Intubation drug pack containing pre-filled syringes reduces the time to endotracheal intubation in a simulated paediatric emergency.

To determine if an intubation drugs pack containing pre-filled syringes can reduce the time to endotracheal intubation compared with standard care during a simulated paediatric emergency. Twenty doctors (10 consultants and 10 registrars) who worked in the paediatric intensive care unit or anaesthetic department of a tertiary paediatric hospital were asked to participate in an in situ simulated emergency paediatric intubation scenario. The participants were instructed to prepare and administer intubation medications. They were randomised to either an intubation drug pack, containing pre-filled syringes or to standard care where each of the drugs had to be individually drawn-up. The mean time to intubation when using the pre-filled syringes of 159.5 s was over three times faster than with standard care of 497.5 s (p<0.001), allowing intubation to occur on average 5 min and 38 s earlier. Utilising an intubation drug pack containing pre-filled syringes significantly reduced the time from decision to intubate to intubation in a simulated paediatric emergency. This applied irrespective of clinical experience with registrars utilising the pre-filled syringes outperforming consultant anaesthetists when they used standard care.

Chemical pneumonitis in a 9-year-old following chlorine gas exposure.

A previously fit and well 9-year-old boy developed shortness of breath and chest pain after playing with friends on a building site where bonfire materials were being collected. Firstline investigations failed to explain his symptoms, which worsened over the next 24 hours, necessitating endotracheal intubation and mechanical ventilation. When public health and the police retraced his steps, they found barrels of sodium hypochlorite and red diesel at the bonfire site, which when mixed had the potential to form chlorine gas leading to the diagnosis of a chemical pneumonitis secondary to chlorine gas inhalation. Supportive care was continued, and he was successfully extubated after 48 hours. At 6-week follow-up, he had no ongoing pulmonary symptoms.

Incidental diagnosis of an H-type tracheo-oesophageal fistula.

A 6-day-old term neonate who was intubated on day 1 of life for apnoeic episodes, was transferred to the regional paediatric intensive care unit (PICU) for specialist opinion following 3 failed extubations in the neonatal unit. Escherichia coli congenital pneumonia was diagnosed and the child discharged to the local hospital. Chest radiographs and inflammatory markers were in keeping with infection. However, ongoing difficulties with secretions necessitated readmission to the PICU, following a significant cyanotic episode associated with coughing. On arrival at the PICU, a large leak around the endotracheal tube (ETT) was noted. On direct laryngoscopy, the ETT was found correctly positioned, through the cords, but air was noted to be coming back from the oesophagus. Advancing the ETT towards the carina terminated the leak and raised the suspicion of a tracheo-oesophageal fistula. An H-type tracheo-oesophageal fistula was confirmed on bronchoscopy. An uneventful fistula repair was performed and the baby discharged from the PICU on day 23 of life.

Are APLS formulae for estimating weight appropriate for use in children admitted to PICU?

AIM: To determine if the revised APLS UK formulae for estimating weight are appropriate for use in the paediatric intensive care population in the United Kingdom. METHODS: A retrospective observational study involving 10,081 children (5622 male, 4459 female) between the age of term corrected and 15 years, who were admitted to Paediatric Intensive Care Units in the United Kingdom over a five year period between 2006 and 2010. Mean weight was calculated using retrospective data supplied by the 'Paediatric Intensive Care Audit Network' and this was compared to the estimated weight generated using age appropriate APLS UK formulae. RESULTS: The formula 'Weight=(0.5×age in months)+4' significantly overestimates the mean weight of children under 1 year admitted to PICU by between 10% and 25.4%. While the formula 'Weight=(2×age in years)+8' provides an accurate estimate for 1-year-olds, it significantly underestimates the mean weight of 2-5 year olds by between 2.8% and 4.9%. The formula 'Weight=(3×age in years)+7' significantly overestimates the mean weight of 6-11 year olds by between 8.6% and 20.7%. Simple linear regression was used to produce novel formulae for the prediction of the mean weight specifically for the PICU population. CONCLUSIONS: The APLS UK formulae are not appropriate for estimating the weight of children admitted to PICU in the United Kingdom. Relying on mean weight alone will result in significant error as the standard deviation for all age groups are wide.

Bilateral total parenteral nutrition pleural effusions in a 5-week-old male infant.

A 5-week-old male infant was admitted to the paediatric intensive care unit with small bowel obstruction secondary to an inguinal hernia. His postoperative course was complicated by suspected migration of his left internal jugular central venous catheter into branches of the inferior thyroid artery and mediastinum. This resulted in bilateral pleural effusions which were biochemically and visually similar to the total parenteral nutrition he was receiving. After drainage of the pleural effusions he made an uneventful recovery.

Students prescribing emergency drug infusions utilising smartphones outperform consultants using BNFCs.

OBJECTIVE: To compare the use of a drugs calculator on a smartphone with use of the British National Formulary for Children (BNFC) for accuracy, speed and confidence of prescribing in a simulated paediatric emergency. DESIGN: 28 doctors and 7 medical students in a paediatric department of a District General Hospital, were asked to prescribe both a dopamine infusion and an adrenaline infusion for a hypotensive child. For one calculation they used the BNFC as their reference source and for the other they used the 'PICU Calculator' on the iPhone. RESULTS: The drugs calculator on the smartphone was more accurate than the BNFC, with 28.6% of participants being able to correctly prescribe an inotropic infusion using the BNFC and 100% of participants being able to do so using the drugs calculator on the smartphone (p<0.001). The smartphone calculator was 376% quicker than the BNFC with the mean time saved being 5 min and 17s per participant (p<0.001). Participants were more confident in their prescription when using the drugs calculator on the smartphone with a mean confidence score of 8.5/10 compared with 3.5/10 when using the BNFC (p<0.001). CONCLUSIONS: Utilising the smartphone was significantly more accurate and faster, with prescribers more confident in their calculations, than use of the BNFC. This applied irrespective of clinical experience with medical students utilising the smartphone technology outperforming Consultant Paediatricians when they used the BNFC.

Faulty fetal packing.

A male infant was born by emergency caesarean section at 34(+4) weeks for failed induction of labour. Shortly after birth a depression about the same size as the baby's fist was noted over the right parietal region. After careful consideration of the perinatal history and examination findings, the baby was diagnosed with faulty fetal packing. At 3-month follow-up, the defect had completely corrected without intervention.