Paediatric Critical Care Issues Database (PaediCRID) Dr Andrea Cooper Consultant Paediatric Intensivist KIDSNTS and BWC Aimee Haynes Governance Support Administrator WMPCCN/KIDSNTS
Since 28 th November 2017: Gathering information Encouraging reporting Identifying themes Some uniformity throughout the region Others seem to affect some trusts more than others RCAs/SIRIS Now time to share some learning!
Themes causing issues: Neurosurgical Emergencies: Recognition Management Time critical/local transfer Anaesthetic/AICU support: Intubation Extubation Support whilst awaiting Transport team
Themes for Excellence reporting: Anaesthetic Support/Involvement Neonatal Units supporting patient pathway delays due to winter pressures Palliative Care and Community support both in local hospitals and in PICU
Neurosurgical Emergencies: 6 reports around Neurosurgical Emergencies One RCA carried out with excellent learning Another very extensive investigation into delays obtaining CT Brain with good learning.
2.5 hr delay in referring a child with intracranial bleed. This child required time critical transfer, had developed unequal pupils an hour before being referred to KIDS. At referral child was bradycardic. Advised to intubate & ventilate, neuroprotective strategy. We activated CAT 1 transfer and informed Consultant Paediatrician to also organise transfer. Child further deteriorated with increase in unequal pupils which improved after administration of mannitol. Transferred by KIDS team as CAT1. Earlier in the day (around 1pm?) Paediatric Consultant had contacted neurosurgical registrar, NS registrar had asked to resend the scans and around 2.15 had contacted PICU Consultant for PIC bed. I was the KIDS Consultant and alerted about this patient at 2.30pm when I tried contacting the DGH to get information.
11 year old presented to ED @1130- right sided headache, vomiting and neck pain. Developed slurred speech en-route. ED Reg assesses- GCS 11-12, PERL. Not moving left side Paediatric Reg informed and urgent CTB requested CTB performed at 1200 and a large intracranial bleed is identified 1220 1230 ED Nurse notes that child is struggling to swallow saliva and requiring 15 minutely suctioning Paediatric Consultant informed and reviews pt in ED. Refers to BCH Neurosurgeons and requests images to be PACSed across to BCH for NS to review
1245 Call from BCH Neurosurgery to say that images have not been received 1327 CT images were transferred electronically to BCH PACS system. Received by BCH at 1334. No record from Radiology as to when they were requested to send the images over, but state that they did it immediately. Neurosurgical Registrar calls back at 1334. He advises that he will speak to BCH PIC and that the Paediatric Consultant should call KIDS.
Paediatric Consultant re-reviews the child Referral to KIDS 1405-1430 (BCH PIC Cons calls KIDS Cons to ask about child in the meantime) KIDS team despatched with view that whoever is ready first facilitates the time critical transfer. Anaesthetic team informed about the child at 1455. KIDS arrived 1510 (child already intubated!) Departed 1705
Concerns raised by Local Consultant Anaesthetist- why not contacted as soon as bleed diagnosed as could have facilitated TCT? Paedicrid raised by KIDS Consultant
RCA identified: Numerous points where Anaesthetics could/should have been contacted Lack of understanding about what Anaesthetics role is: I&V, Neuroprotection, CTB, Transfer Local policies do exist, but some give conflicting information KIDS guideline not accessed Another child in ED Resus at the time this case was also present
Recommendations from RCA: • All policy and guidance relating to critical neurosurgical conditions and transfer to critical care units should be reviewed urgently to ensure consistency in their guidance in relation to referral to KIDS; and subsequently communicated to all the relevant staff- DONE • Standardised practice for referral to Anaesthetics for paediatric neurosurgical cases. Protocol to be shared across paediatrics and presented at both Paediatric and ED Governance- DONE • Standardised record keeping for image sharing requests
In addition: Neurosurgical Emergency guideline updated, reviewed and discussed Time Critical Transfer Guideline reviewed Local Education and debrief MDT Training- “walk through” of patient pathway
KIDS CLINICAL GUIDELINE – NEUROSURGICAL EMERGENCY TRANSFER CONSIDER RAISED ICP Reduced GCS, focal neurological deficit, unequal or dilated pupils, relative bradycardia & hypertension, seizures, abnormal posture If present, commence resuscitation as below and inform anaesthetic team ASAP. Alert radiology of a patient requiring urgent CT brain. Call KIDS on 0300 200 1100 - A conference call will be set up with the KIDS Consultant, Neurosurgeons and other relevant parties. If head injury Activate Trauma Team where local provision exists. Time critical emergencies will require a primary transfer by the referring team! INITIAL ASSESSMENT AND MANAGEMENT INITIAL ASSESSMENT AND MANAGEMENT ACUTELY RAISED ICP - EMERGENCY TREATMENT CIRCULATION ( AVOID HYPOTENSION! ) (e.g. unequal or dilated unreactive pupil, ↑ BP ↓ HR) AIRWAY & BREATHING ( AVOID HYPOXIA! ) – Ensure all routine measures as opposite are – Continuous ECG and SpO 2 monitoring – Assess and maintain airway patency instituted (e.g. well sedated, 30 o head up) – Cycle NIBP every at least every 3 minutes – Seek senior anaesthetic support early – Insert IV access x 2 – Give osmotherapy: – Assess adequacy of ventilation and – Consider invasive BP monitoring support with bag & mask if necessary o 3 mls/kg of 3% Saline or – Do not delay CT to insert lines o 2.5 mls/kg of 20% Mannitol over 15 mins Criteria for intubation: Use mean arterial pressure targets as shown below: – Loss of airway reflexes AGE TARGET MBP – GCS ≤ 8 PREPARATION FOR TRANSFER CHECKLIST <2 60-65 mmHg – Signs of raised ICP – ‘ Blown ’ pupil, ↑ BP ↓ HR 2-6 70-75 mmHg – Respiratory insufficiency or spontaneous Emergency airway equipment inc. AmbuBag >6 80-85 mmHg hyperventilation (CO 2 ≤ 3.5 ) Secure IV access x2 with long extension Fluid boluses : 10 mls/kg 0.9% Saline connected to allow fluid / drug administration TRAUMA PATIENTS REQUIRE CONTINUOUS C-SPINE Sufficient volumes of infusion drugs and rates Inotropes may be needed to maintain MAP – seek KIDS IMMOBILISATION (Do not use cervical collars!) advice. checked Emergency drugs including osmotherapy POST – INTUBATION: Bleeding trauma patients require blood products – see guidance Sufficient portable O 2 for whole journey x2 – Secure ET tube using tapes (click for description) Sufficient battery life on monitor and infusion DISABILITY & EXPOSURE – Sedate and paralyse with Morphine, Midazolam pumps – Perform 15 minute neurological observations (>6 months) and Rocuronium – see calculator Case notes, blood results, observation and – Maintain normothermia and normoglycaemia – Ensure PaCO 2 4.5-5.0 kPa & PaO 2 10-12kPa prescription charts photocopied – Keep Hb > 10g/dL and correct coagulopathy – Monitor End-Tidal CO 2 Images sent to receiving unit via PACS – Give phenytoin 20 mg/kg – Satisfactory restraint (protect C-spine!) – If open fracture, give IV antibiotics – Keep PEEP at 5cm H 2 O where possible Receiving unit notified of departure Maintain 30 o head up tilt – – PERFORM URGENT CT BRAIN and discuss result V1.0.4 J Tyler / B Fule, July 2016 Review June 2019
Delay in local team mobilising for time critical transfer. 3month old with sub dural bleed, midline shift. Needs time critical transfer. Child attended A&E around 12noon, CT head done "an hour before KIDS referral" I looked at the scans- shows massive midline shift. While on the phone waiting for neurosurgeon to join the conference call, I advised the Paed consultant to come off the conference call and organise time critical transfer by his anaesthetist. KIDS had another pending referral which was likely to need transfer. Called back 30minutes later(17.35) I was informed that the anaesthesia registrar had seen the child and had gone to speak to his consultant. They had not called for an ambulance yet. I mobilised KIDS team as CAT 1.
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