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PubMed2006

Paediatric critical care nurses' attitudes and experiences of parental presence during cardiopulmonary resuscitation: a European survey.

BACKGROUND: Although recent resuscitation guidelines are supportive of family presence during cardiopulmonary resuscitation literature from the last decade suggests that it is often discouraged, and the subject remains a controversial issue. OBJECTIVES: To determine the experiences and attitudes of European paediatric critical care nurses about parental presence during the resuscitation of a child. DESIGN: A survey design was employed. PARTICIPANTS: A convenience sample of European paediatric critical care nurses was used. METHODS: A structured questionnaire was used, which incorporated a series of attitude statements that were rated using a 5-point Likert scale. Differences in attitudes were explored in three areas: decision-making, processes and outcomes of resuscitation. RESULTS: The results from this survey suggest that European paediatric nurses are very supportive of parental presence during cardiopulmonary resuscitation. Only a few nurses reported that their unit had a policy that covered parental presence during cardiopulmonary resuscitation and most nurses did not support the use of a dedicated nurse to look after the parents during resuscitation. CONCLUSIONS: Compared with previous studies relating to adult cardiopulmonary resuscitation, paediatric nurses experience family member presence more frequently than adult critical care nurses and appear to be more supportive of relatives' presence. It is recommended that paediatric intensive care units establish local policies that cover parental presence during cardiopulmonary resuscitation.

Adult↗

PubMed2006

From multidimensional support to decreasing visibility: a field study on care culture in paediatric and adult diabetes outpatient clinics.

BACKGROUND: As the incidence of Type 1 diabetes mellitus has increased during childhood, more patients will experience the transfer from paediatric diabetes care to adult diabetes care. In order to achieve a coherent care system it is essential to identify conditions, events and actions that hinder and facilitate a successful transition between these settings. OBJECTIVES: The aim of this study was to describe care culture in paediatric and adult diabetes outpatient clinics and implications for care of adolescents in those settings. METHODS: Fifty-one participant observations and 10 semi-structured interviews with diabetes care providers were carried out in two paediatric clinics and two adult clinics in Sweden. Data were analysed simultaneously with data collection, using a constant comparative method developed in the grounded theory tradition. RESULTS: In the analysis process, one core category, four categories and subcategories were generated. The core category shifting aspects of diabetes care culture is related to the categories. The categories support of self-management and unfocused behaviour describes mostly similar strategies and attitudes in paediatric and adult diabetes care, while multidimensional support and decreasing visibility describes differences in characteristics of care culture in paediatric versus adult diabetes care. CONCLUSIONS: The decreased visibility might have consequences for vulnerable patients, such as those with insufficient metabolic control and self-management abilities. By illuminating shifting aspects of care culture, care providers can be given a basis for reflection and discussion of how the care is provided in their own setting and how different environmental conditions and care strategies can promote formal and informal contacts between patients and care providers.

Adult↗

PubMed2005

The burden of paediatric intensive care: a South American perspective.

Paediatric intensive care is a relatively new medical specialty that has shown a marked growing up around the world over the last three decades. The limits and the development of this new specialty are not uniform from country to country. Original articles relating to paediatric intensive care and some South American data bases of health care were evaluated and relevant results were selected. Using these data, we describe the main characteristics of paediatric intensive care in South America and discuss some associated factors (e.g. economic aspects, health systems, ethical aspects) that could interfere with the quality and extent of care. A strong relationship between the financial stability of each region and the complexity and quality of paediatric intensive care was seen. A better coverage and more sophisticated paediatric intensive care units (PICUs) are concentrated in the more developed countries (Brazil, Chile and Argentina). Compared to the northern hemisphere, children admitted to the South American PICUs have higher mortality and higher rates of intervention (mechanical ventilation and indwelling catheters). Medical paternalism has a strong influence in the decision-making process offered to terminally ill patients. This phenomenon increases the length of stay, reduces the number of available beds and increases costs. In conclusion, during the last 20 years PICUs have developed and increased their coverage in South America. However, the most sophisticated and well equipped PICUs are preferentially located in the more developed areas whereas those areas with higher infant mortality rates have few PICU beds. Improvements in the economical stability, regional health organisation as well as the rationale for PICU localisation are some of the important goals to be reached in the near future.

Child↗

PubMed2004

Is optimal paddle force applied during paediatric external defibrillation?

INTRODUCTION: Optimal paddle force minimises transthoracic impedance; a factor associated with increased defibrillation success. Optimal force for the defibrillation of children < or =10 kg using paediatric paddles has previously been shown to be 2.9 kgf, and for children >10 kg using adult paddles is 5.1 kgf. We compared defibrillation paddle force applied during simulated paediatric defibrillation with these optimal values. METHODS: 72 medical and nursing staff who would be expected to perform paediatric defibrillation were recruited from a University teaching hospital. Participants, blinded to the nature of the study, were asked to simulate defibrillation of an infant manikin (9 months of age) and a child manikin (6 years of age) using paediatric or adult paddles, respectively, according to guidelines. Paddle force (kgf) was measured at the time of simulated shock and compared with known optimal values. RESULTS: Median paddle force applied to the infant manikin was 2.8 kgf (max 9.6, min 0.6), with only 47% operators attaining optimal force. Median paddle force applied to the child manikin was 3.8 kgf (max 10.2, min 1.0), with only 24% of operators attaining optimal force. CONCLUSION: Defibrillation paddle force applied during paediatric defibrillation often falls below optimal values.

Body Weight↗

PubMed1997

General practitioners use of hospital and community based paediatric out-patient services in Nottingham.

The paper compares and contrasts the referral patterns of general practitioners in Nottingham for paediatric specialist opinion in a hospital and community setting. Data were collected from case notes review and medical activity data returns on 100 consecutive referrals made by GPs to a hospital paediatric consultant out-patient clinical and 100 consecutive referrals to a community based consultant clinic. Multiple diagnoses are more commonly made and recorded by community based paediatricians with a bias towards behavioural, nutrition, growth and neurodevelopmental problems. Hospital clinic staff made more system and disease based diagnoses with more investigations arranged than the community staff [53 cf. 15 (OR 6.39, 95% CI; 3.25-12.55, P = < 0.0001)]. More children under five were seen in the community clinic sample compared to the hospital sample [75 cf. 57 under fives (OR 2.26, 95% CI; 1.24-4.13, P = 0.01)]. Patients are more likely to be discharged from the hospital clinic than the community clinic after the initial visit. [59 cf. 33 (OR 2.92, 95% CI; 1.64-5.20, P = 0.0004)]. Costs per new case consultation were substantially less in the community clinic than the hospital setting. A broadly similar range of clinic problems are referred to both hospital and community based paediatricians in Nottingham. The educational and liaison value of local community paediatric clinics together with relatively easier access by parents and lower per case costs is an advantage. Commissioners of paediatric and child health services need to take into consideration these factors when purchasing out-patient specialist paediatric opinion. Further research is required into the quality and desirability of these developments.

Ambulatory Care↗

PubMed2002

Effectiveness of ventilation-compression ratios 1:5 and 2:15 in simulated single rescuer paediatric resuscitation.

Current guidelines for paediatric basic life support (BLS) recommend a ventilation-compression ratio of 1:5 during child resuscitation compared with 2:15 for adults, based on the consensus that ventilation is more important in paediatric than in adult BLS. We hypothesized that the ratio 2:15 would provide the same minute ventilation as 1:5 during single-rescuer paediatric BLS due to the reduced time required to change between ventilations and compressions. Fourteen lay rescuers were trained with both ratios and thereafter performed single rescuer BLS for approximately 4 min with each of the two ratios in random order on a child-sized manikin with a built-in respiratory monitor. Quality of chest compressions was assessed by measurement of the rate, depth and position. There were no significant differences in tidal volumes or minute ventilation between the ratios. Nearly all chest compressions were within acceptable limits for depth and place with both methods, but the mean number of chest compressions per minute was 48+/-15% greater with ratio 2:15. In conclusion, there was no difference in ventilation, but nearly one and a half times as many compressions with a ratio of 2:15 than 1:5 for lay rescuers during single rescuer paediatric CPR. In order to simplify CPR training for laypersons, we recommend a 2:15 ratio for both single- and two-person, adult and paediatric layperson BLS.

Adult↗

PubMed2003

Anaesthesia for day case surgery: a survey of paediatric clinical practice in the UK.

BACKGROUND AND OBJECTIVE: In October 2000, we conducted a national postal survey of day case consultant anaesthetists in the UK to explore the range and variation in practice of anaesthetizing a patient for day case surgery (paediatrics, urology and orthopaedics). This paper reports the findings of this national survey of paediatric day case anaesthetic practice carried out as part of a major two-centre randomized controlled trial designed to investigate the costs and outcome of several anaesthetic techniques during day care surgery in paediatric and adult patients (cost-effectiveness study of anaesthesia in day case surgery). METHODS: The survey used a structured postal questionnaire and collected data on the duration of surgical procedure; the use of premedication; the anaesthetic agents used for induction and maintenance; the fresh gas flow rates used for general anaesthesia; the use of antiemetics; and the administration of local anaesthesia and analgesia. RESULTS: The overall response rate for the survey was 74 and 63% for the paediatric section of the survey. Respondents indicated that 19% used premedication, 63% used propofol for induction, 54% used isoflurane for maintenance, 24% used prophylactic antiemetics and 85%, used a laryngeal mask. The findings of this national survey are discussed and compared with published evidence. CONCLUSIONS: This survey identifies the variation in clinical practice in paediatric day surgery anaesthesia in the UK.

Ambulatory Surgical Procedures↗

PubMed2006

A survey of the use of 2D ultrasound guidance for insertion of central venous catheters by UK consultant paediatric anaesthetists.

BACKGROUND AND OBJECTIVE: National Institute for Clinical Excellence guidance states that 2D imaging ultrasound guidance should be used when inserting internal jugular venous lines in adults and children in the elective situation and should be considered in most clinical circumstances requiring central venous catheter insertion. This survey explored the availability, training and use of ultrasound devices by consultant paediatric anaesthetists in the UK. METHODS: A questionnaire was distributed to UK members of the Association of Paediatric Anaesthetists of Great Britain and Ireland. RESULTS: There was a response rate of 63% and of those responding, 212 (81%) inserted paediatric central venous catheters. Ultrasound devices were available in the workplace of 216 (82%) and the average number of devices available per department was two. For elective paediatric theatre cases, 26% of paediatric anaesthetists with access to an ultrasound device always used it when inserting an internal jugular central venous line. The majority (74%) of respondents had received training in the use of 2D ultrasound. CONCLUSIONS: National Institute for Clinical Excellence guidance on the use of ultrasound locating devices for placing central venous catheters is not universally adhered to. Among the reasons for this are problems with availability of equipment, lack of training in the use of ultrasound and non-acceptance of the guidelines.

Anesthesiology↗

PubMed1999

Paediatric nosocomial urinary tract infection at a regional hospital.

From a total of 26,603 admissions to the paediatric wards, 1360 paediatric nosocomial urinary tract infections (PNUTI) were identified during a 5-year retrospective chart review at the SFGH. The ages ranged from 3 days to 13 years, with 46% boys and 54% girls. The highest rates of PNUTI per service per 100 admissions were seen in the nursery (11.28) followed by paediatric surgery (2.89) and paediatric medicine (2.86). Although the greatest number of PNUTI occurred in the nursery, comparison between the years was not statistically significant. About 90% (1218 of 1360) of PNUTI occurred in catheterized patients. No documentation was found specifying the type of catheterization (intermittent or continuous). About 90% (1210 of 1360) of isolates were single organisms with Escherichia coli, Proteus mirabilis, Klebsiella spp. and Group B streptococci accounting for a total of approximately 70% of all pathogens. However, the composition of the most common isolate in each service differed. The most common isolate in the nursery was E. coli, in the paediatric medical and surgical services the most common isolates were Klebsiella spp. and Proteus mirabilis, respectively. Proteus mirabilis was isolated predominantly from boys with structural abnormality of the urethral tract. No PNUTIs were complicated by bacteraemia. The antibiotics with least effectiveness (in increasing order) for UTIs were cephalexin, ampicillin, trimethoprim, co-trimoxazole and tetracycline. The most effective antibiotics were nalidixic acid, gentamicin and amoxicillin-clavulanic acid.

Adolescent↗

PubMed2006

Paediatric vs adult retinal detachment.

OBJECTIVE: To evaluate the causes, incidences, characteristics, and treatment outcomes of paediatric vs adult retinal detachment. PATIENTS AND METHODS: One hundred and sixty (136 patients) out of 2408 consecutive retinal detachments (6.6%) at our facility occurred in children under the age of 18 years. Of them, 144 eyes (90%) of 127 (93%) children were treated and compared with a sample of 56 consecutive retinal detachments in 50 adults (over the age of 18 years). The parameters for comparison included cause, type of retinal detachment, its extent, macular involvement, number of tears, number and types of surgery, and the anatomic and functional surgical outcome. RESULTS: Statistically significant differences were found in the type of retinal detachment. Rhegmatogenous RD was less common (P=0.004), and exudative RD was more common (P=0.021) in the paediatric group. Ocular trauma and ocular syndromes were more common in the paediatric group (P<0.001), while myopia, posterior vitreous detachment, and retinal detachment following cataract surgery were less common in this group compared with adults (P<0.001, <0.001, and 0.001, respectively). Ocular pathologies associated with retinal detachment were more common in the paediatric group (P<0.001). Initial and last visual acuity of >20/400, last visual acuity of >20/40, and retinal complete reattachment were higher in adults (P<0.001). CONCLUSIONS: The type of retinal detachment, causes and outcomes were statistically different between paediatric and adult cases. The less successful functional and anatomical outcomes of retinal detachment surgery in children may reflect the different aetiologies and indicate the need for aetiology-specific treatment strategies according to each aetiology.

Adolescent↗

PubMed2001

Paediatric absorbed doses from rotational panoramic radiography.

OBJECTIVES: To determine the paediatric doses in rotational panoramic radiography with film/screen and photostimulable phosphor receptors. STUDY DESIGN: A paediatric anthropomorphic head and neck phantom was used. Absorbed doses were measured for two panoramic systems, the Orthophos (Sirona Dental Systems, Bensheim, Germany) and the PM 2002 CC (Planmeca Oy, Helsinki, Finland), with and without programmable child settings, using both screen/film and photostimulable phosphor receptors. RESULTS: Absorbed doses to the eye ranged from 5 to 24 micro Gy. Doses to the dental arches with the Orthophos unit ranged from 50 to 555 micro Gy with the adult and from 27 to 436 micro Gy with the child program; using the PM 2002 CC unit, doses ranged from 56 to 1040 micro Gy using the adult settings, and from 60 to 890 micro Gy with the paediatric settings. The paediatric exposure settings reduced doses at most locations for both panoramic systems. The highest doses were measured near the rotational axes of the X-ray beam. Paediatric settings with the Orthophos P10 resulted in the dose reduction more than 50% to the thyroid but not with the PM 2002 CC. When lower kVcp or mA settings were used, absorbed doses were effectively reduced for all combinations of machines, programs and detectors. CONCLUSIONS: Specific program settings for children reduced the absorbed doses from panoramic radiography irrespective of the machine or receptor used.

Absorption↗

PubMed2003

Survey of effective dose levels from typical paediatric CT protocols.

Concern over reported large radiation doses leading to a high cancer risk for paediatric CT patients has prompted considerable investigation in paediatric CT. The recent release of software from Germany has allowed effective doses to be calculated from CT protocol information and radiation measurement for standard paediatric patient sizes for both sexes. An initial study has been undertaken in nine radiology departments, four of which were dedicated paediatric departments, for routine chest and abdominal CT procedures. The dose calculation software is based on Monte Carlo simulation of X-ray conditions during a CT procedure and utilized a 'tomographic' phantom model of a 7-year-old child and an 8-week-old baby to allow calculation of organ dose and hence effective dose. Results of the survey indicate that effective doses were higher for females than males, and higher for abdominal procedures. Slightly higher effective doses were calculated for the child compared to the baby. All centres but one recorded lower effective doses with their current protocols than if they had used recommended CT protocols found in the literature. Analysis of the survey data indicates that scan parameters are the main cause of dose variations, although the type of scanner can affect dose by a factor of 2 (when comparing different units) as well as variation in anatomy scanned in protocols. Dose reduction appears to be most closely linked with reduced mAs and increased pitch as expected. The calculation of effective dose appears to be a key factor in assessing CT protocols, particularly for paediatric patients.

Child↗

PubMed2001

Ethical relationships in paediatric emergency medicine: moving beyond the dyad.

Most areas of health-services research concentrate on a dyadic relationship between doctor and patient. In paediatric emergency medicine it may be necessary to focus on a more complicated relationship because the parents of the child play an important role in the delivery of medical services. This paper discusses the ethical principles in paediatric emergency medicine from the perspective of five disciplines: health economics, paediatrics, medical ethics, law and mental health. The general consensus is that the traditional dyadic model is inadequate and that a more complicated relationship is needed for the paediatric emergency setting, such as triadic, multiple-dyadic or polyadic. Such models allow the inclusion of the parents and possibly other family members, medical providers and community members. If the paediatric setting is considered in such a framework, it may be possible to deliver a more socially beneficial medical service.

Adolescent↗

PubMed2002

The recruitment and training crisis in community paediatrics: what do registrars think?

OBJECTIVE: There is currently a crisis in the recruitment of trainees into community paediatrics. Focus groups were conducted to explore the views of paediatric specialist registrars about this crisis. DESIGN: A total of 18 registrars participated in two focus groups. Data were analysed qualitatively by content analysis. RESULTS: The overriding theme was the poor status and image of community compared with acute paediatrics. This existed at five levels, which could be arranged from a 'macro' structural level down to a 'micro' individual level. These were: the hospital/community divide, issues related to training, practical experience, the influence of role models, and personal factors. CONCLUSIONS: We identified several specific implications for community paediatric training. However, the deep divide between acute and community paediatrics, as perceived by registrars, is unlikely to change unless training programmes are designed to produce paediatricians suited to the needs of future child health services rather than existing models of acute and community paediatricians.

Attitude of Health Personnel↗

PubMed2003

Relative analgesia and general dental practitioners: attitudes and intentions to provide conscious sedation for paediatric dental extractions.

AIM: To examine the attitudes and intentions of general dental practitioners (GDPs) who work within the remit of the National Health Service (NHS) to provide relative analgesia (RA) for paediatric extractions. METHODS: All 45 GDPs working within the boundaries of one Trust were asked to complete a questionnaire to assess demography, etc., intention and attitudes to provide RA for paediatric extractions. RESULTS: Ninety-eight per cent of GDPs took part. All GDPs worked within the NHS. Twenty-nine per cent of GDPs stated that they had RA equipment available in their practices and 68% stated that they discussed RA as treatment alternative. Eighty-seven per cent referred their paediatric extraction cases for dental general anaesthesia. The behavioural intention was predicted by total attitude score and the availability of RA equipment in the practice (R2=0.97, F(37,5)=260.11, P<0.001). Total attitude was predicted by clinical competency, few financial worries or time concerns and the availability of RA equipment (R2=0.91, F(38,4)=106.21, P<0.001). CONCLUSIONS: This study suggests that GDPs' concerns of clinical competence and costs have an inhibiting effect upon their intention to provide RA for paediatric extractions. These concerns must be addressed by planners and policy makers if there is to be a shift from hospital-based DGA to surgery-based RA services for paediatric extractions.

Analgesia↗

PubMed2002

Improvement in resuscitation knowledge after a one-day paediatric life-support course.

OBJECTIVE: To assess the effect of a one-day paediatric life-support course on the knowledge of paediatric trainees. METHODS: A telephone survey was performed prior to and at set intervals following the course. Responses to individual questions before and after the course were analysed and an overall test score was calculated. The acquisition and retention of knowledge was measured by comparing test scores for the same group of trainees at time intervals after the course. RESULTS: All candidates were surveyed. The median duration of paediatric training prior to the course was 3 years. Eighteen candidates (78%) had previously intubated a child and 13 (57%) had previously used an intraosseous needle. Prior to the course, few of the 23 candidates had adequate knowledge of either the management of the cervical spine in the seriously injured child (17%), fluid resuscitation in meningococcal septicemia (52%), shock dose in ventricular fibrillation (61%), or the management of anaphylactic shock (35%). There was a significant improvement in the knowledge of the group after the course, with median test scores increasing from 19 to a maximum of 22 (P < 0.001). This knowledge was retained at 4 months after the course. CONCLUSION: Despite a high level of experience and previous training in paediatric resuscitation, many candidates lacked the basic knowledge necessary for the resuscitation of seriously ill or injured children. There was a significant improvement in this knowledge after the course, and this was maintained for 4 months. The paediatric life-support course is an important means of resuscitation training for junior doctors.

Australia↗

PubMed2000

The topics of international publications on paediatric anaesthesia from 1993 to 1998.

A comprehensive compilation of the current international literature on paediatric anaesthesia is still lacking. It was the aim of this study to identify all publications with a focus on paediatric anaesthesia, and to determine the spectrum of topics, as well as the publication type and language for the period between 1993 and 1998. All articles published in 12 major anaesthesia journals were evaluated and, additionally, a computerized, Internet-based Medline-search was performed using selected keywords. The analysis was limited to original articles, case reports, reviews and editorials. For the period between 1993 and 1998, a total of 2259 (377 per year) publications on paediatric anaesthesia were identified in 295 different journals, the majority of which were on the topic of 'providing anaesthesia' in children (n=1424, 63.0%). In contrast, publications on, for example, 'postanaesthesia care' (6. 3%), and 'organizational aspects of paediatric anaesthesia' (2.2%) were rare. Most articles were written in English (85.1%), and more than 50% reported original data (57.1%). Our results suggest that several topics may be of interest for future research and communication in the field of paediatric anaesthesia and new results should be published in English to reach a large international readership.

Anesthesia↗

PubMed2001

Aspiration and regurgitation prophylaxis in paediatric anaesthesia.

BACKGROUND: Surveys of aspiration prophylaxis in paediatric anaesthesia do not exist. METHODS: A postal survey was sent out to all UK members of the Association of Paediatric Anaesthetists (APA) to assess current practice. We asked about minimum fasting times for liquids and solids/milk, their routine acid aspiration prophylaxis and perceived risk factors for emergency and elective surgery in children those less than 1 year old and those aged 1-14 years. We also asked if the APA member had more than 10 years experience in paediatric anaesthesia. RESULTS: One hundred and two (55.1%) APA members replied out of a total of 185 questionnaires sent. Eighty-eight (88/102) were considered valid. Fasting in emergencies is approximately 4 h for solids/milk and 2 h for clear liquids. Fasting for elective surgery is between 5 and 6 h for solids/milk and 2 h for clear liquids. Pharmacological methods to reduce the risk of aspiration are not used. Mechanical methods vary from 40-50% for cricoid pressure and 20-30% for nasogastric aspiration if a tube is present. The presence of a hiatus hernia is perceived by over 80% as a risk factor, previous aspiration by over 60%, difficult intubation, cerebral palsy and sepsis by 20-30%. CONCLUSION: Perceived risk factors vary with "experience": hiatus hernia, difficult intubation and cerebral palsy are less important whereas previous aspiration and renal failure appear to be more important for paediatric anaesthetists with less than 10 years in paediatric anaesthetic practice.

Adolescent↗