Paediatric Intensive Care

Objective
In English paediatric practice, English law requires that parents and clinicians agree the 'best interests' of children and, if this is not possible, that the courts decide. Court intervention is rare and the concept of best interests is ambiguous. We report qualitative research exploring how the best interests standard operates in practice, particularly with decisions related to planned non-treatment. We discuss results in the light of accounts of best interests in the medical ethics literature.

Design
We conducted 39 qualitative interviews, exploring decision making in the paediatric intensive care unit, with doctors, nurses, clinical ethics committee members and parents whose children had a range of health outcomes. Interviews were audio-recorded and analysed thematically.
Results
Parents and clinicians indicated differences in their approaches to deciding the child's best interests. These were reconciled when parents responded positively to clinicians' efforts to help parents agree with the clinicians' view of the child's best interests. Notably, protracted disagreements about a child's best interests in non-treatment decisions were resolved when parents' views were affected by witnessing their child's physical deterioration. Negotiation was the norm and clinicians believed avoiding the courts was desirable.

Conclusions
Sensitivity to the long-term interests of parents of children with life-limiting conditions is defensible but must be exercised proportionately. Current approaches emphasise negotiation but offer few alternatives when decisions are at an impasse. In such situations, the instrumental role played by a child's deterioration and avoidance of the courts risks giving insufficient weight to the child's interests. New approaches to decision making are needed.

Abstract


Objective Report on survival to discharge of children in a combined paediatric/neonatal intensive care unit (PNICU).


Design and setting Retrospective cross-sectional record review.


Participants All children (medical and surgical patients) admitted to PNICU between 1 January 2013 and 30 June 2015.


Outcome measures Primary outcome—survival to discharge. Secondary outcomes—disease profiles and predictors of mortality in different age categories.


Results There were 1454 admissions, 182 missing records, leaving 1272 admissions for review. Overall mortality rate was 25.7% (327/1272). Mortality rate was 41.4% (121/292) (95% CI 35.8% to 47.1%) for very low birthweight (VLBW) babies, 26.6% (120/451) (95% CI 22.5% to 30.5%) for bigger babies and 16.2% (86/529) (95% CI 13.1% to 19.3%) for paediatric patients. Risk factors for a reduced chance of survival to discharge in paediatric patients included postcardiac arrest (OR 0.21, 95% CI 0.09 to 0.49), inotropic support (OR 0.085, 95% CI 0.04 to 0.17), hypernatraemia (OR 0.16, 95% CI 0.04 to 0.6), bacterial sepsis (OR 0.32, 95% CI 0.16 to 0.65) and lower respiratory tract infection (OR 0.54, 95% CI 0.30 to 0.97). Major birth defects (OR 0.44, 95% CI 0.26 to 0.74), persistent pulmonary hypertension of the new born (OR 0.44, 95% CI 0.21 to 0.91), metabolic acidosis (OR 0.23, 95% CI 0.12 to 0.74), inotropic support (OR 0.23, 95% CI 0.12 to 0.45) and congenital heart defects (OR 0.29, 95% CI 0.13 to 0.62) predicted decreased survival in bigger babies. Birth weight (OR 0.997, 95% CI 0.995 to 0.999), birth outside the hospital (OR 0.21, 95% CI 0.05 to 0.84), HIV exposure (OR 0.54, 95% CI 0.30 to 0.99), resuscitation at birth (OR 0.49, 95% CI 0.25 to 0.94), metabolic acidosis (OR 0.25, 95% CI 0.10 to 0.60) and necrotising enterocolitis (OR 0.23, 95% CI 0.12 to 0.46) predicted poor survival in VLBW babies.


Conclusions Ongoing mortality review is essential to improve provision of paediatric critical care.

Abstract Objective: To assess the care-giving practices of health-care practitioners in the paediatric intensive care unit (PICU) through their qualitative insights, reflections and
experience in participatory action research. Design and methods: Qualitative research in the form of ‘participatory action research’ was used to gather data from three sources within the unit: focus groups within disciplines, observations within the PICU, and semi-structured interviews. All staff members were active collaborators and equal stakeholders in the decision-making process, research and feedback. Setting: The paediatric intensive care unit (PICU) of the Red Cross War Memorial Children’s Hospital (RCWMCH). Participants: All staff members from various disciplines working in the PICU. Results: Staff members described problems with respect to relationships, trust and decisionmaking within care-giving practices. Conclusion: The study qualitatively describes how poor communication amongst staff members in respect of
relationships and decision-making impacted on trust and how this tended to compromise care-giving practices in the PICU. The data suggested that this was more evident in informal
rather than formal clinical decisionmaking procedures. The strength of the study was that the participatory action design in the research allowed staff members to address the very
dynamics that they themselves cited as problematic.

Symptomatic pulmonary thromboembolism (PTE) is rare in neonates, and the diagnosis is often made only postmortem. The true incidence is probably underestimated because of its varying presentations, ranging from mild respiratory distress to acute right-heart failure and cardiovascular collapse. We report a sudden cardiorespiratory collapse on day 10 of life in a preterm neonate who was subsequently diagnosed as having a saddle pulmonary embolus. The patient underwent an emergency surgical embolectomy as a salvage procedure. Considering the potentially lethal complications of PTE, neonatologists and pediatricians should maintain a high degree of suspicion in infants with sudden inexplicable deterioration in cardiorespiratory status. Surgical removal of the thrombus is an invasive procedure and potentially carries a high mortality rate. Two term neonatal survivors of surgical intervention have been reported in the medical literature so far. However, we believe that this is the first documented preterm neonatal survivor after surgical intervention for a massive saddle PTE.

bstract
Objective: To describe the short-term outcome of critically ill HIV-infected children with access to highly active antiretroviral therapy (HAART)
in a developing region.
Methods: Prospective observational study conducted in a paediatric teaching hospital in Cape Town, South Africa. All children admitted to the
paediatric intensive care unit (PICU) with suspected HIV infection were screened. Data are n (%) with 95% confidence intervals (CI).
Results: Sixty-eight of 96 HIV antibody positive children, median age 3 months, were confirmed HIV-infected. Predicted PICU mortality was
0.42. Fifty-one children (75%; CI 65 – 85%) survived to PICU discharge, but hospital survival was only 51% (CI 40 – 63%). Limitation of
intervention (LOI) decisions were a factor in the majority of PICU and ward deaths. Twenty-one PICU survivors (31%; CI 20 - 42%) commenced
HAART, and 2 children were already on treatment. Nineteen children (28%) were considered to be established on HAART after 1 month. Thirteen
HIV-infected children (19%; CI 10 – 28%), representing 25% (CI 14 – 37%) of all PICU survivors, and 68% (CI 48 – 89%) of those PICU
survivors who were established on HAART, remain well on treatment after median 350 days.
Conclusion: The majority of HIV-infected children survived to discharge from PICU, but only half survived to hospital discharge. LOI decisions,
usually made in PICU, directly influenced short-term survival and the opportunity to commence HAART. Although few critically ill HIV-infected
children survived to become established on HAART, the long-term outcome of children on HAART is encouraging and warrants further
investigation.

Objective To compare the difference in plasma sodium
at 16–18 h following major surgery in children who were
prescribed either Hartmann’s and 5% dextrose or 0.45%
saline and 5% dextrose.
Design A prospective, randomised, open label study.
Setting The paediatric intensive care unit (650
admissions per annum) in a tertiary children’s hospital in
Brisbane, Australia.
Patients The study group comprised 82 children
undergoing spinal instrumentation, craniotomy for brain
tumour resection, or cranial vault remodelling.
Interventions Patients received either Hartmann’s and
5% dextrose at full maintenance rate or 0.45% saline
and 5% dextrose at two-thirds maintenance rate.
Main outcomes measures Primary outcome
measure: plasma sodium at 16–18 h postoperatively;
secondary outcome measure: number of fl uid boluses
administered.
Results Mean postoperative plasma sodium levels
of children receiving 0.45% saline and 5% dextrose
were 1.4 mmol/l (95% CI 0.4 to 2.5) lower than those
receiving Hartmann’s and 5% dextrose (p=0.008).
In the 0.45% saline group, seven patients (18%)
became hyponatraemic (Na <135 mmol/l) at 16–18 h
postoperatively; in the Hartmann’s group no patient
became hyponatraemic (p=0.01). No child in either fl uid
group became hypernatraemic.
Conclusions The postoperative fall in plasma sodium
was smaller in children who received Hartmann’s and 5%
dextrose compared to those who received 0.45% saline
and 5% dextrose. It is suggested that Hartmann’s and 5%
dextrose should be administered at full maintenance rate
postoperatively to children who have undergone major
surgery in preference to hypotonic fl uids

Abstract
Objective: To assess caregivers’ perceptions of the effects of intensive care and antiretroviral therapy (ART) on the health and quality of life of critically ill HIV-infected children.

Design: Eight primary caregivers were interviewed within six months of discharge, and seven of these were re-interviewed 12-18 months later. Transcripts were analysed using qualitative research methodology and the NVivo software package. Themes drawn from the analysis were used to structure the results as quotes, summaries, tables and a model describing the subjects’ responses.

Setting: The Red Cross Children’s Hospital (RCCH) PICU, Cape Town, South Africa.

Patients: Eight ART-naïve children under 12 months old who were started on ART after discharge from the Paediatric Intensive Care Unit (PICU).

Main Results: Results are presented under the following sets of themes: Socio-Economic Factors contains data on Living Conditions, Household, Income, Diet; Medical Care and Child’s Health contains data on Medical Care, Antiretroviral Therapy, Child’s Health and Behaviour, Health Beliefs, Quality of Care; Community and Family Factors contains data on Stigmatisation and Disclosure, Family and Burden of Care. A diagram (Figure 1) shows relationships between these themes.

Conclusions: Caregivers perceived ART as effective, the PICU as useful in improving their children’s health, and the proximity of the hospital as essential to their children’s ongoing good health. There was an effective continuum of care between the RCCH and family settings. However, there were major concerns about the local clinics as sites of therapy. Issues arising in the children’s social, cultural and economic background included stigmatization, poor infrastructure and resources, co-dependency with kin, and language and culture-barriers as challenges to effective follow-up.