Paediatric Critical Care Issues Database (PaediCRID) Dr Andrea Cooper Consultant Paediatric Intensivist KIDSNTS and BWC Aimee Hodgson Governance Support Administrator WMPCCN/KIDSNTS
LAST TIME AT PCCN! Neurosurgical Emergencies- Shared some excellent RCA finings and learning Anaesthetic confidence/issues- effecting one trust more than others Multi-site SIRI mentioned- awaiting investigation Investigation of report that advice given by KIDS Consultant was potentially dangerous- Internal responses received, awaiting independent review
Last six months: Further Issues reporting around Neurosurgical Emergencies Communication- perceived rudeness Information not transferred satisfactorily Inaccurate report of Cardiac arrest Perceived chaotic resuscitation scenarios Lack of understanding regarding management Equipment/drug availability- delayed administration of prostin in collapsed neonate with duct dependent lesion as not available in ED Drug error- adrenaline infusion (wrong concentration adrenaline used) Provision for care of DSH- anti ligature precautions (reported as unwillingness to accept patient back to DGH)
Neurosurgical Emergencies: 14 year old presented to ED and was treated for encephalitis. CTB indicated due to low GCS, shows large intracranial mass with midline shift. Call directly to Neurosurgery who advise time critical transfer. KIDS called who identify that there has not yet been Anaesthetic involvement. Clarify that this is a time critical local transfer. When Anaesthetists are called, the process is then very effective, but they should have been involved earlier. Awaiting review by local team. Previous Paedicrid reports highlight that the role of the Anaesthetist in Neurosurgical emergencies is poorly understood. ? Contributing factor here
Neurosurgical Emergencies: Delay in communicating an abnormality on CT Brain The handover from the paediatric team to the KIDS team was that the CTB was normal and scans had been sent to BCH. The scans had to be chased and were unavailable until 4 hours post admission, despite calls to the local hospital. BCH Radiologist reviewed the scans and reported extensive changes- dilated ventricles and infarcts. These findings were also reported by local radiologist, but not conveyed to the Paediatric team Awaiting review by local team- Where did the communication break down? What was the cause of the delay sending the images? KIDS team- where feasible must ensure that they personally review the scans and reports prior to departure.
Neurosurgical Emergencies: 3 year old with depressed skull fracture and subdural haematoma Concerns about delayed presentation to the hospital. Neurosurgeons requested ward transfer. KIDS follow up- local team planned to send child in parents car. Given subdural haematoma and safeguarding concerns this was not appropriate. KIDS advised ambulance transfer. Concerns raised around transport plans. ? Education required regarding interhospital transfers and the use of ambulances. Also a 24 hour delay in getting the CTB post diagnosing a skull fracture on XR, despite advise from Neurosurgery. Awaiting results of local investigation.
Neurosurgical Emergencies: Delay in transfer of a child with neurosurgical emergency Alleged assault a school of a 12 year old boy. Presents with low GCS and unequal pupils . Referral by Paediatric team to KIDS Primary time critical transfer advised. Reluctance by Anaesthetic team to transfer and delayed transfer occurred. Awaiting response from local Anaesthetic team.
Neurosurgical Emergencies: 18 month old child with TBI and seizures bought to local hospital en-route to MTC for stabilisation. Local Anaesthetic team intubate and ventilate the child and load with phenytoin. CTB locally shows a frontal subdural bleed. Initially discussed with KIDS at 1735 and advised that there was a bed in BCH. Either KIDS or MERIT would transfer when team available. Call to ED at 1930 from a different KIDS Consultant who stated that Neurosurgeons were not going to intervene and recommended local extubation. No need for PIC transfer. Local clinical team unhappy with advice and uncomfortable extubating in a busy ED Resus without the support of PICU. Given GCS of 4/15 on arrival and seizures there were concerns that she would not wake up appropriately to be extubated. No HDU provision locally if she did.
Neurosurgical Emergencies: Concerns were conveyed to the KIDS team, who refused to assess the patient or retrieve. Case escalated to the executive team locally and at BCH with involvement of local ICU and PICU. Agreed that there was a need to transfer to PICU. KIDS arrived 3am (on back to back transfers) and departed 5am. KIDS CL investigation- Discussed at M&M meeting and felt that the advice should not have been to wake up. A number of contributing factors identified including lack of teams and beds and pressure of calls. Advice from Neurosurgery was that they did not need the child to be transferred in. Awaiting response from Neurosurgical team regarding their advice to wake up locally and opinion that ICU was not required.
Neurosurgical Emergencies: 5 day old baby referred to KIDS two days previously for advice regarding neonatal meningitis. Called again next day to ask about timing of LP and concern that plt count had fallen. Call 12 hours later as baby now bradycardic with differing size pupils and more hypertonic. Advice- I&V and CTB Follow up call by KIDS as no local update- CTB not performed as local Consultant didn’t feel that it was indicated.
Neurosurgical Emergencies: At time of following up, there was a call from an out of region neonatal transfer service stating that there was no NNU cot available, but also concerns that NNU would not accept a baby that had been home. Neonatal Transfer Service were unaware of Neurosurgical concerns. Felt to be an inappropriate referral to a NTS as main concern was neurosurgical issue and not uplift of care. KIDS happy to move and NTS felt this was appropriate. Direct discussion with local Anaesthetic team, who were unaware of the baby agreed to help facilitate CTB. KIDS team retrieved. Child seizing on arrival to Unit. Further imaging at BCH- devastating brain injury and CSF confirmed pneumococcal meningitis. Life sustaining treament withdrawn.
Neurosurgical emergencies: Concerns that advice regarding CTB was not taken and that another referral/transfer process was explored instead. Concerns that local team stated that there was no provision to perform CTB. This should be the same process as NAI presenting through ED. Case is being investigated as a perinatal mortality case via the national neonatal perinatal mortality tool. Investigation has taken place and we are awaiting the report
Neurosurgical Emergencies still seem to be an issue Multiple and new issues are being identified Await investigations and disseminate learning Most recommendations to extubate locally are based on normal CTB and a high likelihood that extubation will be successful. It is very important that concerns are heard and acknowledged. No refusals to support or extubate locally have been reported in the last six months.
Anaesthetic Confidence Issues: Highlighted Trust Patient with respiratory illness. Local Intensivist stated that unless child needed imminent intubation in extremis, the team did not have the skillset to undertake intubation of the child. Table top investigation Reminder of local policy- Escalation to two other Consultant Anaesthetists if AICU Consultant doesn’t feel that have the competencies to intubate. Support and measures being put in place to help the individual Reassuringly, this is the only report in the last six months of this nature.
Multi site SIRI: 2 year old who presented with gastroenteritis and dehydration picture. Evolving sepsis concerns Cardiac compromise with tachycardia, hypotension and pallor. Metabolic acidosis on VBG with pH 6.2 and Lac 7 Referred to KIDS and started on Adrenaline infusion whilst preparing for intubation PEA arrest on induction despite appropriate cautious anaesthetic induction 2 minutes CPR and one dose adrenaline Post arrest gas pH 6.88, pCo2 7, BE -22 Lac 11 5 hour stabilisation time with KIDS No beds locally. No cardiac bed. Drive through Echocardiogram at BCH- “reduced” Ventricular function
Multi site SIRI: No beds at BCH, so transferred to another non-cardiac ICU out of region Required inotropes CTB Normal Deranged coagulation- improved by Vitamin K LP clear NPA Rhino/entero/adenovirus positive Extubated 4 days post admission and discharged back to DGH on same day Well in DGH on the day of transfer, but concerns about tachycardia the following day Bloods revealed very elevated ALT CXR showed large heart with patchy shadowing Lactate of 2, hepatomegaly 2cm Treated with frusemide and periods of improvement.
Multi site SIRI: Episode of tachycardia 200 – pulsed VT Dose of adenosine- no effect 5 x DC cardioversion attempts (Ketamine cover) Then amiodarone and DC Cardioversion- Sinus rhythm, but poorly perfused. Peri-arrest Required intubation and ventilation PEA on induction despite cautious induction RIP SIRI not being held, but there is an investigation being lead by BCH Governance team. Highlights challenges of multi-site investigations and winter pressures Learning from this is important- could anything have been done differently? Family have been waiting for feedback for almost a year
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