Big Trouble, Little People: Paeds Retrieval by Lockie

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Little Adults? Fran Lockie examines our approach to critically ill children and the importance of sticking with our tried and tested formulae.

Little Adults? Fran Lockie examines our approach to critically ill children and the importance of sticking with our tried and tested formulae.

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  • Thanks the organisers for asking me to speak
  • Declaration.
    I am not the other Francis Lockie, Sydney Based Health prof.
    If you came to see her, you are in the wrong talk!

    She, disappointingly is google hits 1-20
    So get in there early, establish your web presence, don’t make the same mistake I have
  • 998 miles
    GC map.com
    I am lucky enough to live and work in Adelaide, capital of South Australia
  • Overlapmaps.com

    To put in a UK perspective
  • 1 million sq kn
    1.6 million people largely based in Adelaide

    Roughly the size of Texas
  • When we look at the population density map, we can see Australia virtually disappears into a thin slither in the SE corner of the world map, compared to the bloated areas of the SC, china and even the UK

    Population density

  • Makes my life interesting as I am luck enough to have a split roles in PEM and Paeds / neonatal retrieval

    With the retrieval work MedSTAR travels as far afield as Darwin and Alice Springs, to Melbourne for our cardiac babies. Of course we serve regional SA and metro Adelaide too.

    We are the only Children’s Hospital in the sate so of course all cases of critical illness and trauma comes through our department.

    My role has put me in a good position to notice recurring themes

    Yes, we live in a post imms era, with air bags, pool fences and child proof screw tops kids

    There is still the burdon of critical illness – it’s rarity makes the challenge greater if anything


    It’s great that that cardiac anaesthetist can tube kids with one arm tied behind his back, but he or she isn’t in the community hospital at midnight

    Doesn’t matter if we’re sitting in our ivory towers or we’re in the outback

    In fact in the outback I’ve met some of the most talented doctors in rural areas going above and beyond

    Didn’t mean to put the solutions on the horizon..but that’s sometimes where it feels like they are.

    However by keeping things simple and doing the basics well – we can change the trajectory for our sick kids
  • Lives with me and affects the way I practice medicine on a daily basis
  • How good are we at implementing ACCM guidelines. C/W ACCM guideline NOT timeline! Replicated in other setting including surviving sepsis campaign audit’s.

    Sub-optimal treatment related to FAILURE to RECOGNISE SHOCK
    Unsupervised juniors / lack of paediatric consultant supervision
    Failure to start inotrope
  • This study from UTAH worried me a lot

    OBJECTIVES: Traumatic brain injury is a leading cause of death and
    disability in children. Guidelines have been established to prevent secondary UTAH
    brain injury caused by hypotension or hypoxia. The purpose of
    this study was to identify the prevalence, monitoring, and treatment of
    hypotension and hypoxia during “early” (prehospital and emergency
    department) care and to evaluate their relationship to vital status and
    neurologic outcomes at hospital discharge.
    METHODS: This was a retrospective study of 299 children with moderate-
    to-severe traumatic brain injury presenting to a level 1 pediatric
    trauma center. We recorded vital signs and medical provider response
    to hypotension and/or hypoxia during all portions of early care.
    RESULTS: Blood pressure (31%) and oxygenation (34%) were not recorded
    during some portion of “early care.” Documented hypotension
    occurred in 118 children (39%). An attempt to treat documented hypotension
    was made in 48% (57 of 118 children). After adjusting for
    severity of illness, children who did not receive an attempt to treat
    hypotension had an increased odds of death of 3.4 and were 3.7 times
    more likely to suffer disability compared with treated hypotensive children.
    Documented hypoxia occurred in 131 children (44%). An attempt
    to treat hypoxia was made in 92% (121 of 131 children). Untreated
    hypoxia was not significantly associated with death or disability, except
    in the setting of hypotension.
    CONCLUSIONS: Hypotension and hypoxia are common events in pediatric
    traumatic brain injury. Approximately one third of children are
    not properly monitored in the early phases of their management. Attempts
    to treat hypotension and hypoxia significantly improved outcomes
  • And look at the effect on mortality!

    Adjusted OR for death and GOS

    Growing body of evidence that secondary insults occur frequently and exert a powerful, adverse influence on outcomes from severe TBI.
    Enemies are hypoxaemia and hypotension
    Trauma Coma Data Bank: hypoxaemia occurred in 22.4% of severe TBI patients: asociated with significantly increased morbidity and mortality.
    HEMS series 55% of patients were hypoxic prior to intubation. 46% normal BP.
    In non-hypoxic pts mort 14.3% and 4.8% disability. If SaO2 < 60% mort rate 50% with 100% severely disabled.
    Hypoxaemia <90% in an inhospital study of 124 TBI patients independent RF for mortality
    HYPOTENSION. Single pre-hospital obseration of hypotension SBP < 90 was amoung 5 most powerful predictors of outcome. Incr morbidity and doubled mortality
    Induction of anaesthesia is risky:
  • Recurring themes in the Sim Lab

    75 Simulations
    12.4 doctors / nurses per session
    194 incidents of subobtimal care


    Knowledge deficit: delay starting inotropes, dose of dextrose for hypoglycaemia, delay starting fluid bolus

    This is not just in paeds




  • THIS IS THE CFIT OF THE MEDICAL WORLD


    ED staff
    Anaethetics
    Theatre staff
    Standardised scenarios
    Causes of error
    75 Simulations
    12.4 doctors / nurses per session
    194 incidents of subobtimal care


    Knowledge deficit: delay starting inotropes, dose of dextrose for hypoglycaemia, delay starting fluid bolus

    This is not just in paeds
    This is the (hopefully present)
    Examples of scenarios

    Knowledge
    Clinical skills
    Leadership
    Communication
    Resourse utlisation
    Anticipation and planning
    Situational awareness



  • At medstar we run joint scenarios.

    We as paediatric specialists can learn lots from the trauma and CCM delivery outside theatre / Particularly in the vital areas of clinical decision making, CRM, leadership and teamwork

    Hopefully our holistic view and what we consider good communication skills are useful to the adult teams

    Training with the SOT paramedics has been a revelation to me not something I would do anywhere else in the world.

    Changed the way we run in the kids hospital where it’s often difficult to generate the momentum to make things happen quickly

  • MCDonalds – I probably shouldn’t be promoting this as a paediatrician!

    One thing they are famous for – in addition to childhood obsesity is the consistency of their product!

    In fact, the strength of a nation’s currency is often judged aginst the price of a big mac!

    I know that if I travel to London and order a Big Mac – I will get:

    I just won’t be allowed to donate blood again!

    If I jump on the Eurostar and order Un Big Mac, I will get Ummm hopefully: albeit with a bit of surly attitude thrown in.

    Consistent approach to out of theatre anaesthesia to be applied to all patients from 90 years to newborn and all in between

    Indispensible for certain situations

    Generates a degree of muscle memory and automaticity that is vital when it all goes wrong.

  • Creat Space: look how this adult team has created space.

    The scene is secure: they can get to work
  • Everyone knows there place, literally where to stand and their role.

    We use this in PED and it has been revolutionary
  • Patient assessment
  • Often predictable
  • Every moment spent on patient position is time well spent!
  • Dump bag: everything laid out and ready.

    Amazing the effect on the room when a piece of kit is not available: what was a calm environment becomes visible tense: everything changes

  • This is a key CRM moment: everything is calm, everyone is focussed
    Leadership
    Build confidence in the team that is both Immediate and latent

    I authorise the c-spine controller to relax their death grip of the head to flex the neck and allow me to visualise the larynx

    These techniques of preparation are often amazingly eye opening for our trainees rotating through. They take them with them for the rest of their careers and always feedback that this was the most powerful message of their MedSTAR rotation.

    Our nursing staff love it too and feel empowered to trouble shoot and guide less experienced medical staff

    The most effective Graded assertivess I have encounterred was on retrieval in the middle of the night when I was being particularly physicianly when a baby patently needed a chest drain. Beard stroking was not getting the job done.

    I was fresh off the boat from England and shocked to be told to just “fucking do it Fran”

    Amazing to see that CRM is still not featuring highly in Medical education
  • Time
    Checks
    Briefs

    Leadership
    Build confidence
    Immediate
    Latent
  • Keep the momentum going: not pause to high five each other and nip out for coffee
    Amazingly hard to derail this process
    We did a sim recently where I was trying to be an incompetent team leader.

    The nurses feel so empowered in their CRM skills: worst doctor nurse, wost doctor, worst patient, worst day

    And still be safe.
  • 10 different induction agents,
    20 different LMA including one you’ve never seen before
  • Limited AP expansion, limited lateral expansion. Ventilation depends on the diaphragm: fatigues easily, lacks Type 1 muscle fibres. Any restriction of diaphragm movement results in resp difficulties
    Ie stomach inflation due to forced inflation
    Lung compliance 5ml/cm H2O, 1/12 adult value, chest compliance 260ml/cm H2O (5x aduly value. High risk of barotrauma
    Small lung vol rel to body size Small FRC: high RR to maintain the FRC
    Under GA anaesthesia FRC declines by 10-25% in health adults and 35-45% in 6-18yo.
    Stress: ratio of MV to FRC is doubled, FRC is diminished and desat occurs
    PEEP important in kids <3, essential in infants <9m. Mean pee to respore FRC to normal:
    Infants < 6 months 6, children 6-12
    Higher O2 consumption 6-7ml/kg, adults 3-4 ml / kg
    Rapid desatiration
    Smaller FRC
    Greater VO2 per unit weight than adults
    Critical hypoxia rapid after apnoea
    Consider 1 month old
    no pre-oxygenation = 90% sats in 15 seconds
    Pre –oxygenation for 1 min = 90% sats in 90 seconds


    Patterns of Injury
    Size and shape
    Smaller body mass - greater force per unit body area
    Less protective tissues and close proximity of organs
    Frequently multiple organs injured
    Skeleton
    Pliable skeleton often deforms without fracture allowing significant injury to underlying organs
    Presence of rib fractures suggests massive force and high risk multiple organ injury
    Psychological
    Developmental stages
    Language skills – difficult to communicate symptoms; may deny symptoms
    Fear – alters normal vital signs making them difficult to interpret
    Parents – help and hindrance
    Long term effects
    Growth and development
    Psychological – child and family


    Size
    Proportions

    Breathing
    Circulation

    Stress

    Sugar

    Family

    Scared
    Lonely
  • What can we do to overcome this rapid desaturation after apnoea?

    Apnoeic oxygenation and PEEP

    Mapleson F, Jackson-Rees modification to the Ayer’s T-piece.
    Compact 
 Inexpensive 
 No valves 
 Minimal dead space 
 Minimal resistance to breathing 
 Economical for controlled ventilation
    Disadvantages
     The bag may get twisted and impede breathing
 High gas flow requirement
    Uses
     Children under 20 kg weight

  • Mapleson F, Jackson-Rees modification to the Ayer’s T-piece. Cildren under 20KgCompact 
 Inexpensive 
 No valves 
 Minimal dead space 
 Minimal resistance to breathing 
 Economical for controlled ventilation
    Disadvantages
     The bag may get twisted and impede breathing
 High gas flow requirement
    Uses
     Children under 20 kg weight

  • ABSTRACT
    Background: A crossover study was performed in
    healthy volunteers to compare the efficacy of a selfinflating
    bag with the Mapleson C breathing system for
    pre-oxygenation.
    Method: 20 subjects breathed 100% oxygen for 3 min
    using each device, with a 30 min washout period. The
    end tidal oxygen concentration and subjective ease of
    breathing were compared.
    Results: There was a statistically significant difference in
    performance between the two devices, with the
    Mapleson C providing higher end expiratory oxygen
    concentrations at 3 min. The mean (SD) end expiratory
    oxygen concentration was 74.2 (3.8)% for the selfinflating
    bag (95% CI 72.4% to 75.9%) and 86.2 (3.7)% for
    the Mapleson C system (95% CI 84.5 to 88.0);
    p,0.0001. The 95% CI of the difference between the
    mean values for end expiratory oxygen concentration at
    3 min was 10.0% to 14.2%. There was also a statistically
    significant difference in the subjective ease of breathing,
    favouring the Mapleson C system.
    Conclusion: The Mapleson C breathing system is more
    effective and subjectively easier to breathe through than a
    self-inflating bag when used for pre-oxygenation.
    However, these benefits must be weighed against the
    increased level of skill required and possible complications
    when using a Mapleson C breathing system.
    Pre-oxygenation is an established prerequisite to
    rapid sequence induction of anaesthesia and
    tracheal intubation.1 It is undertaken to maximise
    the oxygen fraction of the functional residual
    capacity by displacing nitrogen with oxygen. This
    delays the onset of oxygen desaturation of arterial
    blood after induction of apnoea. Good pre-oxygenation
    is essential in the emergency department
    before rapid sequence induction of anaesthesia,
    because intubation is often undertaken in patients
    with significant acute morbidity who are therefore
    prone to early and rapid desaturation.2 3 Preoxygenation
    must therefore be optimal in this
    environment4 and emphasised during training.5
    Adequate pre-oxygenation is indicated by achieving
    an end expiratory oxygen concentration of
    .90%.6 7
    Pre-oxygenation in the emergency department is
    often achieved using a self-inflating bag with a
    valve-mask assembly and a reservoir bag with highflow
    supplemental oxygen. In some centres a
    Mapleson C breathing system is used for this
    purpose (fig 1). The Mapleson C system can also be
    used for oxygenation during sedation.8
    Self-inflating bags are universally available in UK
    emergency departments because they are easy to
    use and will function without an oxygen supply.
    They are appropriate for use during assisted
    ventilation, but during spontaneous breathing they
    may increase the resistance to breathing.9
    Furthermore, a self-inflating bag may deliver a
    lower inspired oxygen concentration than an
    anaesthetic breathing system.10
    We aimed to determine whether a self-inflating
    bag with reservoir and supplemental oxygen
    supply provides the same degree of pre-oxygenation
    as a Mapleson C anaesthetic breathing system
    when both are used correctly. We also compared
    the subjective ease of breathing for patients preoxygenated
    using these devices.
    METHODS
  • Objective: For decades, intraosseous (IO) access has been a standard of care for pediatric emergencies in the absence of conventional intravenous access. After the recent introduction of a battery-powered IO insertion device (EZ-IO; Vidacare Corporation, San Antonio, TX), it was recognized that a clinical study was needed to demonstrate device safety and effectiveness for pediatric patients.
    Methods: We measured the insertion success rate, patient pain levels during insertion and infusion, insertion time, types of fluid and drugs administered, device ease of use on a scale of 1 (easy) to 5 (difficult), and complications.
    Results: There were 95 eligible patients in the study; 56% were males. Mean patient age was 5.5 ± 6.1 years. Successful insertion and infusion was achieved in 94% of the patients. Insertion time was 10 seconds or less in 77% of the one-attempt successful cases reporting time to insertion. There were 4 minor complications (4%), but none significant. For patients with a Glasgow Coma Scale (GCS) score >8, mean insertion pain score was 2.3 ± 2.8, and mean infusion pain score was 3.2 ± 3.5. The device was rated easy to use 71% of the time (n = 49) and the mean score was 1.4.
    Conclusions: The results of this study support the use of the powered IO insertion device for fluid and drug delivery to children in emergency situations. The rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients.
  • Objective: For decades, intraosseous (IO) access has been a standard of care for pediatric emergencies in the absence of conventional intravenous access. After the recent introduction of a battery-powered IO insertion device (EZ-IO; Vidacare Corporation, San Antonio, TX), it was recognized that a clinical study was needed to demonstrate device safety and effectiveness for pediatric patients.
    Methods: We measured the insertion success rate, patient pain levels during insertion and infusion, insertion time, types of fluid and drugs administered, device ease of use on a scale of 1 (easy) to 5 (difficult), and complications.
    Results: There were 95 eligible patients in the study; 56% were males. Mean patient age was 5.5 ± 6.1 years. Successful insertion and infusion was achieved in 94% of the patients. Insertion time was 10 seconds or less in 77% of the one-attempt successful cases reporting time to insertion. There were 4 minor complications (4%), but none significant. For patients with a Glasgow Coma Scale (GCS) score >8, mean insertion pain score was 2.3 ± 2.8, and mean infusion pain score was 3.2 ± 3.5. The device was rated easy to use 71% of the time (n = 49) and the mean score was 1.4.
    Conclusions: The results of this study support the use of the powered IO insertion device for fluid and drug delivery to children in emergency situations. The rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients.
  • Solutions:

    Recognise the physiology.
    Not rely on concensus based dogma about fixed physiological limits across many ages
  • Solutions:

    Recognise the physiology.
    Not rely on concensus based dogma about fixed physiological limits across many ages
  • We Say the physiology never lies: except sometimes it does!

    Don’t intubate Jonny because he’s scared and misses his mum

Transcript

  • 1. BIG problems, little people: lessons learned from paediatric retrieval Dr Fran Lockie franlockie@gmail.com
  • 2. Sydney Based Health practitioner Passion for female weight loss ‘www.hotfatchicks.com’
  • 3. Sydney Based Health practitioner Passion for female weight loss ‘www.hotfatchicks.com’
  • 4. Recurring Themes….. Recurring Themes…. Case Issues Solutions
  • 5. 15 month old male with fever • NVD at term, BW 2.7kg • Previously fit and well • No meds, NKDA • Immunisations UTD • Family all coryzal
  • 6. Country Hospital • At triage – Alert and playful – Temp 39, Hr 160, Rr 40 – Good central perfusion – Mottled peripherally
  • 7. 4hrs later Seen by RMO • Given panadol with resolution of fever, HR never < 170 since triage • Bloods sent • Urine NAD
  • 8. 4 hrs after that… • Given panadol with resolution of fever, HR never < 170 since triage • Bloods • Urine NAD • 2 small vomits in waiting room, then a small area of petechiae
  • 9. 22:00 • A BVM with high flow O2 • B RR 60, marked increased resp effort • C peripheral CRT: absent, central >5 secs • Multiple attempts at iv access unsuccessful • D alert, talking to mum
  • 10. Rapid deterioration – AVPU – Increasing respiratory distress – HR >200, Only femoral pulse palpable – IO sited – Aggressive filling – DA started
  • 11. Courtesy: Stefan Mazur Ketamine, sux, adrenaline bolus
  • 12. PEA Arrest • Filling, filling, filling • Dopamine started at 20mcg/kg/min • Filling, filling, filling – 4% albumin – Blood products (packed cells, plts, FFP, cryo) • Noradrenaline, Adrenaline, infusions commenced • Stat dose hydrocortisone
  • 13. 6hrs later….still PEA / ROSC • Maximal inotropic / pressor support • multiple dextrose, Ca, Mg boluses • Total fluids 180ml/kg • Sustained bradycardia, worsening acidosis • Massive pulmonary haemorrhage
  • 14. Recurring Themes…. • Oxygen delivery • Vascular access • Fluid, antibiotic administration
  • 15. Recurring Themes…. • Oxygen delivery • Vascular access • Fluid, antibiotic administration • Teamwork, leadership and communication • Recognition of paediatric critical illness
  • 16. Recurring Themes…..At audit
  • 17. • Audit of 17 PICU’s • 107 patients with septic shock • 8% received care c/w ACCM guideline – 21% not given >60ml/kg despite ongoing shock – 15% not given dopa/ dobu despite fluid refractory shock – 23% not given catechol for dopa/ dobu refractory shock – 30% not given steroid despite catechol resistant shock Arch Dis Child 2009
  • 18. Early Resuscitation of Children with Moderate to severe TBI Pediatrics 2009 • 299 kids with mod-severe TBI • 39% became hypotensive – Of these only 48% were treated • 44% became hypoxic – Of these 92% were treated
  • 19. Resuscitation 2014
  • 20. Resuscitation 2014
  • 21. Train together daily! • One Base • Adult teams – ED – Intensivists – Anaesthetists • Paediatric and neonatal teams • Special operations paramedics
  • 22. McDonalds approach to ‘out of theatre’ anaesthesia Courtesy: Stefan Mazur
  • 23. PREPARATION PHASE Courtesy: Matt Hooper
  • 24. PREPARATION PHASE ELM
  • 25. PREPARATION PHASE
  • 26. PREPARATION PHASE
  • 27. PREPARATION PHASE
  • 28. PREPARATION PHASE
  • 29. PREPARATION PHASE
  • 30. INTUBATION PHASE
  • 31. POST - INTUBATION PHASE
  • 32. Patients intubated by MedSTAR: Date Location Wt (kg) Indication Ket Sux Prop Roc Fent View ETT size ETT depth ETCO2 ILS Adjuncts Cricoid Comment Seniority 02/01/14 Yorketown Hospital 100 Cardiac 40 200 I 8 24 Calorimetric No None No Adrenaline Infusion + Fluid 1000mL ED Registrar >100 08/01/14 Stansbury 70 Head Injury – threatened airway 100 200 I 8 23 Calorimetric Yes Bougie No Anaesthesia Reg > 100 12/1/14 Whyalla 45 Gastrointestinal 25 100 II 7 22 No None Yes N. Saline 200mL Para > 100 14/1/14 Moonta 120 Combative / Agitated 200 200 II 8 24 Waveform Yes Bougie No Fluid 500mL Anaesthesia Reg >100 16/01/14 Balaklava 80 Neurological 100 100 50 I 7 22 Waveform No Bougie Yes Fluid 1000mL Anaesthesia Reg > 100 17/01/14 115 Head Injury – threatened Airway; Chest trauma 150 200 IV 8 23 Yes Bougie No Anaesthesia Reg >100 17/01/14 Mt. Compass Head injury-threatened 100 100 I 8 24 Waveform Yes Bougie No Anaesthesia Reg > 100 18/01/14 Pt. Broughton 100 Neurological 50 150 10mL / hr III 8 24 Calorimetric No Bougie No Pancuronium + N. Saline 1000mL ICU Reg > 100 18/01/14 Head Injury – Threatened airway I 7 23 Calorimetric Yes Bougie Yes In car – difficult access; no induction meds. Para 10-100 19/01/14 Victor 65 Respiratory 50 100 40 III 7 23 Yes No Nil / Bougie No 2 attempts – nurse then MD, unexpected Gr III Nurse <10 ; Consultant > 100 28/01/14 Berri Combative / Agitated 100 100 30 None then II Waveform Yes Nil / Bougie Yes 2 Attempts – same MD; desat <92% Anaesthesia Reg > 100
  • 33. Ann Emerg Med. 2012
  • 34. Ann Emerg Med. 2012
  • 35. BMJ 2007 • Mapleson circuit – Significantly easier to breath through – More effective
  • 36. Ann Emerg Med. 2012 Kids have smaller FRC Greater VO2 than adults Rapid desaturation (with stress and apnoea)
  • 37. 10 days, pCO2 100, pH 7.00 • He’s Tired Doctor: • Diaphragmatic exhaustion • Lacks type 1 muscle fibres • Decompress the stomach – Often results in dramatic improvement! • Know your vent: wt limits – Generally TV 4-6 ml/kg
  • 38. • 95 patients • Mean age 5.5 • 95% success • 10 seconds or less • Pain score 2.3 Pediatr Ermerg Care 2008
  • 39. • 95 patients • Mean age 5.5 • 95% success • 10 seconds or less • Pain score 2.3 • Fluids, ABx, DA Pediatr Emerg Care 2008
  • 40. Lancet 2011; 377: 1011–18 • Listen to the physiology! • Don’t rely on consensus based dogma with fixed physiological limits a cross many ages
  • 41. Lancet 2011; 377: 1011–18
  • 42. Is lactate really the ‘Holy Grail’ of sepsis biomarkers? I n
  • 43. Is lactate really the ‘Holy Grail’ of sepsis biomarkers? No, but sepsis often masquerades as respiratory disease in kids I n
  • 44. Sugar and temperature • Large SA: body wt (2-2.5 x BW) • Thin skin and subcut fat (less insulation) • No shivering • Immature thermoregulatory center • Sugar ALWAYS goes down in critical illness…
  • 45. Just before Christmas..
  • 46. Just before Christmas..
  • 47. Lessons learned… • Collaborate / cross-pollinate • Drills, teamwork • Evaluate practice • Attention to detail, keep it simple
  • 48. Thanks to: A/Prof Stefan Mazur A/Prof Matt Hooper