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CHILD AND PARENT SATISFACTION WITH LASER TREATMENT IN CHILDREN AND YOUNG PEOPLE WITH ORAL MUCOSITIS UNDERGOING CHEMOTHERAPY, RADIOTHERAPY OR HAEMATOPOIETIC STEM CELL TRANSPLANTATION

E. Earnshaw, G. Yesudian, J. Short, D. Yeomanson

Sheffield Children's Hospital NHS Trust, UK

Background

Oral mucositis is a significant consequence of chemotherapy, radiotherapy and haematopoietic stem cell transplantation, affecting 52 to 80% of children and young people receiving treatment for cancer (1). It is a complex condition that causes severe mouth and throat pain, oral ulceration, xerostomia and can lead to difficulties in eating and drinking, hospitalisation for hydration, pain relief and parenteral nutrition. It has become a major dose-limiting toxicity which can affect the delivery of effective anticancer therapy and impact quality of life.

Problem

Many strategies are used in the treatment of oral mucositis including oral rinses, cryotherapy, growth factors and opiates. A meta-analysis by Oberoi et al., highlighted the effectiveness another modality, Photobiomodulation (PBM) treatment (2). Oberoi stated that when used prophylactically, PBM treatment reduces the severity of oral mucositis and the need for opioid analgesia. However, PBM is rarely utilised in the paediatric population.

Strategy for change

Photobiomodulation (PBM) treatment was introduced to the Haematology/Oncology ward at Sheffield Children’s Hospital in January 2022. A Service Evaluation was undertaken to assess the thoughts and experiences of children and their carers on the effectiveness of this new intervention.

Measure of improvement

Grading of oral mucositis were undertaken in accordance with current WHO recommendations. PBM dose was determined by grade of mucositis, with pain scores recorded pre- and post-operatively. A free text option was offered to the child and their carers to capture their thoughts and experiences of this new intervention.

Lessons Learnt

Sixty patient episodes of PBM treatment were reported over a one-year period, with 21 children and young people engaging with the service. The age range was 3 to 16 years.

70% of patient episodes (18 patients) reported a positive impact on their oral mucositis, with significant reduction in their pain scores pre- and post-treatment. 15% (3 patients) requested prophylactic PBM treatment prior to commencement of their chemotherapy with one child stating they

‘liked to have it before chemo as it makes chemo not as bad’.

 

One child reported that it felt ‘tickly’ while another stated that the effect was ‘magical’. Two patients were unable to report their outcome due being upset at the time of treatment.

A parent reported the treatment was beneficial to their child as they were able to eat after treatment.

Message for others

This study highlights the beneficial effect of PBM in children and young people who experience oral mucositis as a result of their chemotherapy. NICE guidance (2018) exists for PBM but is largely based on adult evidence (3). A systematic review by Redman et al., (2022), highlighted a paucity of good quality studies to confirm its efficacy as a prevention or treatment tool for oral mucositis in children with cancer (4).

References:

  1. Ethier MC, Regier DA, Tomlinson D, et al., Perspectives toward oral mucositis prevention from parents and health care professionals in paediatric cancer. Support Care Cancer 2012;20: 1771-7.
  2. Oberoi S, Zamperlini–Netto G, Beyene J, Treister NS, Sung L (2014) Effect of Prophylactic Low Level Laser Therapy on Oral Mucositis: A Systematic Review and Meta-Analysis. PLoS ONE 9(9):

e107418. https://doi.org/10.1371/journal.pone.0107418

  1. National Institute for Health and Care Excellence. Low-level laser therapy for preventing or treating oral mucositis caused by radiotherapy or chemotherapy, 2018. Available:

https://www.nice.org.uk/guidance/ipg615/chapter/2-The-condition-current-treatments-and-procedure;.

  1. Redman MG, Harris K, Phillips BS. Low-level laser therapy for oral mucositis in children with cancer. Archives of Disease Childhood 2022;107: 128-133.

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ENHANCED RECOVERY IN CRANIOFACIAL PATIENTS, DOES CHOICE OF ALPHA-2 AGONIST MATTER?

C. V. Berwick, S. A. Roberts

Alder Hey Children's Hospital, UK

Background

Craniofacial patients undergo major remodelling surgery such as total vault reconstruction (TVR) and fronto-orbital advancement reconstruction (FOAR) surgery. A database of all patients undergoing these procedures is maintained with the aim of measuring and improving outcomes including vomiting rate, time to drinking and eating, pain and length of stay. Data from this has been used to implement a successful standardised enhanced recovery package of post-operative measures including regular analgesia and antiemetic prophylaxis.

Problem

Patients undergoing major craniofacial surgery have high levels of post-operative vomiting, delaying eating and drinking, however there is considerable variation between patients. Post-operative vomiting rates may be influenced by anaesthetic techniques, such as the use of dexmedetomidine1 as the alpha-2 agonist of choice used as part of a multimodal analgesic technique2.

Strategy for change

The craniofacial database was reviewed to identify variations between practice and whether these had any impact on vomiting rates or times to eating and drinking. 151 patients underwent TVR or FOAR over a 4 year period (2020-2023) and survived to discharge. Intra-operative drug dosing, vomiting rates and times to drinking and eating were analysed. Two core variations in anaesthetic technique were identified, use of intra-operative morphine (107 patients mean morphine dose 90mcg/kg, 47 patients no morphine) and choice of alpha-2 agonist (103 patients given clonidine [mean dose 1.57mcg/kg], 47 patients had dexmedetomidine [mean dose 1.44mcg/kg]).

Measure of improvement

Improvements in outcomes and experience were measured in terms of time to drinking and eating and vomiting rates. All groups had similar vomiting rates on post-operative day 0 (POD0: theatre to midnight) at 0.65-0.67. On POD1, vomiting rates were 0.7 in the clonidine patients vs 0.31 in dexmedetomidine patients, while intra-operative morphine had a lesser variation in rates (0.62 [morphine] vs 0.49 [no morphine]). Time to first drink was 06h07m in clonidine patients vs 02h15m in dexmedetomidine patients. Patients who received morphine drank at 05h17m vs 04h02m for those who received no morphine. Time to first meal was 20h24m in clonidine patients vs 13h51m in dexmedetomidine patients, and 19h28m in morphine patients vs. 15h47m in those who received no morphine.

Lessons learnt

Analysis of patient outcome data is vital to identifying the impact of variations in practice, and maintaining a robust database facilitates this. Time to first meal suggests that patients who receive dexmedetomidine drink earlier and have breakfast on POD1, while those who receive clonidine drink later and do not eat until lunchtime on POD1. In toddlers aged 1-2, eating after waking on POD1 is a measure of recovery and comfort.

Message for others

Use of dexmedetomidine rather than clonidine as an alpha-2 agonist appears to be associated with lower vomiting rates and reductions in length of time to first drink and meal.

References:

  1. Reddy SK, Jones JJ, Gordish-Dressman H, Pestieau SR. Dexmedetomidine as an Opioid-Sparing Agent in Pediatric Craniofacial Surgery. 2020 7:68 Children.
  2. Kattail D, Macmillan A, Musavi L, Pedreira R, Faateh M, Cho R, Lopez J, Dorafshar AH. Pain Management for Nonsyndromic Craniosyntosis: Adequate Analgesia in a Pediatric Cohort?. 2018 29:5. The Journal of Craniofacial Surgery.

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A SYSTEMATIC REVIEW CONDUCTED ON THE USE OF INTRAVENOUS LIDOCAINE AND ITS EFFECTS ON POST-OPERATIVE PAIN IN PAEDIATRIC ANAESTHESIA

A.Akhtar, University of Manchester, UK

Introduction and aims

Lidocaine is commonly used as a local anaesthetic, but it has also been found to have useful properties as an analgesic adjunct in surgery. Currently, there is a wide range of evidence supporting the use of intravenous lidocaine in reducing post-operative pain in adults, and the Association of Anaesthetists have published a consensus with guidelines to ensure safe use of intravenous lidocaine. While there is a lot of evidence supporting use of intravenous lidocaine in adult anaesthesia, there is not much evidence of its use in paediatrics. This review aims to find and assess trials using intravenous lidocaine in paediatric surgery to evaluate its efficacy in paediatric populations.

The aim of this review using the different aspects of PICO (patient, intervention, control, outcome) is:

  • P: patients aged < 18 years undergoing surgery
  • I: use of IV lidocaine
  • C: either use of a placebo or simply not being given IV lidocaine
  • O: degree of post-operative pain

Methods

6 different databases were searched using keywords to maximise search results. A screening software was used to remove any duplicates, and then the titles and abstracts were screened. The relevant inclusion and exclusion criteria were applied, and studies that passed this stage of screening moved on to a full text review. After a full text review, six studies were included in the final review. Each study was assessed for its risk of bias individually using the Cochrane Risk of Bias Tool. From the included studies, data was extracted about their characteristics and about their results, including the dose and duration of lidocaine, the control used, and how pain was measured.

Results

The results of the search yielded 383 studies. 57 articles were retrieved for the final stage of screening, and of these six were utilised in composing the final review. The risk of bias overall was low in all six of the studies included in this review. five out of six of the studies had statistically significant results showing that use of intravenous lidocaine had some form of positive effect on reduction of post-operative pain, whether this was by reducing post-operative pain scores, or by reducing post-operative opioid consumption.

Discussion and conclusion

Overall, intravenous lidocaine has been shown to have promising results as an analgesic adjunct in paediatric surgery. The only study out of the six that didn’t show a reduction in post-operative pain from using intravenous lidocaine, did see a reduction in post-operative nausea and vomiting. This shows that lidocaine may be a useful adjunct in reducing other post-operative complications. However, further research needs to be done using larger population sizes and across a variety of different surgeries to further evaluate its efficacy within both minor and major procedures.

 

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NATIONAL COMPARATIVE AUDIT OF PATIENT BLOOD MANAGEMENT IN ELECTIVE PAEDIATRIC SURGERY

J. McArdle1, N. Ladak2, B. Clevenger3

1Newcastle-upon-Tyne NHS Foundation Trust, UK

2Sheffield Children's NHS Foundation Trust, UK

3Royal National Orthopaedic Hospital, UK

Introduction:

Patient blood management (PBM) during the peri-operative period is well established in adult practice; however, it has lagged behind in paediatrics. Considering this, a national comparative audit of patient blood management in elective paediatric surgery was carried out across 31 hospitals in the UK in 2022. The aim was to compare PBM practice against standards in guidelines for children undergoing elective surgery where blood loss was expected to be significant and provide opportunities for improvement.

Methods:

All hospitals in the UK that perform predefined major paediatric surgical procedures were invited to participate. Sites audited a maximum of 40 cases, with no minimum number of cases, undertaken during the whole of 2022.

Inclusion criteria were; patients greater than 4 weeks old and less than 18 years old undergoing elective non-cardiac surgery where blood loss was expected to be significant and a group and screen sample was taken, or the patient cross-matched for the procedure.

Specific patient groups were excluded from the audit; these included: children with haemaglobinopathies and any form of haematological malignancy, children undergoing urgent or emergency surgery and any re-do or second side surgery.

The audit standards were:

Full blood count (FBC) measured at least six weeks preoperatively [1]

Optimising pre-operative haemoglobin by treating iron deficiency [2,3]

Transfusion threshold of 70 g/L in stable patients without co-morbidities or ongoing blood loss [3]

Tranexamic acid given where there is a risk of significant bleeding [3]

Consideration of using red cell salvage [3]

Patients at risk of blood loss should be informed about the risk of blood transfusion preoperatively [2].

Results:

Across 31 hospitals there were 735 patients’ data analysed. 89.4% (n=657) of patients had a pre-operative FBC measurement. 17.7% (n=116) of patients were anaemic on their last FBC check before surgery and of this group only 19% (n=22) were investigated with haematinics. 11.2% (n=81) received iron therapy. There was a total of 226 transfusions in 213 patients, giving an overall transfusion rate of 30%.

71% (n=505) of patients in whom it was not contra-indicated received tranexamic acid.

Cell salvage was used in 44% (n=320) of cases. There were 84 cases (39% of all transfused patients) where cell salvage was not used but the patient received an allogeneic transfusion. 16.6% (n=122) of patients had documented evidence of written information about blood transfusion pre-operatively.

Discussion:

This audit reviewed a range of standards relating to practice in PBM in the elective paediatric setting, with significant numbers of children receiving blood transfusions in the peri-operative period. Better implementation of the standards of PBM may reduce the rate of peri-operative blood transfusions.

References:

[1] International Consensus Statement on the perioperative management of Anaemia and Iron deficiency Anaesthesia Dec 2016 DOI: 10.1111/anae.13773

[2] NICE quality standard QS138: Blood transfusion 2016 https://www.nice.org.uk/guidance/qs138/chapter/Quality-statements

[3] British Society of Haematology: Guidelines on transfusion for fetuses, neonates and older children 2016  https://doi.org/10.1111/bjh.14233

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INTRODUCTION OF A PEER-LED JOURNAL CLUB TO FACILITATE LEARNING AND ACHIEVING CURRICULUM REQUIREMENTS FOR ADVANCED PAEDIATRIC TRAINING

N. Gostelow, S. Greenaway

Guy's and St Thomas' NHS Trust, London, UK

Introduction

Journal clubs help develop critical appraisal skills, keep clinicians abreast of recent literature(1), promote lifelong learning and facilitate social interaction(2). Our institution is a tertiary paediatric hospital with eight to twelve senior anaesthetic registrars completing training in advanced paediatric anaesthesia, alongside more junior trainees completing shorter rotations. Like many institutions, our department faces competing pressures from COVID-19 recovery, increasingly complex clinical workload and, in 2023, disruption from industrial action. Meeting training requirements for advanced modules, in addition to generic professional capabilities outlined by the 2021 Royal College of Anaesthetists (RCOA) curriculum(3) can be challenging alongside these pressures. This educational initiative aimed to evaluate if a peer-led journal club is beneficial for both clinical practice and achieving non-clinical competencies.

Methods

An initial survey gathering opinions towards a paediatric anaesthetic journal club was circulated to anaesthetic trainees. A trainee lead allocated registrars as presenters for journal clubs held every two weeks between November 2023 and January 2024. Presenters could choose any article related to paediatric anaesthesia. Journal clubs were held both in-person and via Microsoft Teams™. Feedback surveys were distributed immediately after the presentation.

Results

The initial survey had a 50% response rate. 100% of respondents agreed a journal club would have a positive impact upon their training and 71% that attending could provide evidence for other curriculum competencies. Six journal clubs were held and attended by between three and eight anaesthetic trainees. Topics included perioperative blood transfusion guidelines, perioperative cardiac arrest (7th National Audit project), Total Intravenous Anaesthesia and controversies around nitrous oxide use. Likert scale surveys (scale 1-5) showed presentations were relevant to practice (median = 5) and useful for stage of training (median = 5). Attendees also reported presentations were likely to change practice, see figure 1. Free text responses showed attendees valued the opportunity for discussion alongside specific learning points covered.

Discussion

This educational initiative shows a peer-led journal club produced learning with the potential to change practice for future paediatric anaesthetists. Peer-led sessions allowed trainees to choose topics of relevance to them and their colleagues, encouraged discussion and can contribute towards a sense of community.  Hybrid structures can increase attendance and engagement(1). The journal club also experience in other curriculum requirements such as teaching, appraising research and data, and organisation and management. The journal club will be continued for the next rotation aiming to become more established in departmental culture encouraging more junior trainee and consultant attendance.

References:

  1. Eusuf D, Shelton C. Establishing and sustaining an effective journal club. BJA Educ. 2021; 22(2): 40-42
  2. Brzezinski M, Sawatzki R, Tran HN et al. An Analysis of Successful Features of Anesthesiology Journal Clubs. J Educ Perioper Med. 2020;22(4):E648.
  3. Royal College of Anaesthetists. 2021 Curriculum for a CCT in Anaesthetics [Internet]. London: RCoA. 2021.[cited 01/02/2024]. Available from: https://www.rcoa.ac.uk/sites/default/files/documents/2023-11/2021%20Curriculum%20for%20a%20CCT%20in%20Anaesthetics%20v1.2_0.pdf

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ANALGESIA FOR PATIENTS UNDERGOING LOWER LIMB AMPUTATION

D. Cunningham, H. Laycock, V. Ratnamma

Great Ormond Street Hospital, UK

Lower limb amputation is a common surgical intervention in both adults and children. Up to 80% of patients who undergo lower limb amputation will go on to develop residual stump pain or phantom limb pain. Control of pain in the peri-operative period is a priority for the anaesthetic team as evidence shows that uncontrolled acute pain can lead to worsening chronic pain. There is currently no agreed gold standard approach to managing the pain associated with lower limb amputation in children. Options include central neuraxial or peripheral nerve approaches, and intravenous and oral analgesia. We aimed to explore the approaches used for perioperative pain management in paediatric patients undergoing lower limb amputation at Great Ormond Street Hospital and to determine efficacy in managing post operative pain using post operative pain scores.

Method

The SlicerDicer function on EPIC (search criteria “Through knee amputation” OR “Below knee amputation” OR “Above knee amputation”) was used to identify all patients who underwent a lower limb amputation between 20th September 2017 to 19th September 2023 (earliest recorded amputation was 10/05/2019). A data collection proforma (Microsoft Excel) was completed from reviewing patient notes. Data were extracted including patient characteristics, indication for amputation, analgesic techniques used in the perioperative period and postoperative pain scores.

Results

Eighteen patients (Median age: 8.5 years, Range: 1- 17 years) underwent lower limb amputation. Twelve patients (66%) received preoperative gabapentinoids (pregabalin or gabapentin). A range of analgesic approaches were used intraoperatively including caudal (17%), epidural (22%), single shot nerve block (50%), and IV analgesia only (11%). An opiate only PCA/NCA was used postoperatively in 50%, a combined opiate/ketamine PCA/NCA in 39% and epidural only in 11% of patients. The median highest recorded pain score in recovery was 0 (Range 0-7). On day 0 median highest recorded pain score was 0 (Range 0-7) and day 1 median 1 (Range 0-6). High pain scores were not related to use of iv analgesia only.

Conclusion

There is currently no local or national standard approach to the management of pain in the perioperative period for children undergoing lower limb amputation. As a result, various techniques are utilised in the perioperative period by anaesthetists at Great Ormond Street Hospital. The number of patients undergoing this procedure makes it difficult to determine improved pain outcomes with particularly techniques. Future work is required to establish an evidence-based approach to rationalising perioperative pain management in children undergoing lower limb amputation.

References:

1)               Major lower limb amputation audit – introduction and implementation of a multimodal perioperative pain management guideline. Aladin, Adrian Jennings, Max Hodges, and Alifia Tameem – British Journal of Pain 2018

 

2)               The Influence of pre-amputation pain on post-amputation stump and phantom pain. L.Nikolajsen, S.Ilkjaer, K.Kroner, J H Christensen, T S Jensen – Pain 1997

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THE INCIDENCE AND IMPACT OF DIFFICULT INTUBATION IN A PAEDIATRIC ICU

D. Kerrigan, N. Rousseau, M. Lawlor, A. Walsh

CHI Temple Street, Dublin, Ireland

Intubation is a common procedure carried out on critically ill children in Paediatric Intensive Care Units (PICU). Difficult intubation in children has been quantified at 9% in PICU and 0.9% in paediatric Anaesthesia 1,2.  The incidence of difficult intubation has not yet been studied in PICU in Ireland.

1 To quantify difficult intubation in children admitted to PICU

2 To quantify the incidence of adverse events which occur in these cases

3 To identify risk factors for difficult intubation

This was a retrospective chart review of electronic medical records for patients admitted to the PICU of Children’s Health Ireland at Temple St (CHIT), from April 2020-April 2023. Database search terms included; Difficult + airway, Difficult + intubation, Failed + Intubation, Grade 3 + View, Grade 4+ view, Grade 3 + intubation, Grade 4 + intubation, CL +3, CL +4, C&L +3, C&L +4, Multiple + attempts + intubation, Difficult + BMV. Inclusion criteria were a documented history of “difficult intubation” or “difficult airway”, 3 or more attempts at intubation or a C&L view of 3 or 4. Data collected included; age, sex, reason for intubation, weight, location of intubation, co-morbidities, if bag mask ventilation (BMV) was difficult, number of intubation attempts, Cormack & Lehane (C&L) Grade, laryngoscope used, size of endotracheal tube , if a supraglottic airway device or fiberoptic scope was used, desaturation episodes, haemodynamic instability or any other adverse events during intubation and the speciality and grade of the intubating Doctor(s). Data analysis involved descriptive statistics.

809 intubated patients were admitted to PICU during this period.10 cases met inclusion criteria. The difficult airway rate  was 1.24 %. The median weight was 4.6 Kg (2.7-19), median age was 37 months (19 -193) . 70% were Male. 20% of patients had no co-morbidities. 40% had syndromes involving craniofacial abnormalities.  None had difficulty in BMV. The median number of intubation attempts was 4 (2-6). 40% of cases had a C&L grade documented. One C&L 1, one C&L 3, one C&L 4 and one case had more than one grade documented. One case used  a parsons laryngoscope and rigid bronchoscope . In 50% of cases a video laryngoscope was successfully used to intubate. There were no cases in which a child successfully intubated with direct laryngoscopy.20% used an LMA, 20% used a fiberoptic scope. 40% had a desaturation episode and 40% had haemodymanic instability.

The incidence of difficult intubation in this study is lower than previously published in PICU. Children with craniofacial abnormalities were relatively over represented, reflecting the fact that they are known to be more likely to have a difficult airway 3. The high success rate with videolaryngoscopy in paediatric difficulty in this study is consistent with previous studies 4.

References:

1      Graciano AL, Tamburro R, Thompson AE, Fiadjoe J, Nadkarni VM, Nishisaki A. Incidence and associated factors of difficult tracheal intubations in pediatric icus: A report from National Emergency Airway Registry for Children: NEAR4KIDS. Intensive Care Medicine. 2014 Aug 27;40(11):1659–69. doi:10.1007/s00134-014-3407-4

  1. Engelhardt T, Virag K, Veyckemans F, Habre W. Airway management in paediatric anaesthesia in Europe—insights from Apricot (anaesthesia practice in children observational trial): A prospective multicentre observational study in 261 hospitals in Europe. British Journal of Anaesthesia. 2018 Jul;121(1):66–75. doi:10.1016/j.bja.2018.04.013
  2. Garcia‐Marcinkiewicz AG, Stricker PA. Craniofacial Surgery and specific airway problems. Pediatric Anesthesia. 2019 Dec 31;30(3):296–303. doi:10.1111/pan.13790
  3. Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, et al. Airway management complications in children with difficult tracheal intubation from the pediatric difficult intubation (pedi) registry: A prospective cohort analysis. The Lancet Respiratory Medicine. 2016 Jan;4(1):37–48. doi:10.1016/s2213-2600(15)00508-1

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A REVIEW OF PAEDIATRIC EPIDURALS AT A TERTIARY PAEDIATRIC TRUST

C. Lewis, F. Harrison, O’ Clancy

Royal Manchester Children's Hospital, UK

Background

We decided to audit the use of epidurals at our tertiary paediatric trust due to a safety incident, as well as concerns raised by nursing staff regarding safe and appropriate staffing levels on wards accepting patients with epidurals.

Aim

To review our current practice with regard to the insertion and management of epidurals in paediatric patients

Methods

A search was conducted on our electronic database to identify patients who received an epidural as part of their anaesthetic care for procedures within Royal Manchester Childrens Hospital between July and December 2023. Caudal epidural catheters were excluded.

Results

A total of 14 patients were identified between the ages of 10-17 (median age 14). The epidurals were inserted for a variety of procedures including 9 orthopaedic, 3 general paediatric surgery and 2 urology, all of which were elective procedures. 5 out of 14 were thoracic epidurals, 9 were lumbar, all of which were uncomplicated insertions under general anaesthesia with no complications immediately identified. The majority, 12 out of 14, were inserted and used throughout the surgical procedure, with only two being inserted post procedure. Plain Levobupivacaine (0.25%) was used in all cases; loading boluses varied in quantity and timing at the discretion of the anaesthetist. Post operatively levobupivacaine 0.1-0.125% was used plain or with either 2 microgram/ml fentanyl or 1microgram/ml clonidine according to the anaesthetists preference and was started at an infusion of 0.4mg/kg/h. One headache was identified post procedure that was reviewed for possible dural puncture, however the headache resolved without an epidural blood patch. There were two cases of accidental disconnection which resulted in premature removal of the epidural. Significant motor block was reported in 6 cases and there were 6 cases of inadequate or unilateral block requiring opiod analgesia, sometimes as a result of pausing the infusion to assess the reversibility of the motor block. Hypotension was seen in 6 cases, one of which may have contributed to a new acute kidney injury seen on day 3 post operatively of a complex patient. The hourly monitoring of epidurals including Bromage scores was poorly documented.

Conclusion

Although the technical insertion of epidurals appears to be uncomplicated, the incidence of unwanted side effects including motor block and hypotension is high and impacting negatively on the patients post operative experience. We aim to review current guidelines with regard to loading doses and infusion protocols, as well as continuously audit future epidurals. A new software update introduced in December 2023 allowing all pain and epidural observations in one flowsheet will aid monitoring and documentation.

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PARADIGM SHIFT TO ORAL PARACETAMOL AND IBUPROFEN AS PREMEDICATIONS TO REDUCE CARBON FOOTPRINT AND IMPROVE COST EFFECTIVENESS IN PAEDIATRIC THEATRES

M. S. Bakir, Royal London Hospital, UK

Introduction

For paediatric surgical procedures in our department, the predominant practice has been to administer intravenous paracetamol and diclofenac intraoperatively. Paracetamol has similar efficacy and safety profile when given orally or intravenously, as do intravenous diclofenac and oral ibuprofen. However there are significant differences between intravenous and oral preparations in terms of cost-effectiveness and environmental impact. This project aimed to develop a pathway and system to move from intraoperative administration of intravenous paracetamol and diclofenac, towards patient-centred nurse-led administration of oral paracetamol and ibuprofen as premedication.

Methods

The project represented a shift in practice and required consideration of potential risks and challenges. The proposed system relied on nurses having the confidence and competence to prescribe and administer analgesia on admission, requiring education on dose calculations and contra-indications, and electronic prescribing training. A decision-making flowsheet was created to facilitate nurse-led weight-adjusted dose calculations and prescriptions on admission. Patient Group Directives (PGDs) were created that included doses, indications and contra-indications. The support of the anaesthetic clinical team was crucial to implementation, including troubleshooting nurses’ queries. The risk of repeat analgesic administration intraoperatively was addressed by ensuring handover of administered premeditations once patient transferred to theatre; incorporating record of administration in preoperative checklist; signing administration electronically; checking administration in theatre sign-in; including premedication in WHO checklist.

Results

The proposed changes were well received by nursing staff, management, pharmacists and anaesthetists. The explanation of the problem highlighted the issue, and the suggested solutions were seen to be realistic and achievable. The clarity of the decision making flow-chart and PGDs helped enhance the safety of the changes and the empowerment of nurses. The anaesthetic department was on board and actively supported the ward in premedication prescription queries. Handover in theatre was effective and adjustments to sign-in sheets and WHO checklist introduced.

Discussion

Cost-effectiveness and environmental impact are crucial factors in the current financial and environmental climate. When considering packaging, administration supplies, transport and waste disposal processes, the carbon-footprint of intravenous paracetamol is twelve-times that of oral tablets, and twice that of oral liquid preparations. Similarly, the cost of intravenous paracetamol is thirteen-times that of oral tablets, and twice that of oral liquid preparations. This is compounded in children, where weight-adjusted doses are extracted from bottles and the remainder discarded for infection control, posing an additional financial and environmental burden. Oral liquid preparations enable administration of doses to different patients from the same bottle, without risking cross-infection. The shift towards a strategy for administering oral analgesia as premeditation worked towards reducing theatre costs and carbon-footprint, and increased theatre utilisation and efficiency. Furthermore, it was seen to improve patient care, as the oral preparations had time to be effective for the start of the procedure.

Reference:

Davies J McAlister S, Eckelman M, McGain F, Seglenieks R, Gutman E, Groome J Palipane, Latoff K, Nielsen D, Sherman J. Environmental and financial impacts of perioperative paracetamol use: a multicentre international life-cycle analysis, British Journal of Anaesthesia, 2024

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EMERGENCY PAEDIATRIC FRONT OF NECK ACCESS: GETTING HELP AND REDUCING COGNITIVE BURDEN

C. Macrow, S. Sen

Mid Yorkshire Hospitals NHS Trust, Wakefield, UK

Background/Context

Although extremely rare (1), emergency paediatric front-of-the-neck access (FONA) may be the only life-saving option in a “Cannot intubate, cannot oxygenate” (CICO) situation.

A recent case, in a complex unwell child, prompted us to evaluate our current District General Hospital (DGH) guidance and equipment. This child presented acutely to our hospital, underwent a difficult intubation before being transferred out and then subsequent emergency FONA.

Problem

Several guidelines for paediatric FONA exist. These offer different advice on the technique to be used in a child of a given age or weight (2), and limited information on specific equipment sizing. These include The Difficult Airway Society’s (DAS) algorithm for 1-8 year old's, The Vortex Approach to Airway Management, The Advanced Paediatric Life Support (APLS) approach and The Advanced Trauma Life Support (ATLS) approach. This variability increases cognitive burden in a time critical situation.

Accessible guidance for theatre staff on how to prepare emergency Paediatric rigid bronchoscopy was also required.

Additionally, within our hospital a method for alerting all available anaesthetists to attend an airway emergency was not established.

Strategy for change

A departmental survey of consultants and trainees (N=47), with regular paediatric exposure, revealed that 91% had never received paediatric FONA training,  and that 87% felt that this would be useful. 64% felt this should be refreshed at least annually. Confidence levels for selecting the appropriate method and size of equipment in 12, 6, 3 and 1 year old's was also collected. Confidence significantly dropped with age.

Actions Taken:

  • Locally agreed paediatric FONA algorithm, with age ranges and equipment listed
  • Age-range FONA grab bags with preselected equipment ( <1, 1-3, 4-8, >8 years)
  • SOP for an “Airway Emergency” 2222 call
  • Grab Bag with instructions for Rigid Bronchoscope assembly and Location
  • Paediatric airway skills Tea-trolley teaching program
  • Funding secured for departmental paediatric airway manikin
  • Algorithm and SOP Presented at joint Paediatric and Anaesthetic Departmental meeting

Measure of improvement

A survey of confidence levels in selecting appropriate equipment and age appropriate methods post teaching will be completed.

Lessons learnt

Paediatric FONA is very rare, with significant risk of iatrogenic injury. Concerns were raised within the survey regarding its relevance to DGH Anaesthetics, and a possible “Dunning-Kruger effect” via teaching, increasing confidence without improving competence, leading to possible unnecessary FONA . This was addressed by making the focus of teaching Basic paediatric airway skills and emphasizing optimization, before familiarization with the new FONA algorithm.

Message for others

In emergencies, especially out of hours, the ability to get appropriate help is essential. A 2222 “airway emergency” may improve this.

Rare, but life threatening emergencies require planning. The availability of equipment and age appropriate grab-bags in paediatrics should reduce cognitive burden and human factors in a highly stressful situation.

References:

  1. Engelhardt T, Virag K, Veyckemans F, Habre W. Airway management in paediatric anaesthesia in Europe-insights from APRICOT (Anaesthesia Practice In Children Observational Trial): a prospective multicentre observational study in 261 hospitals in Europe. Br J Anaesth. 2018 Jul;121(1):66-75.

2.Berger-Estilita J, Wenzel V, Luedi MM, Riva T. A Primer for Pediatric Emergency Front-of-the-Neck Access. A A Pract. 2021 Apr 6;15(4):e01444.

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