Emergency front-of-neck access in infants: A pragmatic crossover randomized control trial comparing two approaches on a simulated rabbit model.

BACKGROUND: Rapid-sequence tracheotomy and scalpel-bougie tracheotomy are two published approaches for establishing emergency front-of-neck access in infants. It is unknown whether there is a difference in performance times and success rates between the two approaches. AIMS: The aim of this cross-over randomized control trial study was to investigate whether the two approaches were equivalent for establishing tracheal access in rabbit cadavers. The underlying hypothesis was that the time to achieve the tracheal access is the same with both techniques. METHODS: Between May and September 2022, thirty physicians (pediatric anesthesiologists and intensivists) were randomized to perform front-of-neck access using one and then the other technique: rapid-sequence tracheotomy and scalpel-bougie tracheotomy. After watching training videos, each technique was practiced four times followed by a final tracheotomy during which study measurements were obtained. Based on existing data, an equivalence margin was set at ∆ = ±10 s for the duration of the procedure. The primary outcome was defined as the duration until tracheal tube placement was achieved successfully. Secondary outcomes included success rate, structural injuries, and subjective participant self-evaluation. RESULTS: The median duration of the scalpel-bougie tracheotomy was 48 s (95% CI: 37-57), while the duration of the rapid-sequence tracheotomy was 59 s (95% CI: 49-66, p = .07). The difference in the median duration between the two approaches was 11 s (95% CI: -4.9 to 29). The overall success rate was 93.3% (95% CI: 83.8%-98.2%). The scalpel-bougie tracheotomy resulted in significantly fewer damaged tracheal rings and was preferred among participants. CONCLUSIONS: The scalpel-bougie tracheotomy was slightly faster than the rapid-sequence tracheotomy and favored by participants, with fewer tracheal injuries. Therefore, we propose the scalpel-bougie tracheostomy as a rescue approach favoring the similarity to the adult approach for small children. The use of a comparable equipment kit for both children and adults facilitates standardization, performance, and logistics. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05499273.

Patterns of airway obstruction of non-acquired origin in children with and without major congenital anomalies.

Major congenital anomalies are known to play a role in the management and prognosis of airway obstruction. Most studies assess acquired forms of airway obstruction. Data on congenital or otherwise non-acquired forms of airway obstruction is sparse. In this retrospective, single-institution cohort study, we sought to evaluate and compare the patterns of airway obstruction in children with and without major congenital anomalies, and to assess the impact of management and outcome, irrespective of aetiology. Fifty-five patients were included, 23 with and 32 without underlying major congenital anomalies. Multilevel airway obstruction (usually affecting the nasopharynx, oropharynx, and the trachea) was more common in children with congenital anomalies (91% vs. 41%, p < .001). Consequently, these children required more frequent and earlier surgical management, especially tracheostomy and adenotonsillar surgery.Conclusions: Major congenital anomalies are associated with multilevel airway obstruction and poor functional prognosis. A simple clinical definition considering impact of major congenital anomalies on development and growth may help guide management plans following endoscopic evaluation of the entire airway and flanked by multidisciplinary discussions. What is Known: • Children with major comorbidities display increased disease severity and more prevalent multilevel airway obstruction • Previous studies include both children with acquired and non-acquired forms of airway obstruction; therefore, the actual impact major comorbidities in children with non-acquired causes of airway obstruction remain unclear. What is New: • A total of 42% children in this study population had major comorbidities with and impact on growth and/or psychomotor development, with a higher prevalence of multilevel airway obstruction and worse rates of functional improvement/recovery. • Children with major comorbidities require tracheostomy more often and earlier than those without major comorbidities, and remain tracheostomy-dependent for a longer time.

Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study.

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348.

Emergency front of neck access in children: a new learning approach in a rabbit model.

BACKGROUND: Cannot intubate-cannot ventilate situations in healthy children are uncommon but are often associated with poor outcome. Several airway management algorithms suggest emergency tracheal access. Little agreement exists on how to perform emergency front of the neck access (eFONA) in children <8 yr. We studied the learning curves of clinicians performing simulated paediatric eFONA. METHODS: After watching an instructional video, 50 physicians, from five medical specialties, performed 10 emergency tracheotomies on rabbit cadavers. We analysed their learning curves relative to performance time and concurring injuries. RESULTS: With an overall success rate of 94%, performance time decreased from 107 s (standard deviation [sd], 45) to 55 s (sd 17) over 10 attempts. The learning curve was steep between the first and the fourth attempts with an 11% decrease in performance time (95% confidence interval [CI], 9-13%; P<0.001) per attempt and then flattened to a 4% (95% CI, 3-5%; P<0.001) decrease per attempt between the fourth and the tenth attempt. Age, years of clinical experience, and sex showed a significant effect on the learning curve, whereas medical specialty and adult eFONA experience did not. The 58% (95% CI, 44-72%) probability for severe injury during the first attempt decreased to 14% (95% CI, 8-20%) at the second attempt. Men were more likely to cause minor injuries than women (P<0.001). CONCLUSIONS: Irrespective of medical specialty, paediatric clinicians acquired the eFONA technique within four attempts and were on average able to establish an airway in <1 min when performing emergency tracheotomy on a paediatric airway simulator. CLINICAL TRIAL REGISTRATION: NCT03576352.

Use of simulation-based medical training in Swiss pediatric hospitals: a national survey.

BACKGROUND: Simulation-based medical training (SBMT) is a powerful tool for continuing medical education. In contrast to the Anglo-Saxon medical education community, up until recently, SBMT was scarce in continental Europe's pediatric health care education: In 2009, only 3 Swiss pediatric health care institutions used SBMT. The Swiss catalogue of objectives in Pediatrics does not acknowledge SBMT. The aim of this survey is to describe and analyze the current state of SBMT in Swiss pediatric hospitals and health care departments. METHODS: A survey was carried out with medical education representatives of every institution. SBMT was defined as any kind of training with a mannequin excluding national and/or international standardized courses. The survey reference day was May 31st 2015. RESULTS: Thirty Swiss pediatric hospitals and health care departments answered our survey (response rate 96.8%) with 66.6% (20 out of 30) offering SBMT. Four of the 20 hospitals offering SMBT had two independently operating training simulation units, resulting in 24 educational units as the basis for our SBMT analysis. More than 90% of the educational units offering SBMT (22 out of 24 units) were conducting in-situ training and 62.5% (15 out of 24) were using high-technology mannequins. Technical skills, communication and leadership ranked among the top training priorities. All institutions catered to inter-professional participants. The vast majority conducted training that was neither embedded within a larger educational curriculum (19 out of 24: 79.2%) nor evaluated (16 out of 24: 66.6%) by its participants. Only 5 institutions (20.8%) extended their training to at least two thirds of their hospital staff. CONCLUSIONS: Two thirds of the Swiss pediatric hospitals and health care departments are offering SBMT. Swiss pediatric SBMT is inter-professional, mainly in-situ based, covering technical as well as non-technical skills, and often employing high-technology mannequins. The absence of a systematic approach and reaching only a small number of healthcare employees were identified as shortcomings that need to be addressed.

[Patient safety 4.0: "Failure of the Week" It's all about role modelling!] / Patient*innen-Sicherheit 4.0: "Fehler der Woche" ­ Um die Vorbildfunktion geht's!

BACKGROUND: The rate of mistakes and near misses in clinical medicine remains staggering. The tendency to cover up mistakes is rampant in "name-blame-shame" cultures. The need for safe forums where mistakes can be openly discussed in the interest of patient safety is evident. Following a comprehensive review of the literature, a semi-structured weekly conference, named "mistake of the week" (MOTW), was introduced, enabling physicians to voluntarily discuss their mistakes and near-misses. The MOTW is intended to encourage cultural change in how physicians approach, process, accept and learn from their own and their peers' mistakes. This study seeks to assess if physicians appreciate, benefit from and are motivated to participate in MOTW. METHODS: Physicians and medical students of the I. and II. Medizinische Klinik at the Academic Teaching Hospital Klinikum Konstanz (Germany) were eligible to participate voluntarily. Four groups of physicians (n=3-6) and one group of medical students (n=5) volunteered to participate in focus group interviews, which were videotaped, transcribed and analyzed. RESULTS: The following success factors are crucial for dealing with and voluntarily disclosing mistakes and near-misses: 1. Exemplification ("follow the boss's lead"), 2. Fixed time slots and a clear forum, 3. Reporting mistakes without fear of penalty or punishment, 4. A trusting working atmosphere. The key effects of the MOTW approach are: 1. People report their mistakes more, 2. Relief, 3. Psychological safety, 4. Lessons learned/errors (potentially) reduced. DISCUSSION: The MOTW conference models an ideal forum to mitigate hierarchy and promote a sustainable organizational dynamic in which mistakes and near misses can be discussed in an environment free from "name-blame-shame", with the ultimate goal of potentially improving patient care and safety.

Preparedness for Life-Threatening Situations in a Pediatric Tertiary-Care University Children's Hospital: A Survey.

Pediatric nurses and physicians are rarely exposed to life-threatening events. Understanding the needs of clinicians is key for designing continuing training programs. A survey exploring preparedness to manage life-threatening events as well as training needs was mailed to all clinically active nurses and physicians at a tertiary-level referral children's hospital. Overall, 469 participants out of 871 answered the questionnaire (54% response rate). Respondents felt well or very well (nurses 93%, physicians 74%) prepared to recognize a deteriorating child and rated their theoretical understanding (70% well or very well prepared) of how to manage life-threatening situations significantly higher (p < 0.0001) than their cardiopulmonary resuscitation (CPR) preparedness (52% well or very well prepared). Both perceived theoretical understanding (p < 0.0001) and CPR preparedness (p < 0.002) were rated higher among nurses than physicians. Arrhythmias, shock, cardiac arrest and airway management constitute main areas of perceived training need. In conclusion, although a majority of pediatric nurses and physicians felt sufficiently trained to recognize a deteriorating child, their perceived ability to actively manage life-threatening events was inferior to their theoretical understanding of how to resuscitate a child. A high degree of institutional confidence and identification of areas of training need provide a good foundation for customizing future continuing education programs.

Communication Patterns During Routine Patient Care in a Pediatric Intensive Care Unit: The Behavioral Impact of In Situ Simulation.

OBJECTIVE: Effective communication minimizes medical errors and leads to improved team performance while treating critically ill patients. Closed-loop communication is routinely applied in high-risk industries but remains underutilized in healthcare. Simulation serves as an educational tool to introduce, practice, and appreciate the efficacy of closed-loop communication. METHODS: This observational before-and-after study investigates behavioral changes in communication among nurses brought on by simulation team training in a pediatric intensive care unit (PICU). The communication patterns of PICU nurses, who had no prior simulation experience, were observed during routine bedside care before and after undergoing in situ simulation.One month before and 1 and 3 months after simulation (intervention), 2 trained raters recorded nurse communications relative to callouts, uttered by the sender, and callbacks, reciprocated by the recipient. The impact of simulation on communication patterns was analyzed quantitatively. RESULTS: Among the 15 PICU nurses included in this study, significant changes in communication behavior were observed during patient care after communication-focused in situ simulation. The PICU nurses were significantly less likely to let a callout go unanswered during clinical routine. The effect prevailed both 1 month (P = 0.039) and 3 months (P = 0.033) after the educational exposure. CONCLUSIONS: This observational before-and-after study describes the prevalence and pattern of communication among PICU nurses during routine patient care and documents PICU nurses transferring simulation-acquired communication skills into their clinical environment after a single afternoon of in situ simulation. This successful transfer of simulation-acquired skills has the potential to improve patient safety and outcome.

Measurement of activated coagulation time in children: evaluation of the blood-saving kaolin i-STAT activated coagulation time technique in pediatric cardiac anesthesia.

OBJECTIVE: To compare the activated coagulation times (ACTs) measured with the blood-saving kaolin i-STAT 1 ACT technique (Abbott Point of Care Inc, Princeton, NJ) with ACTs obtained from the widely used ACTR II device (Medtronic, Inc, Minneapolis, MN) in children undergoing cardiac surgery. DESIGN: A prospective, observational single-center study. PARTICIPANTS: Forty-four pediatric cardiac surgery patients. INTERVENTION: Surgery was performed with cardiopulmonary bypass (CPB) necessitating heparinization. METHODS AND MAIN RESULTS: ACTs measured on the i-STAT 1 device (2 × 95 µL) were compared with those obtained from the Medtronic ACTR II device (2 × 0.5 mL). Blood samples were drawn before, during, and after heparinization for CPB and paired for statistical analysis. The 2 techniques were compared using simple and multiregression analyses and the Bland-Altman method. In total, 179 intrarater and 142 interrater data pairs were analyzed. The intrarater reliability of the 2 devices was good, with a mean bias and limits of agreement of +2.0 and -55.5/+59.5 seconds for the Medtronic ACTR II and +0.5 and -59.9/+60.9 seconds for the i-STAT 1. An interrater reliability analysis of the mean of simultaneously measured ACT of the Medtronic ACTR II and both i-STAT 1 devices yielded a mean bias of -5.3 seconds and limits of agreement of -210.1/+199.5 seconds. A comparison of the higher of the paired ACT values from both devices showed similar results. After the removal of heparin, the i-STAT 1's ACT values became significantly lower than those measured on the Medtronic ACTR II (p < 0.001). Simple and multiregression analyses revealed that base excess independently influenced the mean bias of the ACT values from the Medtronic ACTR II (p = 0.037) and i-STAT 1 devices (p = 0.036). CONCLUSION: The kaolin i-STAT 1 ACT technique agreed well with the Medtronic ACTR II technique during the nonheparinized phase that preceded CPB. The overall agreement between the ACT obtained from the 2 devices was poor. The routine use of i-STAT 1 measured ACT values cannot be recommended as a reliable alternative to the Medtronic ACTR II.

Intellectual and motor performance, quality of life and psychosocial adjustment in children with cystinosis.

Cystinosis is a rare multisystemic progressive disorder mandating lifelong medical treatment. Knowledge on the intellectual and motor functioning, health-related quality of life and psychosocial adjustment in children with cystinosis is limited. We have investigated nine patients (four after renal transplantation) at a median age of 9.7 years (range 5.3-19.9 years). Intellectual performance (IP) was analysed with the Wechsler Intelligence Scale for Children-III (seven children) and the Kaufman Assessment Battery for Children (two children). Motor performance (MP) was evaluated using the Zurich Neuromotor Assessment Test, and quality of life (QOL) was studied by means of the Netherlands Organization for Applied Scientific Research Academical Medical Center Child Quality of Life Questionnaire. Psychosocial adjustment was assessed by the Child Behavior Checklist. The overall intelligence quotient (IQ) of our patient cohort (median 92, range 71-105) was significantly lower than that of the healthy controls (p = 0.04), with two patients having an IQ < 85. Verbal IQ (93, range 76-118) was significantly higher than performance IQ (90, range 68-97; p = 0.03). The MP was significantly below the norm for pure motor, pegboard and static balance, as well as for movement quality. The patients' QOL was normal for six of seven dimensions (exception being positive emotions), whereas parents reported significant impairment in positive emotions, autonomy, social and cognitive functions. Significant disturbance was noted in terms of psychosocial adjustment. Based on the results from our small patient cohort, we conclude that intellectual and motor performance, health-related QOL and psychosocial adjustment are significantly impaired in children and adolescents with cystinosis.

Mutations in PLCE1 are a major cause of isolated diffuse mesangial sclerosis (IDMS).

BACKGROUND AND OBJECTIVES: Diffuse mesangial sclerosis (DMS) is a histologically distinct variant of nephrotic syndrome (NS) that is characterized by early onset and by progression to end-stage kidney disease (ESKD). Besides syndromic DMS, isolated (non-syndromic) DMS (IDMS) has been described. The etiology and pathogenesis of DMS is not understood. We recently identified by positional cloning recessive mutations in the gene PLCE1/NPHS3 as a novel cause of IDMS. We demonstrated a role of PLCE1 in glomerulogenesis. Mutations in two other genes WT1 and LAMB2 may also cause IDMS. We therefore determine in this study the relative frequency of mutations in PLCE1, WT1 or LAMB2 as the cause of IDMS in a worldwide cohort. METHODS: We identified 40 children from 35 families with IDMS from a worldwide cohort of 1368 children with NS. All the subjects were analyzed for mutations in all exons of PLCE1 by multiplex capillary heteroduplex analysis and direct sequencing, by direct sequencing of exons 8 and 9 of WT1, and all the exons of LAMB2. RESULTS: The median (range) age at onset of NS was 11 (1-72) months. We detected truncating mutations in PLCE1 in 10/35 (28.6%) families and WT1 mutations in 3/35 (8.5%) families. We found no mutations in LAMB2. CONCLUSIONS: PLCE1 mutation is the most common cause of IDMS in this cohort. We previously reported that one child with truncating mutation in PLCE1 responded to cyclosporine therapy. If this observation is confirmed in a larger study, mutations in PLCE1 may serve as a biomarker for selecting patients with IDMS who may benefit from treatment.

Cultural Prototypes and Differences in Simulation Debriefing.

INTRODUCTION: Culture is believed to play a role in education, safety, and patient outcome in healthcare. Hofstede's culture analysis permits a quantitative comparison between countries, along different culture dimensions, including power distance (PD). Power distance index (PDI) is a value reflecting social hierarchy in a country. We sought to explore the relation between PDI and self-reported behavior patterns of debriefers during simulation debriefings. We determined six culture-relevant debriefing characteristics and formulated six hypotheses on how these characteristics correlate with national PDIs. METHODS: Low-PDI countries have a PDI of 50 or less, and high-PDI countries have a PDI of 51 or greater as defined by Hofstede. Interviews with simulation debriefers were used to investigate culture-relevant debriefing characteristics: debriefer/participant talking time, debriefer/participant interaction pattern, debriefer/participant interaction style, debriefer/participant initiative for interactions, debriefing content, and difficulty with which nontechnical skills can be discussed. RESULTS: During debriefing, in low-PDI countries, debriefers talked less and used more open-ended questions and focused more on nontechnical issues than on medical knowledge and simulation participants initiated most interactions. In low-PDI countries, debriefers felt that participants interacted more with each other and found it easier to address nontechnical skills such as speaking-up. CONCLUSIONS: Our results supported our hypotheses. National culture is related to debriefing practice. There is a clear relation between PDI and debriefer-participant behavior patterns as described by debriefers. The higher the PDI of a country, the more the debriefer determines the course of the debriefing and the more difficult it becomes to address nontechnical skills.