital de Clínicas de Porto Alegre, Porto Alegre (RS), Brasil
| | - Janice Luisa Lukrafka
- Programa de Posgrado en Pediatría, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS), Brasil
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Ibrahim A, Scruth E, Adeyinka A, Kabara HS, Rivera L, Hartjes T, Minso J, Pierre L. Development of paediatric critical care in northwestern Nigeria: Initial implementation with a needs assessment model. Aust Crit Care 2021; 35:279-285. [PMID: 34593314 DOI: 10.1016/j.aucc.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION There is high paediatric morbidity and mortality in northwestern Nigeria, attributable in part to vaccine-preventable illnesses and lack of comprehensive training of medical and nursing staff in the healthcare delivery of paediatric critical care. Pediatric Universal Life-Saving Effort Inc. (PULSE), a New York-based nonprofit organisation with a mission to develop paediatric critical care in resource-limited settings, collaborated with Aminu Kano University Teaching Hospital to decrease the gaps in knowledge and skills of medical and nursing personnel. The joint effort also aims to address and remove barriers to the delivery of paediatric critical care in northwestern Nigeria. The primary objective was to perform a needs assessment for paediatric intensive care resources in northwestern Nigeria, identify barriers to delivering these services, and designate a hub for the development of paediatric critical care educational programs for healthcare professionals. METHODS An anonymous survey was designed and distributed using SurveyMonkey® online software to medical and nursing staff from nine healthcare institutions in northwestern Nigeria. RESULTS Analysis from 67 responses revealed that care delivered to critically ill paediatric patients was by anaesthesiologists (77%), pediatricians (26%), and adult intensive care specialists (10%). The acquisition of clinical skills was perceived to be an essential need (65%), followed by adequate staffing of critical care units (19%), continuing medical and nursing education (13%), and availability of medical equipment (3%). DISCUSSION There is an identified need for paediatric critical care training and resources in northwestern Nigeria. CONCLUSION The needs assessment conducted has provided important results that will form the basis for building staff capacity and training programs for paediatric critical care in northwestern Nigeria.
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Affiliation(s)
| | - Elizabeth Scruth
- NCAL Quality - Kaiser Foundation Hospital and Health Plan, Oakland, United States.
| | - Adebayo Adeyinka
- Icahn School of Medicine at Mount Sinai, New York, United States.
| | | | - Lorena Rivera
- KECK Medical Center of USC, University of Southern California, Los Angeles, CA, United States
| | - Tonja Hartjes
- Intensive Care Unit, Aminu kano Teaching Hospital, Kano, Nigeria
| | - Jagila Minso
- Sanford Children's Hospital Medical Center, University of North Dakota School of Medicine, Bismarck, ND, United States.
| | - Louisdon Pierre
- The Brooklyn Hospital Center, Brooklyn, NY, United States; Icahn School of Medicine at Mount Sinai, New York, United States.
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Muttalib F, Ballard E, Langton J, Malone S, Fonseca Y, Hansmann A, Remy K, Hovmand P, Doctor A. Application of systems dynamics and group model building to identify barriers and facilitators to acute care delivery in a resource limited setting. BMC Health Serv Res 2021; 21:26. [PMID: 33407458 PMCID: PMC7787401 DOI: 10.1186/s12913-020-06014-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/10/2020] [Indexed: 11/17/2022] Open
Abstract
Background Group model building (GMB) is a method to facilitate shared understanding of structures and relationships that determine system behaviors. This project aimed to determine the feasibility of GMB in a resource-limited setting and to use GMB to describe key barriers and facilitators to effective acute care delivery at a tertiary care hospital in Malawi. Methods Over 1 week, trained facilitators led three GMB sessions with two groups of healthcare providers to facilitate shared understanding of structures and relationships that determine system behaviors. One group aimed to identify factors that impact patient flow in the paediatric special care ward. The other aimed to identify factors impacting delivery of high-quality care in the paediatric accident and emergency room. Synthesized causal maps of factors influencing patient care were generated, revised, and qualitatively analyzed. Results Causal maps identified patient condition as the central modifier of acute care delivery. Severe illness and high volume of patients were identified as creating system strain in several domains: (1) physical space, (2) resource needs and utilization, (3) staff capabilities and (4) quality improvement. Stress in these domains results in worsening patient condition and perpetuating negative reinforcing feedback loops. Balancing factors inherent to the current system included (1) parental engagement, (2) provider resilience, (3) ease of communication and (4) patient death. Perceived strengths of the GMB process were representation of diverse stakeholder viewpoints and complex system synthesis in a visual causal pathway, the process inclusivity, development of shared understanding, new idea generation and momentum building. Challenges identified included time required for completion and potential for participant selection bias. Conclusions GMB facilitated creation of a shared mental model, as a first step in optimizing acute care delivery in a paediatric facility in this resource-limited setting.
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Affiliation(s)
- Fiona Muttalib
- Centre for Global Child Health, Hospital for Sick Children, 555 University avenue, Toronto, ON, M5G 1X8, Canada.
| | - Ellis Ballard
- Social System Design Lab, Brown School of Social Work and Public Health, Washington University in St Louis, St-Louis, MO, USA
| | | | - Sara Malone
- Brown School of Social Work and Public Health, Washington University in St Louis, St-Louis, MO, USA
| | - Yudy Fonseca
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Andreas Hansmann
- Neonatal and Paediatric ICU, National Pediatric Hospital, Phnom Penh, Cambodia
| | - Kenneth Remy
- Departments of Pediatrics and Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Peter Hovmand
- Social System Design Lab, Brown School of Social Work and Public Health, Washington University in St Louis, St-Louis, MO, USA
| | - Allan Doctor
- Pediatric Critical Care Medicine and Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, USA
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Kawaguchi A, Guerra GG, Gilad E, Jain P, DeCaen A. Remote triage in paediatric critical care: A Canadian provincial-wide cohort study. Paediatr Child Health 2020; 26:166-172. [PMID: 33936336 DOI: 10.1093/pch/pxaa036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 02/03/2020] [Indexed: 11/13/2022] Open
Abstract
Objective To describe remote triage of 'potentially' critically ill or injured children in a western Canadian province and to examine the associated factors with 'missings' in vital sign items recorded in centralized telephone triage consultations. Methods This is a provincial-wide prospective cohort study. We included all children under 17 years of age consulted through the central transport coordination centres in Alberta from June 2016 to July 2017. We labeled a value as 'missing' when the actual value was not identified in the audio records. Results In total, 429 cases were included in this study. The median duration of triage calls was 6.8 minutes. Although the patients' demographics and primary diagnoses were similar, backgrounds of the referring physicians and hospitals were significantly different between the two cohorts (i.e., patients referred to Calgary versus Edmonton). The proportion of 'missings' among the vital sign items varied significantly, in which capillary refilling time (60%), pupils (86%), Glasgow Coma Scale (GCS) (79%), and level of respiratory effort (50%) were not well recorded, whereas heart rate (proportion of 'missings': 12%), SpO2 (20%), and respiratory rate (26%) were recorded reasonably well. The lower proportion of 'missings' was observed in older aged patients for several vital sign items including systolic blood pressure and GCS. Conclusions The proportion of missing vital signs recorded varied significantly. The 'missings' could be associated with referring physician's background and patients' demographics such as 'age' that should be considered for the improvement of triage quality in the future.
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Affiliation(s)
- Atsushi Kawaguchi
- Department of Pediatrics, University of Montreal CHU Sainte-Justine, Montreal, Quebec.,Department of Pediatrics, University of Ottawa Children's Hospital Eastern Ontario, Ottawa, Ontario
| | - Gonzalo Garcia Guerra
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta
| | - Eli Gilad
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta
| | - Praveen Jain
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta
| | - Allan DeCaen
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta
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de la Oliva P, Cambra-Lasaosa FJ, Quintana-Díaz M, Rey-Galán C, Sánchez-Díaz JI, Martín-Delgado MC, de Carlos-Vicente JC, Hernández-Rastrollo R, Holanda-Peña MS, Pilar-Orive FJ, Ocete-Hita E, Rodríguez-Núñez A, Serrano-González A, Blanch L. [Admission, discharge and triage guidelines for paediatric intensive care units in Spain]. An Pediatr (Barc) 2019; 88:287.e1-287.e11. [PMID: 29728212 DOI: 10.1016/j.anpedi.2017.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 09/20/2017] [Accepted: 10/09/2017] [Indexed: 10/17/2022] Open
Abstract
A paediatric intensive care unit (PICU) is a separate physical facility or unit specifically designed for the treatment of paediatric patients who, because of the severity of illness or other life-threatening conditions, require comprehensive and continuous inten-sive care by a medical team with special skills in paediatric intensive care medicine. Timely and personal intervention in intensive care reduces mortality, reduces length of stay, and decreases cost of care. With the aim of defending the right of the child to receive the highest attainable standard of health and the facilities for the treatment of illness and rehabilitation, as well as ensuring the quality of care and the safety of critically ill paediatric patients, the Spanish Association of Paediatrics (AEP), Spanish Society of Paediatric Intensive Care (SECIP) and Spanish Society of Critical Care (SEMICYUC) have approved the guidelines for the admission, discharge and triage for Spanish PICUs. By using these guidelines, the performance of Spanish paediatric intensive care units can be optimised and paediatric patients can receive the appropriate level of care for their clinical condition.
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Affiliation(s)
- Pedro de la Oliva
- Servicio de Cuidados Intensivos Pediátricos, Hospital Universitario Materno-Infantil La Paz, Madrid, España; Universidad Autónoma, Madrid, España.
| | - Francisco José Cambra-Lasaosa
- Servicio Área de Críticos Pediátricos, Hospital Sant Joan de Déu, Barcelona, España; Universidad de Barcelona, Barcelona, España
| | - Manuel Quintana-Díaz
- Servicio de Medicina Intensiva, Hospital Universitario La Paz-Carlos III, Madrid, España; Universidad Autónoma, Madrid, España
| | - Corsino Rey-Galán
- Sección de Cuidados Intensivos Pediátricos, Hospital Universitario Central de Asturias, Oviedo, Asturias, España; Universidad de Oviedo, Oviedo, Asturias, España
| | - Juan Ignacio Sánchez-Díaz
- Sección de Cuidados Intensivos Pediátricos y Urgencias Infantiles, Hospital Universitario 12 de Octubre, Madrid, España; Universidad Complutense, Madrid, España
| | - María Cruz Martín-Delgado
- Servicio de Medicina Intensiva, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, España; Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, España
| | - Juan Carlos de Carlos-Vicente
- Sección de Cuidados Intensivos Pediátricos, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
| | - Ramón Hernández-Rastrollo
- Sección de Cuidados Intensivos Pediátricos, Hospital Universitario Materno-Infantil, Badajoz, España; Universidad de Extremadura, Badajoz, España
| | - María Soledad Holanda-Peña
- Unidad de Cuidados Intensivos Materno-Infantil, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | | | - Esther Ocete-Hita
- Unidad de Cuidados Intensivos Pediátricos, Hospital Virgen de Las Nieves, Universidad de Granada, Granada, España
| | - Antonio Rodríguez-Núñez
- Servicio de Críticos y Urgencias Pediátricas, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, La Coruña, España; Universidad de Santiago de Compostela, Santiago de Compostela, La Coruña, España
| | - Ana Serrano-González
- Servicio de Cuidados Intensivos Pediátricos, Hospital Niño Jesús, Madrid, España; Universidad Autónoma, Madrid, España
| | - Luis Blanch
- Centro de Críticos, Corporació Sanitaria Parc Taulí, Sabadell, Barcelona, España; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, España; Instituto de Investigación e Innovación Parc Taulí, Sabadell, Barcelona, España
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de la Oliva P, Cambra-Lasaosa FJ, Quintana-Díaz M, Rey-Galán C, Sánchez-Díaz JI, Martín-Delgado MC, de Carlos-Vicente JC, Hernández-Rastrollo R, Holanda-Peña MS, Pilar-Orive FJ, Ocete-Hita E, Rodríguez-Núñez A, Serrano-González A, Blanch L. Admission, discharge and triage guidelines for paediatric intensive care units in Spain. Med Intensiva 2019; 42:235-246. [PMID: 29699643 DOI: 10.1016/j.medin.2017.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 10/24/2017] [Indexed: 12/16/2022]
Abstract
A paediatric intensive care unit (PICU) is a separate physical facility or unit specifically designed for the treatment of paediatric patients who, because of the severity of illness or other life-threatening conditions, require comprehensive and continuous inten-sive care by a medical team with special skills in paediatric intensive care medicine. Timely and personal intervention in intensive care reduces mortality, reduces length of stay, and decreases cost of care. With the aim of defending the right of the child to receive the highest attainable standard of health and the facilities for the treatment of illness and rehabilitation, as well as ensuring the quality of care and the safety of critically ill paediatric patients, the Spanish Association of Paediatrics (AEP), Spanish Society of Paediatric Intensive Care (SECIP) and Spanish Society of Critical Care (SEMICYUC) have approved the guidelines for the admission, discharge and triage for Spanish PICUs. By using these guidelines, the performance of Spanish paediatric intensive care units can be optimised and paediatric patients can receive the appropriate level of care for their clinical condition.
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Affiliation(s)
- Pedro de la Oliva
- Servicio de Cuidados Intensivos Pediátricos, Hospital Universitario Materno-Infantil La Paz, Madrid, España; Universidad Autónoma, Madrid, España.
| | - Francisco José Cambra-Lasaosa
- Servicio Área de Críticos Pediátricos, Hospital Sant Joan de Déu, Barcelona, España; Universidad de Barcelona, Barcelona, España
| | - Manuel Quintana-Díaz
- Servicio de Medicina Intensiva, Hospital Universitario La Paz-Carlos III, Madrid, España; Universidad Autónoma, Madrid, España
| | - Corsino Rey-Galán
- Sección de Cuidados Intensivos Pediátricos, Hospital Universitario Central de Asturias, Oviedo, Asturias, España; Universidad de Oviedo, Oviedo, Asturias, España
| | - Juan Ignacio Sánchez-Díaz
- Sección de Cuidados Intensivos Pediátricos y Urgencias Infantiles, Hospital Universitario 12 de Octubre, Madrid, España; Universidad Complutense, Madrid, España
| | - María Cruz Martín-Delgado
- Servicio de Medicina Intensiva, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, España; Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, España
| | - Juan Carlos de Carlos-Vicente
- Sección de Cuidados Intensivos Pediátricos, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
| | - Ramón Hernández-Rastrollo
- Sección de Cuidados Intensivos Pediátricos, Hospital Universitario Materno-Infantil, Badajoz, España; Universidad de Extremadura, Badajoz, España
| | - María Soledad Holanda-Peña
- Unidad de Cuidados Intensivos Materno-Infantil, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | | | - Esther Ocete-Hita
- Unidad de Cuidados Intensivos Pediátricos, Hospital Virgen de Las Nieves, Universidad de Granada, Granada, España
| | - Antonio Rodríguez-Núñez
- Servicio de Críticos y Urgencias Pediátricas, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, La Coruña, España; Universidad de Santiago de Compostela, Santiago de Compostela, La Coruña, España
| | - Ana Serrano-González
- Servicio de Cuidados Intensivos Pediátricos, Hospital Niño Jesús, Madrid, España; Universidad Autónoma, Madrid, España
| | - Luis Blanch
- Centro de Críticos, Corporació Sanitaria Parc Taulí, Sabadell, Barcelona, España; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, España; Instituto de Investigación e Innovación Parc Taulí, Sabadell, Barcelona, España
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Ramnarayan P, Lister P, Dominguez T, Habibi P, Edmonds N, Canter RR, Wulff J, Harrison DA, Mouncey PM, Peters MJ. FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): a multicentre pilot randomised controlled trial of high-flow nasal cannula therapy versus continuous positive airway pressure in paediatric critical care. Crit Care 2018; 22:144. [PMID: 29866165 PMCID: PMC5987627 DOI: 10.1186/s13054-018-2080-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/22/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although high-flow nasal cannula therapy (HFNC) has become a popular mode of non-invasive respiratory support (NRS) in critically ill children, there are no randomised controlled trials (RCTs) comparing it with continuous positive airway pressure (CPAP). We performed a pilot RCT to explore the feasibility, and inform the design and conduct, of a future large pragmatic RCT comparing HFNC and CPAP in paediatric critical care. METHODS In this multi-centre pilot RCT, eligible patients were recruited to either Group A (step-up NRS) or Group B (step-down NRS). Participants were randomised (1:1) using sealed opaque envelopes to either CPAP or HFNC as their first-line mode of NRS. Consent was sought after randomisation in emergency situations. The primary study outcomes were related to feasibility (number of eligible patients in each group, proportion of eligible patients randomised, consent rate, and measures of adherence to study algorithms). Data were collected on safety and a range of patient outcomes in order to inform the choice of a primary outcome measure for the future RCT. RESULTS Overall, 121/254 eligible patients (47.6%) were randomised (Group A 60%, Group B 44.2%) over a 10-month period (recruitment rate for Group A, 1 patient/site/month; Group B, 2.8 patients/site/month). In Group A, consent was obtained in 29/33 parents/guardians approached (87.9%), while in Group B 84/118 consented (71.2%). Intention-to-treat analysis included 113 patients (HFNC 59, CPAP 54). Most reported adverse events were mild/moderate (HFNC 8/59, CPAP 9/54). More patients switched treatment from HFNC to CPAP (Group A: 7/16, 44%; Group B: 9/43, 21%) than from CPAP to HFNC (Group A: 3/13, 23%; Group B: 5/41, 12%). Intubation occurred within 72 h in 15/59 (25.4%) of HFNC patients and 10/54 (18.5%) of CPAP patients (p = 0.38). HFNC patients experienced fewer ventilator-free days at day 28 (Group A: 19.6 vs. 23.5; Group B: 21.8 vs. 22.2). CONCLUSIONS Our pilot trial confirms that, following minor changes to consent procedures and treatment algorithms, it is feasible to conduct a large national RCT of non-invasive respiratory support in the paediatric critical care setting in both step-up and step-down NRS patients. TRIAL REGISTRATION clinicaltrials.gov, NCT02612415 . Registered on 23 November 2015.
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Affiliation(s)
- Padmanabhan Ramnarayan
- Children's Acute Transport Service, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, 26-27 Boswell Street, London, WC1N 3JZ, UK. .,Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK.
| | - Paula Lister
- Paediatric and Neonatal Intensive Care Unit, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Troy Dominguez
- Cardiac Intensive Care Unit, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Parviz Habibi
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Naomi Edmonds
- Paediatric Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Ruth R Canter
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, High Holborn, London, UK
| | - Jerome Wulff
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, High Holborn, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, High Holborn, London, UK
| | - Paul M Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), Napier House, High Holborn, London, UK
| | - Mark J Peters
- Paediatric and Neonatal Intensive Care Unit, Critical Care Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK.,Respiratory, Critical Care and Anaesthesia Unit, Infection, Immunity and Inflammation Programme, UCL Great Ormond Street Institute of Child Health, London, UK
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Agrawal S, Branco RG. Neuroprotective measures in children with traumatic brain injury. World J Crit Care Med 2016; 5:36-46. [PMID: 26855892 PMCID: PMC4733454 DOI: 10.5492/wjccm.v5.i1.36] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/01/2015] [Accepted: 01/11/2016] [Indexed: 02/06/2023] Open
Abstract
Traumatic brain injury (TBI) is a major cause of death and disability in children. Severe TBI is a leading cause of death and often leads to life changing disabilities in survivors. The modern management of severe TBI in children on intensive care unit focuses on preventing secondary brain injury to improve outcome. Standard neuroprotective measures are based on management of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) to optimize the cerebral blood flow and oxygenation, with the intention to avoid and minimise secondary brain injury. In this article, we review the current trends in management of severe TBI in children, detailing the general and specific measures followed to achieve the desired ICP and CPP goals. We discuss the often limited evidence for these therapeutic interventions in children, extrapolation of data from adults, and current recommendation from paediatric guidelines. We also review the recent advances in understanding the intracranial physiology and neuroprotective therapies, the current research focus on advanced and multi-modal neuromonitoring, and potential new therapeutic and prognostic targets.
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