Summary
The COVID‐19 pandemic marks an extraordinary global public health crisis unseen in the last century, with its rapid spread worldwide and associated mortality burden. The longevity of the ...crisis and disruption to normality is unknown. With COVID‐19 set to be a chronic health crisis, clinicians will be required to maintain a state of high alert for an extended period. The support received before and during an incident is likely to influence whether clinicians experience psychological growth or injury. An abundance of information is emerging on disease epidemiology, pathogenesis and infection control prevention. However, literature on interventions for supporting the psychological well‐being of healthcare workers during disease outbreaks is limited. This article summarises the available management strategies to increase resilience in healthcare workers during the COVID‐19 pandemic and beyond. It focuses on self‐care and organisational justice. It highlights various individual as well as organisational strategies. With the success of slowing disease spread in many countries to date, and reduced work‐load due to limitations on elective surgery in many institutions, there is more time and opportunity to be pro‐active in implementing measures to mitigate or minimise potential adverse psychological effects and improve, restore and preserve the well‐being of the workforce now and for years to come. The purpose of this review is to review available literature on strategies for minimising the psychological impact of the COVID‐19 pandemic on clinicians and to identify pro‐active holistic approaches which may be beneficial for healthcare workers both for the current crisis and into the future.
Summary
For healthcare workers performing aerosol‐generating procedures during the COVID‐19 pandemic, well fitted filtering facepiece respirators, for example, N95/FFP2 or N99/FFP3 masks, are ...recommended as part of personal protective equipment. In this review, we evaluate the role of fit checking and fit testing of respirators, in addition to airborne protection provided by respirators. Filtering facepiece respirators are made of material with sufficient high filter capacity to protect against airborne respiratory viruses. Adequate viral protection can only be provided by respirators that properly fit the wearer's facial characteristics. Initial fit pass rates vary between 40% and 90% and are especially low in female and in Asian healthcare workers. Fit testing is recommended to ensure a proper fit of respirators for the individual healthcare worker so that alternative respirators can be selected if required. Although fit testing is required to comply with respirator standards, it is not performed consistently within all healthcare settings. Fit checking (a self‐test) is recommended every time a healthcare worker dons a respirator, but is unreliable in detecting proper fit or leak. Additionally, fit testing has a high educational value and as such is best performed as part of a hospital respiratory protection programme. Whether fit checking alone, as opposed to fit tested and fit checked respirators, provides adequate airborne protection against aerosols containing the SARS‐CoV‐2 virus and other respiratory viruses remains unknown. While fit testing undoubtedly incurs additional costs, it is still recommended, not only to protect healthcare workers but also as it may reduce overall healthcare cost when considering the potential costs of sickness leave and the associated legal costs of compensation.
Summary
Children may develop changes in their behaviour following general anaesthesia. Some examples of negative behaviour include temper tantrums and nightmares, as well as sleep and eating ...disorders. The aim of this study was to determine whether dexmedetomidine reduces the incidence of negative behaviour change after anaesthesia for day case surgery in children aged two to seven years. Children were randomly allocated to one of three groups: a premedication group received 2 mg.kg-1 intranasal dexmedetomidine; an intra‐operative group received 1 mg.kg-1 intravenous dexmedetomidine; and a control group. The primary outcome was the incidence of negative behaviour on postoperative day 3 using the Post‐Hospitalisation Behaviour Questionnaire for Ambulatory Surgery (PHBQ‐AS) and the Strength and Difficulties Questionnaire (SDQ). Secondary outcomes included: the incidence of negative behaviour on postoperative days 14 and 28; anxiety at induction; emergence delirium; pain; length of recovery and hospital stay; and any adverse events. The data for 247 patients were analysed. Negative behaviour change on postoperative day 3 was similar between all three groups when measured with the PHBQ‐AS (47%, 44% and 51% respectively; adjusted p=0.99) and the SDQ (median scores 7.5, 6.0 and 8.0 respectively; adjusted p=0.99). The incidence of negative behaviour in the group who received dexmedetomidine intra‐operatively was less at postoperative day 28 (15% compared with 36% in the dexmedetomidine premedication group and 41% in the control group, p<0.001). We conclude that dexmedetomidine does not reduce the incidence of negative behaviour on postoperative day 3 in two to seven‐year olds having day case procedures.
Summary
Propofol is the most commonly administered intravenous agent for anaesthesia in children. However, there are concerns that the emulsified preparation may not be safe in children with an ...allergy to egg, peanut, soybean or other legumes. We conducted a retrospective study of children with immunologically confirmed egg, peanut, soybean or legume allergy and who underwent general anaesthesia at Princess Margaret Hospital for Children between 2005 and 2015. We extracted details regarding allergy diagnosis, each anaesthetic administered and any adverse events or signs of an allergic reaction in the peri‐operative period. A convenience sample of patients without any known food allergies was identified from our prospective anaesthesia research database and acted as a control group. We identified 304 food‐allergic children and 649 procedures where propofol was administered. Of these, 201 (66%) had an egg allergy, 226 (74%) had a peanut allergy, 28 (9%) had a soybean allergy and 12 (4%) had a legume allergy. These were compared with 892 allergy‐free patients who were exposed to propofol. In 10 (3%) allergy patients and 124 (14%) allergy‐free patients, criteria for a possible allergic reaction were met. In nine of the food‐allergic children and in all the controls valid non‐allergic explanations for the clinical symptoms were found. One likely mild allergic reaction was experienced by a child with a previous history of intralipid allergy. We conclude that genuine serious allergic reaction to propofol is rare and is not reliably predicted by a history of food allergy.
Summary
Midazolam is one of many bitter drugs where provision of a suitable oral paediatric formulation, particularly in the pre‐anaesthetic setting, remains a challenge. To overcome this problem, a ...novel chocolate‐based tablet formulation has been developed with positive pre‐clinical results. To further investigate the potential of this formulation, 150 children aged 3–16 years who were prescribed midazolam as a premedication were randomly assigned to receive 0.5 mg.kg−1 either as the novel formulation or an intravenous solution given orally, which is the current standard at our institution. Tolerability was assessed by each child, parent and nurse using a 5‐point facial hedonic scale and efficacy was determined as the time to onset of sedation. Blood samples for midazolam and 1‐hydroxymidazolam levels were analysed using high‐performance liquid chromatography. Population pharmacokinetics were evaluated using non‐linear mixed effects modelling. The novel formulation had significantly improved tolerability scores from children, parents and nurses (all p < 0.001). Time to effect was not different between the groups (p = 0.140). The pharmacokinetics of midazolam and 1‐hydroxymidazolam were able to be modelled simultaneously. The novel formulation was subject to a higher estimated first‐pass metabolism compared with the intravenous solution (8.6% vs. 5.0%) and a significantly lower relative bioavailability of 82.1% (p = 0.013), with no other significant differences. Exposure relative to dose was in the range previously reported for midazolam syrup. We conclude that the novel chocolate‐based formulation of midazolam provides improved tolerability while remaining efficacious with suitable pharmacokinetics when used as a premedicant for children.
•Validated HPLC–UV assay to quantify tramadol and O-desmethyltramadol in human plasma.•Separation of tramadol from multiple drugs co-administered during anaesthesia.•Separation of O-desmethyltramadol ...from multiple drugs co-administered during anaesthesia.•Validated HPLC-UV assay for tramadol pharmacokinetic and toxicology studies.•Novel liquid–liquid extraction and protein precipitation method for HPLC assay.
Multimodal analgesia is employed in paediatric pain management to maximise analgesia and minimise side effects. Tramadol is dosed at 1–1.5 mg/kg to treat severe pain in children but the assay for tramadol in plasma samples for pharmacokinetic and toxicology studies does not often consider concurrently administered medications. In this study we developed and validated an HPLC–UV method to quantify tramadol and its main metabolite (O-desmethyltramadol) in human plasma in the presence of seven potentially interfering drugs. Sample preparation method was developed by combining liquid–liquid extraction and protein precipitation. Chromatographic separation was achieved on a BDS-Hypersil-C18 column (5 µm, 250 × 4.6 mm) using a double gradient method. The limit of quantification was 6.7 ng/ml for both tramadol and ODT. The precision and accuracy were in compliance with ICH guidelines. This method was successfully employed to analyse the blood samples of 137 paediatric participants in a tramadol pharmacokinetic trial.
. Surgical Pleth Index (SPI) is a non-invasive, dimensionless score (0–100) aimed to allow an estimate of intraoperative nociception. Thus, it may be a useful tool to guide intraoperative analgesia. ...However, no optimum SPI target range for the use in children has yet been defined. It was the aim of this study to define a clinically appropriate SPI target to predict moderate-severe postoperative pain in children.
. After ethics approval 105 children (2–16 yr) undergoing elective sevoflurane/opioid-based anaesthesia were included. SPI was recorded directly before the end of surgery and compared with acute postoperative pain (age appropriately assessed on different pain scales in the age groups two to three yr, four to eight yr and nine to16 yr) in the postoperative acute care unit (PACU).
. Data of 93 children were analysed. A significant negative correlation was found between age and SPI (r=−0.43; P=0.03). The SPI cut-off value with the highest sensitivity (76%) and specificity (62%) in all children combined was 40. The negative predictive value for SPI ≤ 40 to predict the absence of moderate-severe pain in PACU was 87.5%. The commonly used SPI cut-off (50) published in all related studies had neither any clinically relevant sensitivity nor specificity to predict the presence or absence of acute pain in PACU.
The results suggest that a lower (≤ 40) than previously published (50) target for SPI may be more appropriate in studies investigating SPI guided anaesthesia in children, if the avoidance of moderate-severe postoperative pain is the main goal.
ACTRN12616001139460.
Summary
Introduction
Pain is a subjective experience. In children with limited understanding and communication skills, reliable assessment of pain is challenging. Self‐reporting of pain is the gold ...standard of pain measurement. For children who are unable to self‐report their pain, assessments made by their parents are often used as a proxy measure. The validity of this approach has not been conclusively determined.
Aim
To investigate differences in the assessment of pediatric pain between children, parents, nurses, and independent observers in the acute postoperative setting.
Method
Three hundred and seven children (207 verbal, 100 nonverbal) undergoing elective day‐case surgery were asked to participate in this quality of care audit. Pain scores given by verbal children, their parents, nurses, and independent observers were collected. A numerical rating scale or the Wong‐Baker Faces Pain Scale was used. All participants were blinded from other scorers.
Results
For verbal children, scores reported by patients and their parents did not differ significantly. Median inter‐quartile range (IQR) scores by children, parents, nurses, and independent observers were, respectively, 2.0 (0–4.0), 2.0 (1.0–4.0), 0.0 (0–2.0), and 1.0 (0–2.0). In nonverbal children, median (IQR) scores by parents, nurses, and independent observers were 1.0 (0–3.0), 0 (0–1.0), and 0 (0–2.0), respectively. The agreement between the different scorers was statistically significant.
Conclusion
Children's pain self‐reports should be used wherever possible to guide management, but in their absence, parental pain scores can be reliably used as a surrogate measure. Nurses and independent observers produce lower pain scores than parents or children, which may result in inadequate treatment of pain.
Summary
Cuffed tracheal tubes are increasingly used in paediatric anaesthetic practice. This study compared tidal volume and leakage around cuffed and uncuffed tracheal tubes in children who required ...standardised mechanical ventilation of their lungs in the operating theatre. Children (0–16 years) undergoing elective surgery requiring tracheal intubation were randomly assigned to receive either a cuffed or an uncuffed tracheal tube. Assessments were made at five different time‐points: during volume‐controlled ventilation 6 ml.kg−1, PEEP 5 cmH2O and during pressure‐controlled ventilation 10 cmH2O / PEEP 5 cmH2O. The pressure‐controlled ventilation measurement time‐points were: just before a standardised recruitment manoeuvre; just after recruitment manoeuvre; 10 min; and 30 min after the recruitment manoeuvre. Problems and complications were recorded. During volume‐controlled ventilation, leakage was significantly less with cuffed tracheal tubes than with uncuffed tracheal tubes; in ml.kg−1, median (IQR range) 0.20 (0.13–0.39 0.04–0.60) vs. 0.82 (0.58–1.38 0.24–4.85), respectively, p < 0.001. With pressure‐controlled ventilation, leakage was less with cuffed tracheal tubes and stayed unchanged over a 30‐min period, whereas with uncuffed tracheal tubes, leakage was higher and increased further over the 30‐min period. Tidal volumes were higher in the cuffed group and increased over time, but in the uncuffed group were lower and decreased over time. Both groups showed an increase in tidal volumes following recruitment manoeuvres. There were more short‐term complications with uncuffed tracheal tubes, but no major complications were recorded in either group at long‐term follow‐up. With standardised ventilator settings, cuffed tracheal tubes produced better ventilation characteristics compared with uncuffed tracheal tubes during general anaesthesia for routine elective surgery.
Effects of anaesthesia on paediatric lung function Trachsel, D.; Svendsen, J.; Erb, T.O. ...
British journal of anaesthesia : BJA,
August 2016, 20160800, 2016-Aug, 2016-08-00, 20160801, Letnik:
117, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Respiratory adverse events are one of the major causes of morbidity and mortality in paediatric anaesthesia. Aside from predisposing conditions associated with an increased risk of respiratory ...incidents in children such as concurrent infections and chronic airway irritation, there are adverse respiratory events directly attributable to the impact of anaesthesia on the respiratory system. Anaesthesia can negatively affect respiratory drive, ventilation/perfusion (V/Q) matching and tidal breathing, all resulting in potentially devastating hypoxaemia. Understanding paediatric respiratory physiology and its changes during anaesthesia will enable anaesthetists to anticipate, recognize and prevent deterioration that can lead to respiratory failure. This review aims to give a comprehensive overview of the effects of anaesthesia on respiration in children. It focuses on the impact of the different components of anaesthesia, patient positioning and procedure-related changes on respiratory physiology.
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