G55(P) Audit on Optimal Positioning of Peripherally Inserted Central Catheters in Neonates

Aims Changes in arm position has been known to cause migration of peripherally inserted central catheter (PICC) tips in neonates, however this relationship is poorly understood. An optimal placement of central catheter tip in neonates is essential to minimise life threatening complications like cardiac tamponade. This study aims to ascertain the relationship between arm position and central catheter tip displacement in neonates, with an aim to subsequently develop a clinical guideline on the optimal use of these lines by minimising catheter tip migration and its complications. Methods After ethical approval was granted by the Education Department at the Deanery, an audit was undertaken at a tertiary neonatal unit to collect data on paired radiographs in order to establish the relationship between the angle of the arm at the shoulder and correlating it with the location of the catheter tip as seen on plain radiography. The angle of the arm with respect to the midline of the body was carefully measured, and the location of the tip of the PICC lines was identified using agreed bony reference points, and its distance from the heart was measured. Paired X-rays (of the same baby) were compared with careful documentation of the perceived changes PICC line tip positions with respect to different angles of arm position. Results A total of 32 pairs of X-rays that met our criteria were reviewed. Arm movements were associated with catheter displacement. For catheters placed in the basilic vein, there was a mean displacement of 0.17mm/degree (–0.53 to +1.4) towards the heart on adduction and 0.1mm/degree (–0.46 to +0.4) away from the heart on abduction of the arm. Similarly, for the cephalic vein, there was a mean displacement of 0.34mm/degree (–0.53 to +1.6) towards the heart on adduction and 0.32mm/degree (–0.8 to +0.43) away from the heart on abduction of the arm. Conclusion Although this study did not establish any correlation in magnitude or direction, a clinically significant degree of catheter tip migration was observed with changes in arm position for each paired radiograph reviewed. A further prospective study under direct ultrasound visualisation is envisaged to study this relationship further.

Aims Changes in arm position has been known to cause migration of peripherally inserted central catheter (PICC) tips in neonates, however this relationship is poorly understood. An optimal placement of central catheter tip in neonates is essential to minimise life threatening complications like cardiac tamponade.
This study aims to ascertain the relationship between arm position and central catheter tip displacement in neonates, with an aim to subsequently develop a clinical guideline on the optimal use of these lines by minimising catheter tip migration and its complications. Methods After ethical approval was granted by the Education Department at the Deanery, an audit was undertaken at a tertiary neonatal unit to collect data on paired radiographs in order to establish the relationship between the angle of the arm at the shoulder and correlating it with the location of the catheter tip as seen on plain radiography. The angle of the arm with respect to the midline G54 G55(P) Background Status epilepticus is a neurological emergency and is refractory to standard treatment at times. New antiepileptic drugs have been introduced but the place of application of these drugs in status is yet to be established. Objective To compare efficacy and adverse effects of intravenous Valproate and intravenous Levetiracetam as second line anti-epileptic drugs in status epilepticus to intravenous Phenytoin. Methodology 42 patients between 6 months to 12 years presenting with status epilepticus were included in the study and randomly distributed in three groups depending on the day of admission and each group was assigned one of three drugs under study as second line anti-epileptic drug. The ability of the drug to stop convulsions as well as time taken to stop convulsions and adverse effects were noted. Analysis of the data was done using chi square test. Results 57% patients studied for phenytoin(12/21), 63% for valproate(7/11) and 80% for levitracetam(8/10) became non convulsive after the use of respective drugs. But on applying chi-square test, p value showed that the comparison was not significant. The average time taken to stop convulsions by phenytoin is 10 min, valproate is 10 min and by levetiracetam is 11 min, which again was not statistically significant. Only 2 out of 42(4.7%) developed minor adverse effects from phenytoin in the form of excessive drowsiness and irritability. Conclusion Clinically the efficacy of i.v. levetiracetam and i.v. valproate was found to be better than i.v. phenytoin but no statistically significant difference was observed. So phenytoin remains the preferred second-line anti-convulsant in status epilepticus with minimal side-effects. Aim To establish the frequency, amount and the diagnostic reasons for fluid bolus administration in children referred to a paediatric intensive care (PIC) retrieval service Methods Retrospective case notes review of all referrals to a PIC retrieval service between May and October 2012 (6 months). Data collected included demographic details, reason for PIC referral, and total amount of bolus fluids given at referral. Blood products were excluded from the total fluid bolus calculations. In children retrieved by the service, additional data on total amount of fluid boluses given during retrieval and patient acuity (need for invasive ventilation, vasoactive agent use and PIM-2 score) were analysed. Categorical data are reported as counts (percentages) and continuous data as mean (standard deviation) or median (inter-quartile range) as appropriate. Results During the 6-month study period, 1031 referrals were made to the retrieval service. At referral, 180 patients had received ≥20mls/kg of fluid boluses (17.5%) and 54 had received ≥40mls/kg (5.2%). The main diagnoses for which children were given fluid boluses ≥20mls/kg were sepsis (30%) and status epilepticus (21%). 548 children (53%) were retrieved to PICU. Patients receiving ≥40mls/kg by PICU admission had a median age of 14 months (IQR 2-47), were mostly male (60%), requiring invasive ventilation (98.3%) and vasoactive agents (61.5%). The median PIM-2 predicted risk of mortality was 10% (IQR 6-19%). A summary of total fluid administered at various time points is provided below in cases where a PIC retrieval team was mobilised (n = 548): Results Total infant PICU admissions due to infectious causes were greater in both male cohorts compared to female cohorts (M < 6-months = 3,592, F < 6-months = 2,468; M > 6-months = 1,020, F > 6-months = 781). However, female mortality due to infectious causes for admission was greater than male mortality in both the under 6-month cohort (F = 4.94%, M = 3.54%) and the over 6-month cohort (F = 6.27%, M = 5.10%). Conclusion Further analysis persistently displays increased female mortality percentages within both cohorts of infants. This recurrence is greater due to a greater population thereby; the expansion of data has yielded stronger correlations. With the help of PICANET epidemiologist, we are increasing this population size further and focusing on admissions related to respiratory infections.

G58(P)
of the body was carefully measured, and the location of the tip of the PICC lines was identified using agreed bony reference points, and its distance from the heart was measured. Paired X-rays (of the same baby) were compared with careful documentation of the perceived changes PICC line tip positions with respect to different angles of arm position. Results A total of 32 pairs of X-rays that met our criteria were reviewed. Arm movements were associated with catheter displacement. For catheters placed in the basilic vein, there was a mean displacement of 0.17mm/degree (-0.53 to +1.4) towards the heart on adduction and 0.1mm/degree (-0.46 to +0.4) away from the heart on abduction of the arm. Similarly, for the cephalic vein, there was a mean displacement of 0.34mm/degree (-0.53 to +1.6) towards the heart on adduction and 0.32mm/degree (-0.8 to +0.43) away from the heart on abduction of the arm. Conclusion Although this study did not establish any correlation in magnitude or direction, a clinically significant degree of catheter tip migration was observed with changes in arm position for each paired radiograph reviewed. A further prospective study under direct ultrasound visualisation is envisaged to study this relationship further. Objectives I set out to investigate how the workings of a complex medical device could be visually represented and documented on paper, and then be translated into computer code to produce an online model. The device chosen was a SiPAP® Infant Flow Driver (Carefusion, Ca) for providing nasal continuous positive airway pressure (NCPAP) ventilation to premature newborn infants. This device is used worldwide, and implements a touch screen control panel to set alarms and change settings. Methods Statechart theory was designed in the late 1980s to diagram flight systems. This system was easy to learn and facilitates the conceptualization and illustration of both simple and, with practise, complex processes.
The Model-View-Controller (MVC) design pattern is a software engineering framework that requires the separation of the user interface from the functionality of the system. Using this pattern, the device was mapped by producing not one, but two statechartsone for the user interface of the device, and the other for my perception of the inner workings.
Adobe Flash (Adobe, Ca) is a computer programme that is commonly used to create interactive multimedia web sites. Using the MVC design pattern I used FLASH to build up the physical 'View' of the device, and then coded the 'View Controller' and 'Model', by using the two statecharts as a map. Results I discovered that by using statecharts and the MVC design pattern, both the inner workings and the user interface of a complex medical device could be represented and documented, then coded into a highly realistic working online simulator. The next stage is to create and implement a statechart for both training and assessment and finally compare the effectiveness with traditional clinical learning in a trial. Conclusions Hi-fidelity online simulators of complex medical devices can be produced much more easily by harnessing the power of statechart theory with the flexibility of the Model-View-Controller design pattern. Additional info The online simulator can be viewed at www. sipap.net.