Intention to use physical restraint in paediatric intensive care units and correlated variables: A multicentre and cross-sectional study.

OBJECTIVES: To determine the intention to use physical restraint (PR) and the relationship with sociodemographic and professional variables of the Paediatric Intensive Care Unit (PICU) nurses. RESEARCH METHODOLOGY/DESIGN AND SETTING: A multicentre and correlational study was carried out from October 2021 to December 2023 in five paediatric intensive care units from five maternal and child hospitals in Spain. The Paediatric Physical Restraint-Theory of Planned Behaviour Questionnaire was provided. Moreover, sociodemographic and employment variables were registered. RESULTS: A total of 230 paediatric nurses participated in the study. A total of 87.7 % were females with an average age of 35.5 ± 9.7 years and working experience of 10.5 ± 8.4 years. The mean scores obtained were 21.1 ± 3.8 for attitude, 13.1 ± 5.0 for subjective norms, 14.4 ± 4.3 for perceived behavioural control and 28.0 ± 6.0 for intention. The nurses apply more physical restraint to anxious patients, with scarce analgesics and sedation, those affected with pharmacological withdrawal symptoms and those with a high risk of accidental removal of vital support devices or fall from bed. The sex (p = 0.007) and type of employment contract (p = 0.01) are the variables that are significantly correlated with the intention to use of PR. CONCLUSION: The paediatric nurses analysed had a moderate attitude, social pressure and perceived behavioural control towards the use of PR. IMPLICATIONS FOR CLINICAL PRACTICE: It is important to know the factors that influence the intention to use physical restraint in order to standardise safe practice for critically ill paediatric and to ensure that patients' rights are respected by obtaining informed consent and assessing the prescription, continuation and removal of physical restraint.

Adaptation and validation of the Physical Restraint-Theory of Planned Behaviour Questionnaire to the paediatric context.

OBJECTIVE: To create and test psychometrically a paediatric version of the Physical Restraint-Theory of Planned Behaviour Questionnaire to assess paediatric critical care nurses' intention to use physical restraint. DESIGN: A psychometric study. SETTING: Five medical-surgical Paeditric Intensive care Units from five hospitals in Spain. METHODS: The study took place in three phases. In phase 1, the questionnaire was adapted. In phase 2, the content validity of each item was determined, and a pilot test was conducted. In phase 3, we administered the questionnaire and determined its psychometric properties. RESULTS: The assessment of the intention to use physical restraint was extended to all critical paediatric patients, two items were eliminated from the initial questionnaire, four new items were included, and the clinical scenarios of the intention subscale were expanded from three to six. Overall content validity index for the full instrument of 0.96 out of 1. The Paediatric Physical Restraint-Theory of Planned Behaviour Questionnaire is made up of four subscales (attitude, subjective norms (SN), perceived behavioural control (PBC), and intention) subdivided into 7 factors and 51 items. The internal consistency for the attitude subscale obtained a Cronbach's Alpha of 0.80 to 0.73, for the SN it was 0.72 to 0.89, for the PBC it was from 0.80 to 0.73 and for the intention subscale it was 0.75. CONCLUSIONS: The Paediatric Physical Restraint-Theory of Planned Behaviour Questionnaire is an instrument composed of seven factors and 51 items that validly and reliably assesses the intention of paediatric nurses to apply PR in PICUs. RELEVANCE FOR CLINICAL PRACTICE: Having this instrument will help health centres move towards restraint-free care by allowing managers to assess professionals' attitudes, beliefs, and intentions around the use of PR in PICUs.

Protective factors of ethical conflict during a pandemic-Quali-Ethics-COVID-19 research part 2: An international qualitative study.

AIMS AND OBJECTIVES: To determine which factors can be considered protective of ethical conflicts in intensive care unit healthcare professionals during a pandemic. BACKGROUND: The COVID-19 pandemic gave rise to new ethical concerns in relation to the management of public health and the limitations on personal freedom. Continued exposure to ethical conflict can have a range of psychological consequences. DESIGN: A qualitative design based on phenomenological approach. METHODS: A total of 38 nurses and physicians who were regular staff members of Barcelona and Milan's public tertiary university hospitals and working in intensive care units during the first wave of the COVID-19 pandemic. Semi-structured online in-depth interviews were conducted. A thematic analysis was performed by two independent researchers following the seven steps of Colaizzi's methods. We adhere COREQ guidelines. RESULTS: One theme 'Protective factors of ethical conflict in sanitary crisis' and four subthemes emerged from the data: (1) knowledge of the infectious disease, (2) good communication environment, (3) psychological support and (4) keeping the same work team together. CONCLUSIONS: Four elements can be considered protective factors of ethical conflict for healthcare professionals during a sanitary crisis. While some of these factors have already been described, the joint identification of this set of four factors as a single element is, in itself, novel. This should help in ensuring the right mechanisms are in place to face future pandemics and should serve to improve institutional organisation and guarantee safe and high-quality patient care in times of healthcare crisis. RELEVANCE TO CLINICAL PRACTICE: Future strategies for the prevention of ethical conflict during sanitary crises, pandemics or other catastrophes need to consider a set of four factors as a single element. These factors are the knowledge of the infectious disease, a good communication environment, psychological support and keeping the same work team together into joint consideration.

The effect of a live music therapy intervention on critically ill paediatric patients in the intensive care unit: A quasi-experimental pretest-posttest study.

BACKGROUND: Music therapy as a nonpharmacological means of managing patient pain, anxiety, and discomfort is a recognised technique, although it is not widely used in the paediatric intensive care unit (PICU). AIM: The aim of this study was to assess the clinical effect of a live music therapy intervention on vital signs and levels of discomfort and pain for paediatric patients in the PICU. METHODS: This was a quasi-experimental pretest-posttest study. The music therapy intervention was carried out by two music therapists who were specifically trained, each possessing a master's degree in the field of hospital music therapy. Ten minutes before the start of the music therapy session, the investigators recorded the vital signs of the patients and assessed their levels of discomfort and pain. The procedure was repeated at the start of the intervention; at 2, 5, and 10 min during the intervention; and at 10 min following the conclusion of the intervention. RESULTS: Two hundred fifty-nine patients were included; 55.2% were male, with a median age of 1 year (0-21). A total of 96 (37.1%) patients suffered a chronic illness. The main reason for PICU admission was respiratory illness, at 50.2% (n = 130). Significantly lower values were observed for heart rate (p = 0.002), breathing rate (p < 0.001), and degree of discomfort (p < 0.001) during the music therapy session. CONCLUSIONS: Live music therapy results in reduced heart rates, breathing rates, and paediatric patient discomfort levels. Although music therapy is not widely used in the PICU, our results suggest that using interventions such as that used in this study could help reduce patient discomfort.

COVID-19 pandemic experiences, ethical conflict and decision-making process in critical care professionals (Quali-Ethics-COVID-19 research part 1): An international qualitative study.

AIM AND OBJECTIVES: The aim of this study was to explore the sources of ethical conflict and the decision-making processes of ICU nurses and physicians during the first and subsequent waves of the COVID-19 pandemic. BACKGROUND: Depside several studies exploring ethical conflicts during COVID-19 pandemic, few studies have explored in depth the perceptions and experiences of critical care professionals regarding these conflicts, the decision-making process or which have analysed the complexity of actually implementing the recommendations of scientific societies and professional/healthcare institutions in interdisciplinary samples. DESIGN: A descriptive phenomenological study. METHODS: Thirty-eight in-depth interviews were conducted with critical care nurses and physicians from five hospitals in Spain and Italy between December 2020 and May 2021. A thematic content analysis of the interview transcripts was conducted by two researchers. Consolidated criteria for reporting qualitative research (COREQ) were employed to ensure the quality and transparency of this study. RESULTS: Two main themes emerged as sources of ethical conflict: the approach to end of life in exceptional circumstances and the lack of humanisation and care resources. The former comprised two subthemes: end-of-life care and withholding and withdrawal of life-sustaining treatment; the latter comprised three subthemes: the impossibility of guaranteeing the same opportunities to all, fear of contagion as a barrier to taking decisions and the need to humanise care. CONCLUSIONS: Professionals sought to take their decisions in line with professional ethics and bioethical principles, but, nevertheless, they experienced moral dilemmas and moral distress when not being able to care for, or to treat, their patients as they believed fit. RELEVANCE TO CLINICAL PRACTICE: Further education and training are recommended on the provision of end-of-life and post-mortem care, effective communication techniques via video calls, disclosure of bad news and bioethical models for decision-making in highly demanding situations of uncertainty, such as those experienced during the COVID-19 pandemic.

Larval Therapy for Treatment of Chronic Wounds Colonized by Multi-resistant Pathogens in a Pediatric Patient: A Case Study.

BACKGROUND: Chronic wounds are susceptible to colonization with gram-positive and gram-negative bacteria that may be resistant to antimicrobial dressings and systemic antibiotics. In January 2004, the US Food and Drugs Administration approved use of medicinal larvae for use in humans and animals for resistant organisms. Despite use in adults, there is a paucity of evidence evaluating its efficacy and safety in the pediatric population. CASE: T was a 5-year-old boy with several chronic wounds infected with multidrug-resistant Pseudomonas aeruginosa. The wounds were originally treated with chemical debridement, dressings containing ionic silver, negative-pressure wound therapy (NPWT), and antibiotics without success. Consequently, a multidisciplinary team implemented maggot debridement therapy (MDT). CONCLUSIONS: After MDT, one wound completely epithelialized and the other wounds achieved a reduction in size with 70% epithelization. Therapy also led to a reduction in wound odor, exudate, and pain. The other wounds were closed after additional management with dressing containing nanocrystalline silver and NPWT.

Eficacia de un plan de acogida teórico-práctico dirigido a profesionales de enfermería de nueva incorporación en una Unidad de Cuidados Intensivos Pediátrica: estudio piloto / Efficacy of a theoretical and practical programme to newly hired nursing personnel in a Paediatric Intensive Care Unit: a pilot study

Objetivos: Diseñar un plan formativo de acogida a enfermeras/os de nueva incorporación y 2) determinar la autopercepción y el estrés percibido antes y después de la realización de la parte teórica y práctica con simulación de alta fidelidad. Método: Se llevó a cabo un estudio piloto de diseño cuasiexperimental tipo pretest-postest sin grupo control en una Unidad de Cuidados Intensivos Pediátricos (UCIP), de octubre de 2018 a abril de 2019. En primer lugar, se diseñó un plan formativo teórico y práctico que se impartió a todo el personal de nueva incorporación de la unidad. Posteriormente, se evaluó la autopercepción personal, el estrés percibido y el grado de satisfacción mediante dos escalas tipo Likert. Resultados: Participaron en el estudio un total de 20 enfermeras/os de nueva incorporación, el 90% (n = 18) eran del sexo femenino, con una edad media de 25,5 ± 4,53 años. Al comparar los datos obtenidos pre y post formación teórica con relación a la autopercepción personal se constató un aumento de puntuación en todos los ítems. A la vez, se objetivaron puntuaciones medias menores de estrés (6,9 ± 1,57 vs. los 5,6 ± 1,79). En la parte práctica se obtuvo también un aumento de las puntuaciones, así como una tendencia a la disminución de las puntuaciones medias globales de estrés percibido (6,4 ± 1,73 vs. 5,6 ± 1,93). Conclusiones: Un plan de acogida teórico-práctico mediante simulación clínica (SC) impartido a enfermeras/os de nueva incorporación de una UCIP mejoró su autopercepción sobre el nivel de conocimientos y disminuyó las puntuaciones medias de estrés.(AU)

Aims: to design a training programme for newly hired nursing personnel and (2) to determine self-perception and perceived stress before and after the theoretical and practical parts of the programme with high fidelity simulation activities. Methods: A pilot quasi-experimental pretest-posttest study without control group conducted in a Paediatric Intensive Care Unit from October 2018 to April 2019 was conducted. A newly hired nursing personnel training programme was first designed and delivered. Later, the participants’ self-perception was assessed, as well as their perceived stress and grade of satisfaction using two different Likert scales. Results: A total of 20 newly hired nurses participated in the study, 90% (n = 18) were female with a median age of 25.5 ± 4.53 years. Higher scores were obtained in participants’ self-perception before and after the theoretical training. Lower significant median scores of the participants’ stress perception were found (6.9 ± 1.57 versus 5.6 ± 1.79). In the practical part of the programme, we obtained higher scores in all items, as well as lower median scores in stress perception (6.4 ± 1.73 versus 5.6 ± 1.93). Conclusions: A theoretical and practical programme for newly hired nursing personnel in a Paediatric Intensive Care Unit improved participants’ self-perception and reduced their perceived median scores in stress levels.(AU)

Impacto de la gamificación en el aprendizaje sobre administración de fármacos en pediatría en estudiantes del grado en enfermería / Impact of gamification on learning of the administration of pediatric medication by nursing degree students

Introducción: La motivación con la que afronta el aprendizaje el alumnado es un aspecto clave que todo docente universitario debe tener en consideración.Objetivos: Analizar la eficacia de un seminario estructurado mediante metodología de gamificación en estudiantes del grado de enfermería durante su formación clínica en unidades hospitalarias pediátricas y determinar el grado de satisfacción con la actividad llevado a cabo.Métodos: Participaron un total de 244 estudiantes de 4º curso del Grado en Enfermería y 50 enfermeras tutoras clínicas de un centro hospitalario. Se llevó a cabo un test pre y post seminario. El caso constó de tres fases: una relacionada con las actividades al ingreso en una Unidad de Cuidados Intensivos, la segunda con el cálculo de medicación pediátrica y la tercera con los cuidados de enfermería a aplicar. Para valorar la eficacia en relación a la práctica clínica se elaboraron dos encuestas ad hoc, una dirigida a los estudiantes y otra a enfermeras asociadas docentes y/o tutoras clínicas. También se administró una encuesta de satisfacción.Resultados: La puntuación media obtenida en el pre test teórico fue de 9,1 puntos sobre 10 y, en el post test, de 9,73. Las tres preguntas relacionadas con el nivel de conocimientos, autoconfianza y seguridad del alumnado obtuvieron las siguientes puntuaciones: 4,09, 4,83 y 3,99 puntos sobre 10 pre seminario versus los 7,71, 7,75 y 7,21 puntos post seminario, observándose significación estadística (p<0.001). Se obtuvo significación estadística en las preguntas que relacionaban la “consecución de objetivos docentes en áreas asistenciales” (enfermero/a) y la de “adquisición de competencias clínicas específicas” (alumnado), p=0.04. El grado de satisfacción global fue de 8,66±1,43 puntos.Conclusiones: La gamificación es una metodología docente eficaz muy bien valorada por parte de las estudiantes, considerándola de gran utilidad. (AU)

Background: The motivation of students in their approach to learning should be a matter of concern to all university instructors.Aims: To analyze the effectiveness of a structured seminar using gamification methodology with nursing degree students during their clinical training in pediatric hospital units, and to determine their level of satisfaction with the activity as carried out.Methods: A total of 244 fourth-year nursing degree students participated, along with 50 nurse clinical tutors from a hospital. A pretest and a post-test were administered. The case had three stages: one related to activities at the time of patient admission to the pediatric intensive care unit, a second involving the calculation of pediatric medication dosages, and a third involving the nursing care to be given. Two ad hoc surveys were used to assess the effectiveness of the seminar, one directed at the students and the other at the nursing instructors and/or clinical tutors. A satisfaction survey was also given.Results: The average score for the theoretical pretest was 9.1 over 10; on the post-test it was 9.73. The three questions addressing the level of knowledge, self-confidence, and self-assuredness of the students yielded the following scores: 4.09, 4.83, and 3.99 over 10 pre- seminar vs 7.71, 7.75, and 7.21 post-seminar; this difference was statistically significant (p<0.001). There was statistical significance in the responses to the questions related to “achieving pedagogical aims in areas of care” (nurses) and “acquisition of specific clinical skills” (students), p=0.04. The overall level of satisfaction was 8.66±1.43 points.Conclusions: Gamification is an effective teaching methodology that is well-received by the students and seen by them as useful. (AU)

Postsurgical pain assessment in children and adolescents with cerebral palsy: A scoping review.

AIM: To investigate factors that influence the assessment of postoperative pain in children and adolescents with cerebral palsy (CP) and the tools available to determine pain intensity. METHOD: The search was performed in January 2022 using six databases. Articles focused on paediatric patients with CP; we included instruments for postsurgical pain assessment in this population published in the last 11 years. RESULTS: Eight of 441 studies were included. Males and females behave differently; their families can be called on to describe their pain responses. Seven instruments for pain assessment were identified: the Non-Communicating Children's Pain Checklist and its Postoperative Version; the Paediatric Pain Profile; the revised Face, Legs, Activity, Cry and Consolability (FLACC) pain scale; the Douleur Enfant San Salvador scale; the Pain Indicator for Communicatively Impaired Children; the University of Wisconsin Children's Hospital Pain Scale; and the Individualized Numeric Rating Scale. INTERPRETATION: The revised FLACC pain scale is suited to postsurgical units because of its ease of use and the fact that parental collaboration is not required. More studies are needed to demonstrate the clinical utility of these scales in postsurgical units and the factors that influence pain assessment. WHAT THIS PAPER ADDS: Families should be asked to collaborate when assessing pain in children and adolescents whenever possible. Larger studies that focus on the factors influencing pain assessment in this population are required.

Grado de disconfort del paciente crítico pediátrico y correlación con variables sociodemográficas y clínicas, analgosedación y síndrome de abstinencia. Estudio multicéntrico COSAIP (Fase 2) / Level of discomfort in critically ill paediatric patients and its correlation with sociodemographic and clinical variables, analgosedation and withdrawal syndrome. COSAIP multicentre study (Phase 2)

Introducción: Existen factores clínicos o sociodemográficos que pueden tener un impacto en el confort del paciente crítico pediátrico. El objetivo principal fue determinar el grado de disconfort de los pacientes pediátricos ingresados en las UCIP de diversos hospitales nacionales y analizar su relación con variables sociodemográficas y clínicas, sedoanalgesia y síndrome de abstinencia.Métodos: Estudio observacional, analítico, transversal y multicéntrico en 5 hospitales españoles. Se valoró el grado de analgosedación mediante el sensor BIS y las escalas de dolor adaptadas a la edad pediátrica, una vez por turno durante 24h. El grado de abstinencia se determinó con la escala Withdrawal Assessment Tool (WAT-1), una vez por turno durante 3 días consecutivos. Además, se valoró simultáneamente el grado de disconfort mediante la COMFORT Behavior Scale-versión española (CBS-ES).Resultados: Se incluyeron un total de 261 pacientes críticos pediátricos con una mediana de edad de 1,61años (RIQ=0,35-6,55). Se objetivaron puntuaciones globales de disconfort de 10,79±3,7 en el turno de mañana versus 10,31±3,3 en el de noche. Se observó asociación estadística al comparar al grupo de pacientes analgosedados con el grupo de no analgosedados en ambos turnos (χ2: 45,48; p=0,001). A la vez, también se observó una relación estadísticamente significativa (p<0,001) entre puntuaciones bajas de disconfort y menor desarrollo de síndrome de abstinencia.Conclusiones: Existe una parte de la población estudiada que padece disconfort, por lo que se hace necesario el desarrollo de protocolos específicos guiados por instrumentos válidos y testados en la práctica clínica, como la COMFORT Behavior Scale-versión española. (AU)

Introduction: There are clinical and sociodemographic factors that have an impact on the comfort of the critically ill paediatric patient. The main aim of this study was to determine the level of discomfort of paediatric patients admitted to different national hospitals, and to analyse its correlation with sociodemographic and clinical variables, analgosedation, and withdrawal syndrome.Methods: An observational, analytical, cross-sectional, and multicentre study was conducted in five Spanish hospitals. The level of analgosedation was assessed once per shift over a 24h period, using a BIS sensor, and pain with scales adapted to paediatric age population. The intensity of withdrawal syndrome was determined using the Withdrawal Assessment Tool (WAT-1) scale once per shift for 3 days. Discomfort level was simultaneous assessed using COMFORT Behaviour Scale-Spanish version (CBS-S).Results: A total of 261 critically ill paediatric patients with median age of 1.61 years (IQR=0.35-6.55) were included. An overall discomfort score of 10.79±3.7 was observed during morning compared to 10.31±3.3 observed during the night. When comparing analgosedation and non-analgosedation groups, statistically differences were found in both shifts (χ2: 45.48; P=.001). At the same time, an association was observed (P<.001) between low discomfort scores and development of withdrawal syndrome development assessed with WAT-1.Conclusions: As there is a percentage of the studied population with discomfort, specific protocols need to be developed, guided by valuated and clinically tested tools, like the COMFORT Behaviour Scale-Spanish version. (AU)

Level of discomfort in critically ill paediatric patients and its correlation with sociodemographic and clinical variables, analgosedation and withdrawal syndrome. COSAIP multicentre study (Phase 2).

INTRODUCTION: There are clinical and sociodemographic factors that have an impact on the comfort of the critically ill paediatric patient. The main aim of this study was to determine the level of discomfort of paediatric patients admitted to different national hospitals, and to analyse its correlation with sociodemographic and clinical variables, analgosedation, and withdrawal syndrome. METHODS: An observational, analytical, cross-sectional, and multicentre study was conducted in five Spanish hospitals. The level of analgosedation was assessed once per shift over a 24 h period, using a BIS sensor, and pain with scales adapted to paediatric age population. The intensity of withdrawal syndrome was determined using the Withdrawal Assessment Tool (WAT-1) scale once per shift for 3 days. Discomfort level was simultaneously assessed using COMFORT Behaviour Scale-Spanish version (CBS-S). RESULTS: A total of 261 critically ill paediatric patients with median age of 1.61 years (IQR = 0.35-6.55) were included. An overall discomfort score of 10.79 ±â€¯3.7 was observed during morning compared to 10.31 ±â€¯3.3 during the night. When comparing analgosedation and non-analgosedation groups, statistical differences were found in both shifts (χ2: 45.48; P = .001). At the same time, an association was observed (P < .001) between low discomfort scores and development of withdrawal syndrome development assessed with WAT-1. CONCLUSIONS: As there is a percentage of the studied population with discomfort, specific protocols need to be developed, guided by valuated and clinically tested tools, like the COMFORT Behaviour Scale-Spanish version.

Barriers to Advance Care Planning Implementation in Health care: An Umbrella Review with Implications for Evidence-Based Practice.

BACKGROUND: Advance care planning (ACP) refers to a process of discussions between professionals, patients, and their families, which allows the patient to define and communicate their care and treatment preferences. Understanding the barriers to advance care planning is the first step on the way to overcoming them and to improving person-centred care and attention. AIMS: To identify the barriers perceived by professionals, patients, and family members when implementing ACP in a clinical context and to analyse the methodological quality of the evidence. METHODS: An umbrella review guided by the Joanna Briggs Institute and a systematic review in accordance with PRISMA 2015 were utilized. Data were obtained from MEDLINE, Cochrane Library, The Joanna Briggs Institute, CINAHL, Scopus, and EMBASE in November 2018. RESULTS: Fourteen systematic reviews were included. The main barriers reported by professionals were lack of knowledge and skills to carry out ACP, a certain fear of starting conversations about ACP, and a lack of time for discussions. Patients and family members considered that the main barriers were fear of discussing their relative's end of life, lack of ability to carry out ACP, and not knowing who was responsible for initiating conversations about ACP. LINKING EVIDENCE TO ACTION: This review has examined the barriers presented by health professionals, patients, and family members, so that future lines of research can develop preventive or decisive measures that encourage the implementation of ACP in health care.

Ethical conflict during COVID-19 pandemic: the case of Spanish and Italian intensive care units.

AIM: To identify factors underlying ethical conflict occurring during the current COVID-19 pandemic in the critical care setting. BACKGROUND: During the first wave of the COVID-19 outbreak, Spanish and Italian intensive care units were overwhelmed by the demand for admissions. This fact revealed a crucial problem of shortage of health resources and rendered that decision-making was highly complex. SOURCES OF EVIDENCE: Applying a nominal group technique this manuscript identifies a series of factors that may have played a role in the emergence of the ethical conflicts in critical care units during the COVID-19 pandemic, considering ethical principles and responsibilities included in the International Council of Nurses Code of Ethics. The five factors identified were the availability of resources; the protection of healthcare workers; the circumstances surrounding decision-making, end-of-life care, and communication. DISCUSSION: The impact of COVID-19 on health care will be long-lasting and nurses are playing a central role in overcoming this crisis. Identifying these five factors and the conflicts that have arisen during the COVID-19 pandemic can help to guide future policies and research. CONCLUSIONS: Understanding these five factors and recognizing the conflicts, they may create can help to focus our efforts on minimizing the impact of the ethical consequences of a crisis of this magnitude and on developing new plans and guidelines for future pandemics. IMPLICATIONS FOR NURSING PRACTICE AND POLICY: Learning more about these factors can help nurses, other health professionals, and policymakers to focus their efforts on minimizing the impact of the ethical consequences of a crisis of this scale. This will enable changes in organizational policies, improvement in clinical competencies, and development of the scope of practice.

[Level of discomfort in critically ill paediatric patients and its correlation with sociodemographic and clinical variables, analgosedation and withdrawal syndrome. COSAIP multicentre study (Phase 2)]. / Grado de disconfort del paciente crítico pediátrico y correlación con variables sociodemográficas y clínicas, analgosedación y síndrome de abstinencia. Estudio multicéntrico COSAIP (Fase 2).

INTRODUCTION: There are clinical and sociodemographic factors that have an impact on the comfort of the critically ill paediatric patient. The main aim of this study was to determine the level of discomfort of paediatric patients admitted to different national hospitals, and to analyse its correlation with sociodemographic and clinical variables, analgosedation, and withdrawal syndrome. METHODS: An observational, analytical, cross-sectional, and multicentre study was conducted in five Spanish hospitals. The level of analgosedation was assessed once per shift over a 24h period, using a BIS sensor, and pain with scales adapted to paediatric age population. The intensity of withdrawal syndrome was determined using the Withdrawal Assessment Tool (WAT-1) scale once per shift for 3 days. Discomfort level was simultaneous assessed using COMFORT Behaviour Scale-Spanish version (CBS-S). RESULTS: A total of 261 critically ill paediatric patients with median age of 1.61 years (IQR=0.35-6.55) were included. An overall discomfort score of 10.79±3.7 was observed during morning compared to 10.31±3.3 observed during the night. When comparing analgosedation and non-analgosedation groups, statistically differences were found in both shifts (χ2: 45.48; P=.001). At the same time, an association was observed (P<.001) between low discomfort scores and development of withdrawal syndrome development assessed with WAT-1. CONCLUSIONS: As there is a percentage of the studied population with discomfort, specific protocols need to be developed, guided by valuated and clinically tested tools, like the COMFORT Behaviour Scale-Spanish version.

La planificación de decisiones anticipadas como estrategia preventiva de conflictos éticos en urgencias y emergencias durante y después de la COVID-19 / Advance Care Planning as a preventive strategy for ethical conflicts in emergencies during and after COVID-19 / La Planificació de Decisions Anticipades com a estratègia preventiva de conflictes ètics a urgències I emergències durant I després de la COVID-19

La actual pandemia por la COVID-19 está ocasionado serias amenazas para la salud pública a nivel mundial, especialmente para los grupos de población más vulnerables. Los casos más graves de la enfermedad han sido primeramente atendidos por los profesionales de urgencias y emergencias, los cuales han tenido que tomar decisiones en contextos altamente complejos donde la priorización en la asignación de los recursos sanitarios disponibles les ha generado situaciones éticamente conflictivas. El objetivo del presente artículo es analizar la importancia de implantar la PDA en los servicios de urgencias y emergencias como herramienta de consulta en la resolución de los problemas éticos surgidos durante la pandemia por COVID-19, concretamente, en la atención al paciente crónico complejo o con enfermedad crónica avanzada

The events of the present CoVID-19 pandemic are causing serious threats to Public Health worldwide, specifically at the most vulnerable population groups. Emergency professionals have served as the first responders for the most serious cases of this disease. At the same time, they have made decisions in highly complex contexts where the prioritization of allocated care resources has generated ethically conflictive situations. The aim of this article is to analyze the importance of implementing the ACP as a tool in the emergency services to solve ethical problems that have arisen during the COVID-19 pandemic, particularly in the care of complex chronic patients or those with advanced chronic disease

L'actual pandèmia per la COVID-19 està ocasionat serioses amenaces a la salut pública a nivell mundial, especialment als grups de població més vulnerables. Els casos més greus de la malaltia han estat primerament atesos pels professionals d'urgències I emergències, els quals han hagut de prendre decisions en contextos altament complexos on la priorització en l'assignació dels recursos sanitaris disponibles els ha generat situacions èticament conflictives. L'objectiu d'aquest article va ser analitzar la importància d'implantar la PDA en els serveis d'urgències I emergències com a eina de consulta a la resolució dels problemes ètics sorgits durant la pandèmia per COVID-19, concretament, en l'atenció al pacient crònic complex o amb malaltia crònica avançada

Incidencia de lesiones por presión en unidades de cuidados intensivos pediátricas y neonatales: Revisión sistemática (2000-2016) / Pressure injury incidence in pediatric and neonatal intensive care units: Systematic review (2000-2016)

OBJETIVOS: Describir la incidencia de lesiones por presión (LPP) en pacientes pediátricos atendidos en unidades de críticos, así como diferentes variables relacionadas con la metodología de su cálculo. INTRODUCCIÓN: Las LPP constituyen un serio problema de salud con importantes repercusiones en los pacientes que las sufren. Las UCI pediátricas (UCIP) y neonatales (UCIN) atienden a pacientes en alto riesgo para el desarrollo de LPP. Existen pocos datos sistematizados acerca de la incidencia y variables definitorias de LPP en UCIP y UCIN. MÉTODOS: Revisión sistemática de la literatura científica publicada entre el 1 de enero de 2000 y el 31 de diciembre de 2016, que incluía artículos que reportaban datos sobre incidencia en UCIP o UCIN. Se han incluido trabajos que notifican datos sobre LPP relacionadas con el apoyo, con o sin lesiones relacionadas con dispositivos sanitarios; se han excluido los artículos que incluían exclusivamente datos de lesiones relacionadas con dispositivos sanitarios. RESULTADOS: La revisión sistemática ha permitido identificar 27 artículos con un total de 53 reportes de incidencia con información sobre 15 587 pacientes. En el caso de las UCIP, la mediana de la incidencia de lesiones por presión es del 19,4% en los trabajos prospectivos que no incluyen de manera implícita lesiones por presión relacionadas con dispositivos sanitarios y del 16,97% en los que incluyen a la vez lesiones relacionadas con dispositivos sanitarios y lesiones por presión por apoyo de los pacientes. En el caso de las UCIN encontramos unos valores del 3,9% y del 23,58%. CONCLUSIONES: Los resultados del presente trabajo permiten definir el alcance de la incidencia de las LPP en pacientes críticos pediátricos y resaltan aspectos relacionados con la metodología utilizada para su cálculo

AIMS: To describe the incidence and main characteristics of pressure injuries in pediatric patients in intensive care units and some variables related to the methodology for pressure injury incidence calculation. BACKGROUND: Pressure injuries (PI) represent a serious health problem with major consequences for the patients affected. Neonatal and pediatric ICU (NICU) (PICU) care for patients at high risk of developing pressure injuries. There is a paucity of systematic data on the incidence and defining variables of injuries in PICU and NICU. METHODS: We conducted a systematic review of the literature published between January 1, 2000 and December 31, 2016, including articles reporting data on the incidence of these injuries in PICU or NICU. We included studies reporting data on pressure injuries related to position, with or without injuries related to medical devices; we excluded studies which only reported data on pressure injuries related to medical devices. FINDINGS: We identified 27 articles with a total of 53 reports on incidence and information on 15,587 patients. In the case of PICU, the mean incidence of PI was 19.4% in prospective studies that did not implicitly include PI related to medical devices, and 16.97% in those which included pressure injuries related both to medical devices and position. For NICU, we found values of 3.9% and 23.58% respectively. CONCLUSIONS: The results of this study shed light on the incidence of pressure injuries in pediatric intensive care patients and highlight aspects related to the methodology used for the calculation of PI incidence

Discomfort of the critically ill paediatric patient and correlated variables.

INTRODUCTION: The care of critically ill children is usually invasive and aggressive, requiring numerous traumatic procedures that may cause fear, pain, and discomfort. OBJECTIVES: The aim of this study was to analyse the level of discomfort of patients admitted to the paediatric intensive care unit of a specialist children's hospital and to determine the sociodemographic and clinical variables that influence the degree of discomfort experienced by critically ill paediatric patients. METHODS: We performed a descriptive observational cross-sectional study that included a total of 311 children with a median age of 5.07 y (interquartile range = 0.9-11.7). A team of 10 paediatric critical care nurses assessed the degree of discomfort once for each shift (morning, afternoon, and night) on 2 successive days using the COMFORT Behavior Scale-Spanish version. RESULTS: In total, 49.8% (n = 155) of the patients were free of discomfort (score ≤10 points) vs. 50.2% (n = 156) who experienced discomfort. There was a significant negative correlation between discomfort and the length of stay in days (Rho = 0.16; p = 0.02), that is, the longer the stay, the less discomfort the patient felt. The correlation between age and degree of discomfort was found to be both positive and significant (Rho = 0.230, p < 0.001); the greater the age, the greater the discomfort. In comparison of all children who received analgosedation (n = 205), with discomfort levels of 10.77 ± 2.94, with those who did not receive analgosedation (n = 106), with discomfort levels of 11.96 ± 2.80, we did find a statistically significant difference (χ2 = -4.05; p < 0.001). CONCLUSIONS: Half of the patients admitted to the paediatric intensive care unit experienced discomfort. Age and analgosedation were the two most important variables involved with a high degree of discomfort. Clinical care practices must consider these factors and try to plan activities designed to relieve discomfort in all critically ill paediatric patients.

Meaning and comfort factors in the paediatric intensive care unit from an adult perspective: a descriptive phenomenological study.

AIMS: To explore the meaning of comfort and know the factors that contribute to it from the point of view of the young adults who received care in a paediatric intensive care unit, the family of the patient and the interdisciplinary team attending the patient. FINDINGS: A total of 30 people were invited to participate in the focus groups; 24 did so. Thematic analysis yielded the following common categories: meaning of comfort, environmental factors in paediatric intensive care unit, family accompaniment during paediatric intensive care unit stay, management of information in the paediatric intensive care unit and, finally, the intimacy and privacy of the critically ill paediatric patient and their family. CONCLUSIONS: Paediatric intensive care unit professionals need to consider not only the environmental input that may lead to discomfort but also aspects such as continuous family accompaniment, the sharing of complete information with the family and the promoting of privacy.

Management of purpura fulminans skin lesions in a premature neonate with sepsis: a case study.

Purpura fulminans is a severe and rapidly progressive septic process characterised by the development of haemorrhagic and ecchymotic lesions and skin necrosis. It can appear on any part of the body but predominantly affects the limbs. Purpura fulminans is a rare but possible complication in paediatric patients, especially neonates. It can increase their risk of morbidity and mortality if not treated early and cause a severe long-term condition in survivors of the infectious episode, including amputation. For professionals involved in wound healing, purpura fulminans poses a major challenge. This report describes the case of a premature neonate with extensive purpura fulminans of the legs and arms. Topical treatment of the limbs and purpuric areas with hyperoxygenated fatty acids (HOFAs) every two hours produced an improvement in the lesions. Complete healing was achieved using moist wound healing products. Early topical application of HOFAs appears to be a safe treatment that improves tissue microcirculation in paediatric patients with Purpura fulminans, minimising sepsis-related skin damage.

Prevalencia de lesiones por presión, incontinencia, dermatitis asociada a la incontinencia y factores de riesgo para el desarrollo de lesiones por presión en un hospital materno-infantil de tercer nivel / Prevalence of pressure injuries, incontinence, incontinence associated dermatitis and risk factors associated with pressure injuries in a mother-and-child third level hospital

Introducción: Las lesiones por presión (LPP) y las dermatitis asociadas a la incontinencia (DAI) constituyen dos importantes problemas de salud reales y potenciales para los pacientes pediátricos ingresados en hospitales de agudos, con consecuencias a diferentes niveles y con escasa información epidemiológica. Pacientes, material y método: Se realizó un estudio transversal para determinar la prevalencia de LPP, incontinencia, DAI y factores de riesgo para LPP en un hospital universitario materno-infantil de tercer nivel. Resultados: Se estimó una prevalencia de LPP del 8% en la Unidad de Cuidados Intensivos Pediátrica (UCIP), del 0% en la Unidad de Cuidados Intensivos Neonatal (UCIN), del 1,12% en las unidades de hospitalización pediátricas y del 0% en las unidades de hospitalización de adultos. La prevalencia de incontinencia fue del 96%, 100%, 56,7% y del 0%, respectivamente, y la de DAI fue del 8,3%, 0%, 6,25% y 0%, respectivamente, en los pacientes incontinentes. Todas las LPP identificadas en el estudio fueron incidentes, con un 60% de categoría I, un 20% de categoría II y un 20% de categoría IV

Introduction: Pressure injury (PI) and incontinence associated to dermatitis injuries (IAD) are assumed to be two of the most important real and potential health problems among pediatric patients admitted in acute care hospitals, with different consequences, and still with a limited epidemiological information. Patients, material and methods: a transversal study with the aim to determine the prevalence of PI, incontinence and IAD, as well as associated factors, was conducted in a third level maternity-pediatric hospital. Results: A prevalence of 8% in Pediatric Intensive Care Unit (PICU) was estimated, that was to 0% in Neonatal Intensive Care Units (NICU), 1.12% in pediatric hospitalization units, and 0% in adult hospitalization units. The incontinence prevalence was 96%, 100%, 56.7% and 0% respectively, and the data related to prevalence of incontinence associated to dermatitis was to 8.3%, 0%, 6.25% and 0%. All the pressure injuries identified in this research was incident, the 60% was classified as I category, a 20% as category II and a 20% as category IV