Lyvonne Tume - Academia.edu (original) (raw)

Papers by Lyvonne Tume

European Journal of Pediatrics

Australian Critical Care

Endotracheal suction is an invasive and potentially harmful technique used for airway clearance i... more Endotracheal suction is an invasive and potentially harmful technique used for airway clearance in mechanically ventilated children. Choice of suction intervention remains a complex and variable process. We sought to develop appropriate use criteria for endotracheal suction interventions used in paediatric populations. The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop the Paediatric AirWay Suction appropriateness guide. This included defining key terms, synthesising current evidence, engaging an expert multidisciplinary panel, case scenario development, and two rounds of appropriateness ratings (weighing harm with benefit). Indications (clinical scenarios) were developed from common applications or anticipated use, current practice guidelines, clinical trial results, and expert consultation. Overall, 148 (19%) scenarios were rated as appropriate (benefit outweighs harm), 542 (67%) as uncertain, and 94 (11%) as inappropriate (harm outweighs benefit). Disagreement occurred in 24 (3%) clinical scenarios, namely presuction and postsuction bagging across populations and age groups. In general, the use of closed suction was rated as appropriate, particularly in the subspecialty population 'patients with highly infectious respiratory disease'. Routine application of 0.9% saline for nonrespiratory indications was more likely to be inappropriate/uncertain than appropriate. Panellists preferred clinically indicated suction versus routine suction in most circumstances. Appropriate use criteria for endotracheal suction in the paediatric intensive care have the potential to impact clinical decision-making, reduce practice variability, and improve patient outcomes. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.

Pediatric Critical Care Medicine, 2020

Article tweet: Parents and PICU healthcare professionals research priorities for critically ill c... more Article tweet: Parents and PICU healthcare professionals research priorities for critically ill children identified Declaration of potential conflicts Dr Lyvonne Tume was an expert member and deputy vice chair of the National Institute for Health Research (NIHR) Health Technology Assessment Maternal, Women's and Child Health topic identification panel during the time this exercise was conducted.

Archives of Disease in Childhood, 2020

Background Routine measurement of gastric residual volume to guide feeding is widespread in neona... more Background Routine measurement of gastric residual volume to guide feeding is widespread in neonatal units but not supported by high-quality evidence. Outcome selection is critical to trial design. Objective To determine optimal outcome measures for a trial of not routinely measuring gastric residual volume in neonatal care. Design A focused literature review, parent interviews, modified two-round Delphi survey and stakeholder consensus meeting. Participants Sixty-one neonatal healthcare professionals participated in an eDelphi survey; 17 parents were interviewed. 19 parents and neonatal healthcare professionals took part in the consensus meeting. Results Literature review generated 14 outcomes, and parent interviews contributed eight additional outcomes; these 22 outcomes were then ranked by 74 healthcare professionals in the first Delphi round where four further outcomes were proposed; 26 outcomes were ranked in the second round by 61 healthcare professionals. Five outcomes were c...

Background The routine measurement of gastric residual volume to guide the initiation and deliver... more Background The routine measurement of gastric residual volume to guide the initiation and delivery of enteral feeding, is widespread in paediatric intensive care and neonatal units, but has little underlying evidence to support it. Objective(s) To answer the question: Is it feasible to conduct a trial of not measuring gastric residual volume on clinical outcomes in mechanically ventilated infants and children in the UK? Design A mixed methods study involving five linked work packages in two parallel arms, neonatal units and paediatric intensive care units. 1. A survey of units to establish current UK practice. 2. qualitative interviews with healthcare professionals and caregivers of children admitted to either setting. 3. A modified two-round e-Delphi survey to investigate health care professionals’ opinions on trial design issues and to obtain consensus on outcomes. 4. National databases were examined to determine the potential eligible populations. 5. Two consensus meetings, of he...

Pediatric Medicine

Nutrition as a therapy in the pediatric intensive care unit Where nutritional support is consider... more Nutrition as a therapy in the pediatric intensive care unit Where nutritional support is considered by some as a cornerstone for therapy during pediatric critical illness, others regard nutrition in critically ill children merely as supportive care. Etymological the word therapy originates from the Greek therapeia or Latin therapia meaning "curing" or "healing" and is an attempted remediation of sickness or illness. As a rule, a therapy should be capable of modifying short-and/or long-term clinical outcome of our patients, and thus has indications and contraindications. And herein lies the pitfall. Nutrition is a key building block of life, and thus a standard prerequisite for everyone, especially for children in their early life who are growing and developing. Nutrition is therefore considered more as standard care as opposed to a therapeutic intervention. Admittedly, despite the abundance of well conducted observational studies on the impact of nutritional status, there is a significant lack of clinical trials to show a causal relationship between nutritional support and clinically relevant outcomes. Undoubtedly, being or becoming undernourished in PICU, has been associated with worse short-term outcome in PICU. Consequently, higher caloric and protein intakes, with no well-designed randomized controlled trials, have been inferred to improve clinical outcomes such as incidence of nosocomial infections, length of (PICU) stay and even mortality. As a consequence, nutritional interventions, such as route, timing and composition of nutrition, but also a broad array of procedures (measurements of gastric-residual volume, anthropometric assessments), have traditionally focussed on overcoming these problems with provision of nutrition to improve the achievement of target intakes. There is however a high risk of confounding with findings of the observational studies, as both the success of enteral feeding and clinical outcome are affected by the severity of illness and other baseline characteristics. Nonetheless, these observations and inferences led to recommendations to provide artificial nutrition early during critical illness and to aim for nutritional targets similar or even higher than in healthy children. The risk that conclusions primarily based upon observational studies might be too simplified or lead to erroneous assumptions and recommendations emphasizes the need for randomized trials. Optimally, these should not be performed with surrogate outcomes, such as laboratory measurements, anthropometrics or even muscle strength, but with clinical outcomes such as length of stay, occurrence of complications, (re)admissions, long-term development or even health-economic and social impact. Despite the lack of such trials, it is becoming more clear that during pediatric (critical) illness providing nutritional support has (contra)indications when it comes down to route, timing and amount and composition. Moreover, nutrition is most certainly capable of modifying some relevant clinical outcomes in the critically ill children as was shown relatively recently. In 2016 the multicentre RCT "Paediatric Early versus Late Parenteral Nutrition In Critical Illness" trial (PEPaNIC), showed that withholding PN for up to one week in the PICU clinically superior and highly cost-effective compared with early PN administration. The findings not only applied to the whole PICU population but also to subgroups perceived to be most vulnerable to low nutritional intakes. Indeed, omitting parenteral nutrition during the first week, and thus allowing a macronutrient deficit, is beneficial term neonates and undernourished critically ill children. Moreover, withholding PN in the PICU did not negatively affect survival, anthropometrics, and health status two and four years after PICU admission and actually improved certain areas of neurocognitive development. Early administration of PN altered DNA methylation, which formed a plausible biological basis for these detrimental long-term effects. This trial not only showed that a nutritional intervention (parenteral nutrition) has contraindications (early phase of pediatric critical illness), but above all provided evidence for the role of nutrition as therapeutic intervention to modify the short-and longterm clinical outcome for critically ill children. The critical care nutrition community should employ this momentum and recognise the role of nutrition as a therapy in pediatric critical care. Nutrition deserves a similar approach as any other pharmacological therapy, with an optimal timing, dose and route of nutrient delivery to be investigated in methodologically sound studies. And similarly, with accepting that a 'one size fits all' approach will not work for nutritional support in critically ill children. Ultimately, this will lead to nutrition therapy tailored to treat critically ill children of all ages and with all different diagnoses throughout their evolving illness.

Pediatric Medicine

The current state of knowledge and research required around nutrition in pediatric critical illne... more The current state of knowledge and research required around nutrition in pediatric critical illness. Pediatr Med 2020;3:7.

Pediatric Critical Care Medicine

BMJ Open

IntroductionEven though respiratory support is a common intervention in paediatric critical care,... more IntroductionEven though respiratory support is a common intervention in paediatric critical care, there is no randomised controlled trial (RCT) evidence regarding the effectiveness of two commonly used modes of non-invasive respiratory support (NRS), continuous positive airway pressure (CPAP) and high-flow nasal cannula therapy (HFNC). FIRST-line support for assistance in breathing in children is a master protocol of two pragmatic non-inferiority RCTs to evaluate the clinical and cost-effectiveness of HFNC (compared with CPAP) as the first-line mode of support in critically ill children.Methods and analysisWe will recruit participants over a 30-month period at 25 UK paediatric critical care units (paediatric intensive care units/high-dependency units). Patients are eligible if admitted/accepted for admission, aged >36 weeks corrected gestational age and <16 years, and assessed by the treating clinician to require NRS for an acute illness (step-up RCT) or within 72 hours of ext...

BMJ Paediatrics Open

ObjectiveDespite little evidence, the practice of routine gastric residual volume (GRV) measureme... more ObjectiveDespite little evidence, the practice of routine gastric residual volume (GRV) measurement to guide enteral feeding in neonatal units is widespread. Due to increased interest in this practice, and to examine trial feasibility, we aimed to determine enteral feeding and GRV measurement practices in British neonatal units.Design and settingAn online survey was distributed via email to all neonatal units and networks in England, Scotland and Wales. A clinical nurse, senior doctor and dietitian were invited to collaboratively complete the survey and submit a copy of relevant guidelines.Results95/184 (51.6%) approached units completed the survey, 81/95 (85.3%) reported having feeding guidelines and 28 guidelines were submitted for review. The majority of units used intermittent (90/95) gastric feeds as their primary feeding method. 42/95 units reported specific guidance for measuring and interpreting GRV. 20/90 units measured GRV before every feed, 39/90 at regular time intervals...

Health Technology Assessment

Background The routine measurement of gastric residual volume to guide the initiation and deliver... more Background The routine measurement of gastric residual volume to guide the initiation and delivery of enteral feeding is widespread in paediatric intensive care and neonatal units, but has little underlying evidence to support it. Objective To answer the question: is a trial of no gastric residual volume measurement feasible in UK paediatric intensive care units and neonatal units? Design A mixed-methods study involving five linked work packages in two parallel arms: neonatal units and paediatric intensive care units. Work package 1: a survey of units to establish current UK practice. Work package 2: qualitative interviews with health-care professionals and caregivers of children admitted to either setting. Work package 3: a modified two-round e-Delphi survey to investigate health-care professionals’ opinions on trial design issues and to obtain consensus on outcomes. Work package 4: examination of national databases to determine the potential eligible populations. Work package 5: t...

Journal of Parenteral and Enteral Nutrition

Background: Choosing trial outcome measures is important. When outcomes are not clinically releva... more Background: Choosing trial outcome measures is important. When outcomes are not clinically relevant or important to parents/patients, trial evidence is less likely to be implemented into practice. This study aimed to determine optimal outcome measures for a trial of no routine gastric residual volume (GRV) measurement in critically ill children. Methods: A mixed-methods approach was used: a focused literature review, parent and clinician interviews, a modified 2-round Delphi, and a stakeholder consensus meeting. Results: The review generated 13 outcomes. Fourteen pediatric intensive care unit (PICU) parents proposed 3 additional outcomes; these 16 were then rated by 28 clinicians in Delphi round 1. Six further outcomes were proposed, and 22 outcomes were rated in the second round. No items were voted "consensus out." The 18 "no-consensus" items were voted in a face-to-face meeting by 30 participants. The final 12 outcome measures were time to reach energy targets, ventilator-associated pneumonia, vomiting, time enteral feeds withheld per 24 hours, necrotizing enterocolitis, length of invasive ventilation, PICU length of stay, mortality, change in weight and markers of feed intolerance (parenteral nutrition administered), feed formula altered, and change to postpyloric feeds all secondary to feed intolerance. Conclusion: We have identified 12 outcomes for a trial of no GRV measurement through a multistage process, seeking views of parents and clinicians.

Intensive Care Medicine

Background: Nutritional support is considered essential for the outcome of paediatric critical il... more Background: Nutritional support is considered essential for the outcome of paediatric critical illness. There is a lack of methodologically sound trials to provide evidence-based guidelines leading to diverse practices in PICUs worldwide. Acknowledging these limitations, we aimed to summarize the available literature and provide practical guidance for the paediatric critical care clinicians around important clinical questions many of which are not covered by previous guidelines. Objective: To provide an ESPNIC position statement and make clinical recommendations for the assessment and nutritional support in critically ill infants and children. Design: The metabolism, endocrine and nutrition (MEN) section of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) generated 15 clinical questions regarding different aspects of nutrition in critically ill children. After a systematic literature search, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was applied to assess the quality of the evidence, conducting meta-analyses where possible, to generate statements and clinical recommendations, which were then voted on electronically. Strong consensus (> 95% agreement) and consensus (> 75% agreement) on these statements and recommendations was measured through modified Delphi voting rounds. Results: The final 15 clinical questions generated a total of 7261 abstracts, of which 142 publications were identified relevant to develop 32 recommendations. A strong consensus was reached in 21 (66%) and consensus was reached in 11 (34%) of the recommendations. Only 11 meta-analyses could be performed on 5 questions. Conclusions: We present a position statement and clinical practice recommendations. The general level of evidence of the available literature was low. We have summarised this and provided a practical guidance for the paediatric critical care clinicians around important clinical questions.

Journal of the Intensive Care Society

Introduction Despite potential benefits, it is not known how widely physiotherapists use mechanic... more Introduction Despite potential benefits, it is not known how widely physiotherapists use mechanical insufflation-exsufflation devices on UK adult intensive care units. This survey aimed to describe mechanical insufflation-exsufflation use in UK adult intensive care units. Methods Cross-sectional electronic survey of physiotherapists working in a permanent post on adult intensive care units. Results One hundred and sixty-six complete surveys were available for analysis, reflecting a diverse geographical spread. Nearly all (98%; 163/166) clinicians had access to mechanical insufflation-exsufflation. The estimated frequency of use varied, with the majority reporting weekly or monthly use (52/163, 32%; 50/163, 31%, respectively). Nearly all clinicians (99%) used mechanical insufflation-exsufflation with extubated patients. In contrast, around half of respondents (86/163, 53%) used mechanical insufflation-exsufflation with intubated patients, with a range of perceived barriers reported. ...

Journal of Intensive Care Medicine

Purpose: In the United Kingdom, critically ill adolescents are treated in either adult or pediatr... more Purpose: In the United Kingdom, critically ill adolescents are treated in either adult or pediatric intensive care units (AICUs or PICUs). This study explores staff perspectives on where and how best to care for this distinct group. Materials and Methods: Semistructured interviews were conducted with 12 members of staff (3 medical, 6 nursing, and 3 allied health professionals) working in 4 ICUs; 2 general hospital AICUs and 2 tertiary centre–based PICUs in England. Interviews were audio-recorded, transcribed, and analyzed using framework analysis. Findings: One overarching theme was identified, reflecting staff understanding of the term “adolescent,” and this was linked to 2 further themes, each of which had several subthemes. “Needs of the critically ill adolescent” included medical needs, dignity and privacy, issues around consent, and the impact of intensive care admission. “Implications for staff” included managing parental presence and lack of familiarity, and emotional impact,...

Archives of Disease in Childhood

ObjectiveTo identify parents’ prioritised outcomes by combining qualitative findings from two tri... more ObjectiveTo identify parents’ prioritised outcomes by combining qualitative findings from two trial feasibility studies of interventions for paediatric suspected severe infection.DesignQualitative synthesis combining parent interview data from the Fluids in Shock (FiSh) and Fever feasibility studies. Parents had experience of their child being admitted to a UK emergency department or intensive care unit with a suspected infection.Participantsn=: 85 parents. FiSh study: n=41 parents, 37 mothers, 4 fathers, 7 were bereaved. Fever study: n=44 parents, 33 mothers, 11 fathers, 7 were bereaved.ResultsIn addition to survival, parents prioritised short-term outcomes including: organ and physiological functioning (eg, heart rate, breathing rate and temperature); their child looking and/or behaving more like their normal self; and length of time on treatments or mechanical support. Longer term prioritised outcomes included effects of illness on child health and development. We found that pare...

European Journal of Pediatrics

Australian Critical Care

Endotracheal suction is an invasive and potentially harmful technique used for airway clearance i... more Endotracheal suction is an invasive and potentially harmful technique used for airway clearance in mechanically ventilated children. Choice of suction intervention remains a complex and variable process. We sought to develop appropriate use criteria for endotracheal suction interventions used in paediatric populations. The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop the Paediatric AirWay Suction appropriateness guide. This included defining key terms, synthesising current evidence, engaging an expert multidisciplinary panel, case scenario development, and two rounds of appropriateness ratings (weighing harm with benefit). Indications (clinical scenarios) were developed from common applications or anticipated use, current practice guidelines, clinical trial results, and expert consultation. Overall, 148 (19%) scenarios were rated as appropriate (benefit outweighs harm), 542 (67%) as uncertain, and 94 (11%) as inappropriate (harm outweighs benefit). Disagreement occurred in 24 (3%) clinical scenarios, namely presuction and postsuction bagging across populations and age groups. In general, the use of closed suction was rated as appropriate, particularly in the subspecialty population 'patients with highly infectious respiratory disease'. Routine application of 0.9% saline for nonrespiratory indications was more likely to be inappropriate/uncertain than appropriate. Panellists preferred clinically indicated suction versus routine suction in most circumstances. Appropriate use criteria for endotracheal suction in the paediatric intensive care have the potential to impact clinical decision-making, reduce practice variability, and improve patient outcomes. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.

Pediatric Critical Care Medicine, 2020

Article tweet: Parents and PICU healthcare professionals research priorities for critically ill c... more Article tweet: Parents and PICU healthcare professionals research priorities for critically ill children identified Declaration of potential conflicts Dr Lyvonne Tume was an expert member and deputy vice chair of the National Institute for Health Research (NIHR) Health Technology Assessment Maternal, Women's and Child Health topic identification panel during the time this exercise was conducted.

Archives of Disease in Childhood, 2020

Background Routine measurement of gastric residual volume to guide feeding is widespread in neona... more Background Routine measurement of gastric residual volume to guide feeding is widespread in neonatal units but not supported by high-quality evidence. Outcome selection is critical to trial design. Objective To determine optimal outcome measures for a trial of not routinely measuring gastric residual volume in neonatal care. Design A focused literature review, parent interviews, modified two-round Delphi survey and stakeholder consensus meeting. Participants Sixty-one neonatal healthcare professionals participated in an eDelphi survey; 17 parents were interviewed. 19 parents and neonatal healthcare professionals took part in the consensus meeting. Results Literature review generated 14 outcomes, and parent interviews contributed eight additional outcomes; these 22 outcomes were then ranked by 74 healthcare professionals in the first Delphi round where four further outcomes were proposed; 26 outcomes were ranked in the second round by 61 healthcare professionals. Five outcomes were c...

Background The routine measurement of gastric residual volume to guide the initiation and deliver... more Background The routine measurement of gastric residual volume to guide the initiation and delivery of enteral feeding, is widespread in paediatric intensive care and neonatal units, but has little underlying evidence to support it. Objective(s) To answer the question: Is it feasible to conduct a trial of not measuring gastric residual volume on clinical outcomes in mechanically ventilated infants and children in the UK? Design A mixed methods study involving five linked work packages in two parallel arms, neonatal units and paediatric intensive care units. 1. A survey of units to establish current UK practice. 2. qualitative interviews with healthcare professionals and caregivers of children admitted to either setting. 3. A modified two-round e-Delphi survey to investigate health care professionals’ opinions on trial design issues and to obtain consensus on outcomes. 4. National databases were examined to determine the potential eligible populations. 5. Two consensus meetings, of he...

Pediatric Medicine

Nutrition as a therapy in the pediatric intensive care unit Where nutritional support is consider... more Nutrition as a therapy in the pediatric intensive care unit Where nutritional support is considered by some as a cornerstone for therapy during pediatric critical illness, others regard nutrition in critically ill children merely as supportive care. Etymological the word therapy originates from the Greek therapeia or Latin therapia meaning "curing" or "healing" and is an attempted remediation of sickness or illness. As a rule, a therapy should be capable of modifying short-and/or long-term clinical outcome of our patients, and thus has indications and contraindications. And herein lies the pitfall. Nutrition is a key building block of life, and thus a standard prerequisite for everyone, especially for children in their early life who are growing and developing. Nutrition is therefore considered more as standard care as opposed to a therapeutic intervention. Admittedly, despite the abundance of well conducted observational studies on the impact of nutritional status, there is a significant lack of clinical trials to show a causal relationship between nutritional support and clinically relevant outcomes. Undoubtedly, being or becoming undernourished in PICU, has been associated with worse short-term outcome in PICU. Consequently, higher caloric and protein intakes, with no well-designed randomized controlled trials, have been inferred to improve clinical outcomes such as incidence of nosocomial infections, length of (PICU) stay and even mortality. As a consequence, nutritional interventions, such as route, timing and composition of nutrition, but also a broad array of procedures (measurements of gastric-residual volume, anthropometric assessments), have traditionally focussed on overcoming these problems with provision of nutrition to improve the achievement of target intakes. There is however a high risk of confounding with findings of the observational studies, as both the success of enteral feeding and clinical outcome are affected by the severity of illness and other baseline characteristics. Nonetheless, these observations and inferences led to recommendations to provide artificial nutrition early during critical illness and to aim for nutritional targets similar or even higher than in healthy children. The risk that conclusions primarily based upon observational studies might be too simplified or lead to erroneous assumptions and recommendations emphasizes the need for randomized trials. Optimally, these should not be performed with surrogate outcomes, such as laboratory measurements, anthropometrics or even muscle strength, but with clinical outcomes such as length of stay, occurrence of complications, (re)admissions, long-term development or even health-economic and social impact. Despite the lack of such trials, it is becoming more clear that during pediatric (critical) illness providing nutritional support has (contra)indications when it comes down to route, timing and amount and composition. Moreover, nutrition is most certainly capable of modifying some relevant clinical outcomes in the critically ill children as was shown relatively recently. In 2016 the multicentre RCT "Paediatric Early versus Late Parenteral Nutrition In Critical Illness" trial (PEPaNIC), showed that withholding PN for up to one week in the PICU clinically superior and highly cost-effective compared with early PN administration. The findings not only applied to the whole PICU population but also to subgroups perceived to be most vulnerable to low nutritional intakes. Indeed, omitting parenteral nutrition during the first week, and thus allowing a macronutrient deficit, is beneficial term neonates and undernourished critically ill children. Moreover, withholding PN in the PICU did not negatively affect survival, anthropometrics, and health status two and four years after PICU admission and actually improved certain areas of neurocognitive development. Early administration of PN altered DNA methylation, which formed a plausible biological basis for these detrimental long-term effects. This trial not only showed that a nutritional intervention (parenteral nutrition) has contraindications (early phase of pediatric critical illness), but above all provided evidence for the role of nutrition as therapeutic intervention to modify the short-and longterm clinical outcome for critically ill children. The critical care nutrition community should employ this momentum and recognise the role of nutrition as a therapy in pediatric critical care. Nutrition deserves a similar approach as any other pharmacological therapy, with an optimal timing, dose and route of nutrient delivery to be investigated in methodologically sound studies. And similarly, with accepting that a 'one size fits all' approach will not work for nutritional support in critically ill children. Ultimately, this will lead to nutrition therapy tailored to treat critically ill children of all ages and with all different diagnoses throughout their evolving illness.

Pediatric Medicine

The current state of knowledge and research required around nutrition in pediatric critical illne... more The current state of knowledge and research required around nutrition in pediatric critical illness. Pediatr Med 2020;3:7.

Pediatric Critical Care Medicine

BMJ Open

IntroductionEven though respiratory support is a common intervention in paediatric critical care,... more IntroductionEven though respiratory support is a common intervention in paediatric critical care, there is no randomised controlled trial (RCT) evidence regarding the effectiveness of two commonly used modes of non-invasive respiratory support (NRS), continuous positive airway pressure (CPAP) and high-flow nasal cannula therapy (HFNC). FIRST-line support for assistance in breathing in children is a master protocol of two pragmatic non-inferiority RCTs to evaluate the clinical and cost-effectiveness of HFNC (compared with CPAP) as the first-line mode of support in critically ill children.Methods and analysisWe will recruit participants over a 30-month period at 25 UK paediatric critical care units (paediatric intensive care units/high-dependency units). Patients are eligible if admitted/accepted for admission, aged >36 weeks corrected gestational age and <16 years, and assessed by the treating clinician to require NRS for an acute illness (step-up RCT) or within 72 hours of ext...

BMJ Paediatrics Open

ObjectiveDespite little evidence, the practice of routine gastric residual volume (GRV) measureme... more ObjectiveDespite little evidence, the practice of routine gastric residual volume (GRV) measurement to guide enteral feeding in neonatal units is widespread. Due to increased interest in this practice, and to examine trial feasibility, we aimed to determine enteral feeding and GRV measurement practices in British neonatal units.Design and settingAn online survey was distributed via email to all neonatal units and networks in England, Scotland and Wales. A clinical nurse, senior doctor and dietitian were invited to collaboratively complete the survey and submit a copy of relevant guidelines.Results95/184 (51.6%) approached units completed the survey, 81/95 (85.3%) reported having feeding guidelines and 28 guidelines were submitted for review. The majority of units used intermittent (90/95) gastric feeds as their primary feeding method. 42/95 units reported specific guidance for measuring and interpreting GRV. 20/90 units measured GRV before every feed, 39/90 at regular time intervals...

Health Technology Assessment

Background The routine measurement of gastric residual volume to guide the initiation and deliver... more Background The routine measurement of gastric residual volume to guide the initiation and delivery of enteral feeding is widespread in paediatric intensive care and neonatal units, but has little underlying evidence to support it. Objective To answer the question: is a trial of no gastric residual volume measurement feasible in UK paediatric intensive care units and neonatal units? Design A mixed-methods study involving five linked work packages in two parallel arms: neonatal units and paediatric intensive care units. Work package 1: a survey of units to establish current UK practice. Work package 2: qualitative interviews with health-care professionals and caregivers of children admitted to either setting. Work package 3: a modified two-round e-Delphi survey to investigate health-care professionals’ opinions on trial design issues and to obtain consensus on outcomes. Work package 4: examination of national databases to determine the potential eligible populations. Work package 5: t...

Journal of Parenteral and Enteral Nutrition

Background: Choosing trial outcome measures is important. When outcomes are not clinically releva... more Background: Choosing trial outcome measures is important. When outcomes are not clinically relevant or important to parents/patients, trial evidence is less likely to be implemented into practice. This study aimed to determine optimal outcome measures for a trial of no routine gastric residual volume (GRV) measurement in critically ill children. Methods: A mixed-methods approach was used: a focused literature review, parent and clinician interviews, a modified 2-round Delphi, and a stakeholder consensus meeting. Results: The review generated 13 outcomes. Fourteen pediatric intensive care unit (PICU) parents proposed 3 additional outcomes; these 16 were then rated by 28 clinicians in Delphi round 1. Six further outcomes were proposed, and 22 outcomes were rated in the second round. No items were voted "consensus out." The 18 "no-consensus" items were voted in a face-to-face meeting by 30 participants. The final 12 outcome measures were time to reach energy targets, ventilator-associated pneumonia, vomiting, time enteral feeds withheld per 24 hours, necrotizing enterocolitis, length of invasive ventilation, PICU length of stay, mortality, change in weight and markers of feed intolerance (parenteral nutrition administered), feed formula altered, and change to postpyloric feeds all secondary to feed intolerance. Conclusion: We have identified 12 outcomes for a trial of no GRV measurement through a multistage process, seeking views of parents and clinicians.

Intensive Care Medicine

Background: Nutritional support is considered essential for the outcome of paediatric critical il... more Background: Nutritional support is considered essential for the outcome of paediatric critical illness. There is a lack of methodologically sound trials to provide evidence-based guidelines leading to diverse practices in PICUs worldwide. Acknowledging these limitations, we aimed to summarize the available literature and provide practical guidance for the paediatric critical care clinicians around important clinical questions many of which are not covered by previous guidelines. Objective: To provide an ESPNIC position statement and make clinical recommendations for the assessment and nutritional support in critically ill infants and children. Design: The metabolism, endocrine and nutrition (MEN) section of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) generated 15 clinical questions regarding different aspects of nutrition in critically ill children. After a systematic literature search, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was applied to assess the quality of the evidence, conducting meta-analyses where possible, to generate statements and clinical recommendations, which were then voted on electronically. Strong consensus (> 95% agreement) and consensus (> 75% agreement) on these statements and recommendations was measured through modified Delphi voting rounds. Results: The final 15 clinical questions generated a total of 7261 abstracts, of which 142 publications were identified relevant to develop 32 recommendations. A strong consensus was reached in 21 (66%) and consensus was reached in 11 (34%) of the recommendations. Only 11 meta-analyses could be performed on 5 questions. Conclusions: We present a position statement and clinical practice recommendations. The general level of evidence of the available literature was low. We have summarised this and provided a practical guidance for the paediatric critical care clinicians around important clinical questions.

Journal of the Intensive Care Society

Introduction Despite potential benefits, it is not known how widely physiotherapists use mechanic... more Introduction Despite potential benefits, it is not known how widely physiotherapists use mechanical insufflation-exsufflation devices on UK adult intensive care units. This survey aimed to describe mechanical insufflation-exsufflation use in UK adult intensive care units. Methods Cross-sectional electronic survey of physiotherapists working in a permanent post on adult intensive care units. Results One hundred and sixty-six complete surveys were available for analysis, reflecting a diverse geographical spread. Nearly all (98%; 163/166) clinicians had access to mechanical insufflation-exsufflation. The estimated frequency of use varied, with the majority reporting weekly or monthly use (52/163, 32%; 50/163, 31%, respectively). Nearly all clinicians (99%) used mechanical insufflation-exsufflation with extubated patients. In contrast, around half of respondents (86/163, 53%) used mechanical insufflation-exsufflation with intubated patients, with a range of perceived barriers reported. ...

Journal of Intensive Care Medicine

Purpose: In the United Kingdom, critically ill adolescents are treated in either adult or pediatr... more Purpose: In the United Kingdom, critically ill adolescents are treated in either adult or pediatric intensive care units (AICUs or PICUs). This study explores staff perspectives on where and how best to care for this distinct group. Materials and Methods: Semistructured interviews were conducted with 12 members of staff (3 medical, 6 nursing, and 3 allied health professionals) working in 4 ICUs; 2 general hospital AICUs and 2 tertiary centre–based PICUs in England. Interviews were audio-recorded, transcribed, and analyzed using framework analysis. Findings: One overarching theme was identified, reflecting staff understanding of the term “adolescent,” and this was linked to 2 further themes, each of which had several subthemes. “Needs of the critically ill adolescent” included medical needs, dignity and privacy, issues around consent, and the impact of intensive care admission. “Implications for staff” included managing parental presence and lack of familiarity, and emotional impact,...

Archives of Disease in Childhood

ObjectiveTo identify parents’ prioritised outcomes by combining qualitative findings from two tri... more ObjectiveTo identify parents’ prioritised outcomes by combining qualitative findings from two trial feasibility studies of interventions for paediatric suspected severe infection.DesignQualitative synthesis combining parent interview data from the Fluids in Shock (FiSh) and Fever feasibility studies. Parents had experience of their child being admitted to a UK emergency department or intensive care unit with a suspected infection.Participantsn=: 85 parents. FiSh study: n=41 parents, 37 mothers, 4 fathers, 7 were bereaved. Fever study: n=44 parents, 33 mothers, 11 fathers, 7 were bereaved.ResultsIn addition to survival, parents prioritised short-term outcomes including: organ and physiological functioning (eg, heart rate, breathing rate and temperature); their child looking and/or behaving more like their normal self; and length of time on treatments or mechanical support. Longer term prioritised outcomes included effects of illness on child health and development. We found that pare...