Managing pain in critically ill children.

There are many sources of pain for children in the Pediatric Intensive Care Unit (PICU) including underlying pathophysiological processes, surgery, and therapeutic procedures. Historically pain has been a common recollection of children discharged from PICU, and in the past pain has been undertreated in critically ill children. Whilst it has long been recognized that untreated pain can have immediate consequences, recent research has demonstrated that the experience of pain in early life can have significant consequences on sensory processing and the response to pain in later life. Questions also remain about the possible long term effects of analgesic agents administered early in life. Clinical guidelines exist for the management of analgesia in critically ill children. Pain should be regularly assessed using an appropriate tool and a therapeutic plan for pain management should routinely be established and regularly reviewed as the clinical condition of the patient changes. Effective analgesia should be provided through the application of multimodal and pre-emptive analgesia utilising both pharmacological and non-pharmacological techniques.

Hyponatraemia and hypokalaemia during intravenous fluid administration.

BACKGROUND: Hospital-acquired hyponatraemia is associated with excessive volumes of hypotonic intravenous fluids and can cause death or permanent neurological deficit. METHODS: A cross-sectional survey was carried out in 17 hospitals on all children receiving intravenous fluids during 1 day of a specified week in December 2004. RESULTS: 77 of 99 children receiving intravenous fluids received hypotonic solutions and 38% received >105% of fluid requirements. 21 of 86 children were hyponatraemic, but the electrolytes of only 79% had been checked in the preceding 48 h. CONCLUSIONS: Intravenous fluids should be used with caution as regards the tonicity and volume administered, and with appropriate monitoring of serum electrolytes.

Accident and emergency services for children within Trent region.

OBJECTIVES: To investigate the provision of accident and emergency (A&E) services for children within Trent region, and to compare these with published recommendations. METHODS: A postal questionnaire was sent to all A&E and minor injury units within Trent region providing services for children. Findings were compared with published recommendations including those of the Multidisciplinary Working Party into Accident and Emergency Services for Children. RESULTS: Thirty six units provided A&E services for children within Trent: 17 mixed units, 17 minor injury units and two children's units. Within mixed A&E units complete audio-visual separation from adult patients was provided by six units (35%), inpatient paediatric facilities were available at 11 units (65%) and a minimum of one registered children's nurse was always on duty in three units (18%). CONCLUSIONS: Few A&E units within Trent region currently meet the recommendations of the Multidisciplinary Working Party. The most common shortfall identified was in the provision of registered children's nurses.

Parental perceptions of comfort during mechanical ventilation.

There are no reports of the parental perceptions of comfort during the mechanical ventilation of children. We have assessed the quality of sedation in 28 mechanically ventilated children and compared these results to an overall parental assessment of comfort, obtained by postal questionnaire. There was no correlation between the parental assessment of comfort and the paediatric intensive care unit (PICU) staff satisfaction with the level of sedation. Parental assessment of comfort was positively correlated with the duration of ventilation, whilst PICU staff satisfaction was positively correlated with the age of the child. Parents appear to become more satisfied with the degree of comfort of their children as the duration of mechanical ventilation increases, which is an effect that may have an important bearing on communication between parents and health professionals. Our results also suggest that the commonly used sedation regime of midazolam and morphine is less effective in younger children.

Recollection of children following intensive care.

BACKGROUND AND AIMS: The recollections of critically ill children following discharge from the paediatric intensive care unit (PICU) have not previously been described. We have interviewed such children to establish the nature of their recollections. METHODS: Children aged 4 years and above were interviewed following discharge from the PICU at the Queens Medical Centre, Nottingham, either in hospital or at home, using a semistructured interview. Their recollections were recorded and interpreted by content analysis. RESULTS: A total of 38 interviews were carried out; 44 specific recollections were reported, the majority being neutral (60%) or positive (25%). Only 15% of recollections were negative. Negative recollections related to aspects of medical care and environmental factors. No child treated with neuromuscular blocking agents remembered any period of therapeutic paralysis. CONCLUSIONS: Children's recollections of PICU are mainly neutral or positive. Mechanically ventilated children sedated with midazolam and morphine remember little of endotracheal intubation.

Quality of sedation during mechanical ventilation.

The aim of the study was to determine the quality of sedation in ventilated patients on a general paediatric intensive care unit (PICU), including those treated with infusions of neuromuscular blocking agents. Twenty-eight ventilated children on a PICU had their level of sedation determined using an arousability scale dependent upon the response to tracheal suction. Observed levels of sedation were then compared to a predetermined desired level of sedation. A total of 81 assessments were performed and 90% were considered satisfactory. Thirty-two of these assessments were performed in 15 children following the temporary discontinuation of infusions of neuromuscular blocking agents; 97% of these assessments were considered satisfactory. A regime of continuous intravenous midazolam and morphine with additional oral sedation using chloral hydrate and antihistamines when required provides a satisfactory level of sedation for the majority of children ventilated on a PICU, including those treated with infusions of neuromuscular blocking agents.

Duration of action of atracurium when given by infusion to critically ill children.

The aim of the study was to investigate the offset time of atracurium when given by continuous infusion on a paediatric intensive care unit and to look for evidence of tolerance. Over a period of 8 months, 20 mechanically ventilated children had a steady-state infusion of atracurium discontinued to enable the assessment of their level of sedation. The offset time of atracurium was assessed by train-of-four (TOF) stimulation of the ulnar nerve. The initial TOF reading was documented as was the time taken to reach a TOF ratio of 0.9. Thirty-five assessments were carried out. The mean offset time of atracurium was 28.7 min (SEM 1.76 min, range 8-56 min). There was no correlation between the dose of atracurium at discontinuation and the offset time of the infusion. The duration of infusion was negatively correlated with the offset time of atracurium, and this effect was most prominent in children who had received infusions for longer than 48 h. When given by continuous infusion, the offset time of atracurium is very variable between individual patients. Infusions administered for longer than 48 h are associated with a significant reduction in the offset time as a result of increasing tolerance.

The effect of induced hypothermia on the duration of action of atracurium when given by infusion to critically ill children.

The aim of the study was to investigate the effect of induced hypothermia on the offset time of atracurium when given by continuous infusion to critically ill children. Over a period of 8 months, six mechanically ventilated children had a steady-state infusion of atracurium discontinued. The offset time of atracurium was assessed by train-of-four (TOF) stimulation of the ulnar nerve; recording the time taken to reach a TOF ratio of 0.9. Nine assessments were carried out. The mean offset time of atracurium was 82 min. This was significantly longer than in patients with temperatures within the normal physiological range. When considering all assessments, performed both in hypothermic and normothermic patients, there is a strong correlation between rectal temperature and the offset time of atracurium. Prolonged moderate hypothermia has a very significant effect on the offset time of atracurium when given by infusion to critically ill children.

Paradoxical embolism in a boy with cystic fibrosis and a stroke.

An 11 year old boy with cystic fibrosis suffered a stroke, producing right sided weakness. Four years previously a totally implantable venous access device (Port-a-Cath) had been inserted. Magnetic resonance angiography revealed a filling defect in the left middle cerebral artery. Transoesophageal echocardiography demonstrated a thrombus attached to the tip of the Port-a-Cath and also the presence of a patent foramen ovale. After an initial period of anticoagulation the defect was closed using a septal occlusion device introduced via a cardiac catheter. The boy's neurological signs completely resolved and he remains free from further thromboembolic episodes. Whilst pulmonary embolism has been described before in relation to a totally implantable venous access device, this is believed to be the first description of a paradoxical embolism in relation to such a device.