Fifteen-minute consultation: Pain relief for children made simple-a pragmatic approach to prescribing oral analgesia in the postcodeine era.

What are the most effective doses of simple oral analgesics such as paracetamol and ibuprofen for pain relief in children? Why can't I prescribe codeine phosphate for children anymore? Is oral morphine really a safe alternative to codeine phosphate, and if so what dose should I prescribe? These questions are frequently asked by clinicians who wish to give analgesics to children for pain relief. In this article I will address these questions and describe a pragmatic approach for pain relief using oral analgesics based on the best evidence available and my experience as a consultant paediatric anaesthetist.

Evaluation of suction detection during different pumping states in an implantable rotary blood pump.

In recent times, the problem of noninvasive suction detection for implantable rotary blood pumps has attracted substantial research interest. Here, we compare the performance of various suction indices for different types of suction and non-suction events based on pump speed irregularity. A total of 171 different indices that consist of previously proposed as well as newly introduced suction indices are tested using regularized logistic regression. These indices can be classified as amplitude based (derived from the mean, maximum, and minimum values of a cycle), duration based (derived from the duration of a cycle), gradient based (derived from the first order as well as higher order differences) and frequency based (derived from the power spectral density). The non-suction event data consists of ventricular ejection with or without arrhythmia and intermittent and continuous non-opening of the aortic valve. The suction event data consists of partial ventricular collapse that occurs intermittently as well as continuously with or without arrhythmia. In addition, we also attempted to minimize the usage of multiple indices by applying the sequential forward floating selection method to find which combination of indices gives the best performance. In general, the amplitude-based and gradient-based indices performed quite well while the duration-based and frequency-based indices performed poorly. By having only two indices ([i] the maximum gradient change in positive slope; and [ii] the standard deviation of the maximum value in a cycle), we were able to achieve a sensitivity of 98.9% and a specificity of 99.7%.

Developments in control systems for rotary left ventricular assist devices for heart failure patients: a review.

From the moment of creation to the moment of death, the heart works tirelessly to circulate blood, being a critical organ to sustain life. As a non-stopping pumping machine, it operates continuously to pump blood through our bodies to supply all cells with oxygen and necessary nutrients. When the heart fails, the supplement of blood to the body's organs to meet metabolic demands will deteriorate. The treatment of the participating causes is the ideal approach to treat heart failure (HF). As this often cannot be done effectively, the medical management of HF is a difficult challenge. Implantable rotary blood pumps (IRBPs) have the potential to become a viable long-term treatment option for bridging to heart transplantation or destination therapy. This increases the potential for the patients to leave the hospital and resume normal lives. Control of IRBPs is one of the most important design goals in providing long-term alternative treatment for HF patients. Over the years, many control algorithms including invasive and non-invasive techniques have been developed in the hope of physiologically and adaptively controlling left ventricular assist devices and thus avoiding such undesired pumping states as left ventricular collapse caused by suction. In this paper, we aim to provide a comprehensive review of the developments of control systems and techniques that have been applied to control IRBPs.

Children's surgery: a national survey of consultant clinical practice.

OBJECTIVES: To survey clinical practice and opinions of consultant surgeons and anaesthetists caring for children to inform the needs for training, commissioning and management of children's surgery in the UK. DESIGN: The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) hosted an online survey to gather data on current clinical practice of UK consultant surgeons and anaesthetists caring for children. SETTING: The questionnaire was circulated to all hospitals and to Anaesthetic and Surgical Royal Colleges, and relevant specialist societies covering the UK and the Channel Islands and was mainly completed by consultants in District General Hospitals. PARTICIPANTS: 555 surgeons and 1561 anaesthetists completed the questionnaire. RESULTS: 32.6% of surgeons and 43.5% of anaesthetists considered that there were deficiencies in their hospital's facilities that potentially compromised delivery of a safe children's surgical service. Almost 10% of all consultants considered that their postgraduate training was insufficient for current paediatric practice and 20% felt that recent Continued Professional Development failed to maintain paediatric expertise. 45.4% of surgeons and 39.2% of anaesthetists considered that the current specialty curriculum should have a larger paediatric component. Consultants in non-specialist paediatric centres were prepared to care for younger children admitted for surgery as emergencies than those admitted electively. Many of the surgeons and anaesthetists had <4 h/week in paediatric practice. Only 55.3% of surgeons and 42.8% of anaesthetists participated in any form of regular multidisciplinary review of children undergoing surgery. CONCLUSIONS: There are significant obstacles to consultant surgeons and anaesthetists providing a competent surgical service for children. Postgraduate curricula must meet the needs of trainees who will be expected to include children in their caseload as consultants. Trusts must ensure appropriate support for consultants to maintain paediatric skills and provide the necessary facilities for a high-quality local surgical service.

A method for control of an implantable rotary blood pump for heart failure patients using noninvasive measurements.

We propose a deadbeat controller for the control of pulsatile pump flow (Q(p) ) in an implantable rotary blood pump (IRBP). Noninvasive measurements of pump speed and current are used as inputs to a dynamical model of Q(p) estimation, previously developed and verified in our laboratory. The controller was tested using a lumped parameter model of the cardiovascular system (CVS), in combination with the stable dynamical models of Q(p) and differential pressure (head) estimation for the IRBP. The control algorithm was tested with both constant and sinusoidal reference Q(p) as input to the CVS model. Results showed that the controller was able to track the reference input with minimal error in the presence of model uncertainty. Furthermore, Q(p) was shown to settle to the desired reference value within a finite number of sampling periods. Our results also indicated that counterpulsation yields the minimum left ventricular stroke work, left ventricular end diastolic volume, and aortic pulse pressure, without significantly affecting mean cardiac output and aortic pressure.

Biventricular assist devices: a technical review.

The optimal treatment option for end stage heart failure is transplantation; however, the shortage of donor organs necessitates alternative treatment strategies such as mechanical circulatory assistance. Ventricular assist devices (VADs) are employed to support these cases while awaiting cardiac recovery or transplantation, or in some cases as destination therapy. While left ventricular assist device (LVAD) therapy alone is effective in many instances, up to 50% of LVAD recipients demonstrate clinically significant postoperative right ventricular failure and potentially need a biventricular assist device (BiVAD). In these cases, the BiVAD can effectively support both sides of the failing heart. This article presents a technical review of BiVADs, both clinically applied and under development. The BiVADs which have been used clinically are predominantly first generation, pulsatile, and paracorporeal systems that are bulky and prone to device failure, thrombus formation, and infection. While they have saved many lives, they generally necessitate a large external pneumatic driver which inhibits normal movement and quality of life for many patients. In an attempt to alleviate these issues, several smaller, implantable second and third generation devices that use either immersed mechanical blood bearings or hydrodynamic/magnetic levitation systems to support a rotating impeller are under development or in the early stages of clinical use. Although these rotary devices may offer a longer term, completely implantable option for patients with biventricular failure, their control strategies need to be refined to compete with the inherent volume balancing ability of the first generation devices. The BiVAD systems potentially offer an improved quality of life to patients with total heart failure, and thus a viable alternative to heart transplantation is anticipated with continued development.

Response of rotary blood pumps to changes in preload and afterload at a fixed speed setting are unphysiological when compared with the natural heart.

Responses of four rotary blood pumps (Incor, Heartmate II, Heartware, and Duraheart) at a single speed setting to changes in preload and afterload were assessed using the human left ventricle as a benchmark for comparison. Data for the rotary pumps were derived from pressure flow relations reported in the literature while the natural heart was characterized by the Frank-Starling curve adjusted to fit outputs at different afterloads reported in the literature. Preload sensitivity (mean ± SD) for all pumps at all afterloads tested was 0.105 ± 0.092 L/min/mm Hg, while afterload sensitivity was 0.09 ± 0.034 L/min/mm Hg-values that were not significantly different (t-test, P = 0.56). By contrast, preload sensitivity of the natural heart was over twice as high (0.213 ± 0.03 L/min/mm Hg) and afterload sensitivity about one-third (0.03 ± 0.01 L/min/mm Hg) the values recorded for rotary pumps (t-test, P < 0.001). Maximum preload sensitivity and minimum afterload sensitivity allow the right and left ventricles to synchronize outputs without neural or humoral intervention. This theoretical study reinforces the need to provide preload sensitive control mechanisms of sufficient power to enable the pump and left ventricle in combination to adapt to changes in right ventricular output automatically.

An improved cylindrical FDTD method and its application to field-tissue interaction study in MRI.

This paper presents a three dimensional finite-difference time-domain (FDTD) scheme in cylindrical coordinates with an improved algorithm for accommodating the numerical singularity associated with the polar axis. The regularization of this singularity problem is entirely based on Ampere's law. The proposed algorithm has been detailed and verified against a problem with a known solution obtained from a commercial electromagnetic simulation package. The numerical scheme is also illustrated by modeling high-frequency RF field-human body interactions in MRI. The results demonstrate the accuracy and capability of the proposed algorithm.

Adaptive multi-infusion decision support for the multivariable circulatory management of critically ill patients.

We have developed a novel adaptive multi-infusion advisory system for circulatory management of critically ill patients which co-ordinates infusion adjustments to ensure safe trajectories. This system should reduce patient hospital stay and improve patient outcome by enhancing the quality of patient circulatory control; alleviating the clinical cognitive load, giving staff more time for direct patient care, while also reducing infusion adjustment errors. We have applied three derived circulatory variables which relate to the three main types of cardiovascular infusions (inotropic, vasoactive and fluid). A lumped parameter steady flow model of the human circulatory system and the effects of cardiovascular infusions was constructed for algorithm development, clinical experts providing feedback on a representative test set of simulated patients in circulatory shock. Independent self-learning fuzzy logic controllers (SLFLC) were found to give good adaptation to variable patient infusion sensitivities. A supervisory, rule-based module co-ordinates infusion adjustments to ensure safe circulatory trajectories. Monitoring of manual infusion adjustments allows timely advice and also a critiquing capability which can train junior staff and reduce infusion adjustment errors. A physical mock circulatory loop was used to construct and test our physical advisory system. Preliminary clinical results show good clinical utility of our adaptive multi-infusion advisory system.

Development of a continuous multisite accelerometry system for studying movements during sleep.

Actigraphy has proven to be a useful tool in the assessment of circadian rhythms, and more recently in the automatic staging of sleep and wake states. Whilst accuracy of commercial systems appears good over 24 hour periods, the sensitivity of detecting wake during time in bed is poor. One possible explanation for these poor results is the technical limitations of currently available commercial actigraphs. In particular, raw data is generally not available to the user. Instead, activity counts for each epoch (typically between 10-60 secs) are calculated using various algorithms, from which sleep state is identified. Consequently morphologically different movements observed during sleep and wake states may not be detected as such. In this paper, the development of a continuous multisite, accelerometry system (CMAS) is described. Initial results, comparing data collected using a commercial actigraph (Actiwatch- Mini Motionlogger), and the continuous multisite accelerometry system are presented. The CMAS is able to differentiate brief movement "twitches" from postural changes.

Pediatric obstructive sleep apnea assessment using pulse oximetry and dual RIP bands.

The diagnosis of Obstructive Sleep Apnea (OSA) in children presents a challenging diagnostic problem given the high prevalence (2-3%), the resource intensity of the overnight polysomnography investigation, and the realisation that OSA poses a serious threat to the healthy growth and development of children. Previous attempts to develop OSA diagnostic systems using home pulse oximetry studies have failed to meet the accuracy requirements - particularly the low false normal rate (FNR) - required for a pre-PSG screening test. Thus the aim of this study is to investigate the feasibility of an OSA severity diagnostic system based on both oximetry and dual respiratory inductance plethysmography (RIP) bands. A total of 90 PSG studies (30 each of normal, mild/moderate and severe OSA) were retrospectively analyzed. Quantifications of oxygen desaturations (S), respiratory events (E) and heart rate arousals (A) were calculated and extracted and an empirical rule-based SEA classifier model for normal, mild/moderate and severe OSA defined and developed. In addition, an automated classifier using a decision tree algorithm was trained and tested using a 10-fold cross-validation. The empirical classification system showed a correct classification rate (CCR) of 0.83 (Cohen's Kappa κ=0.81, FNR=0.08), and the decision tree classifier achieved a CCR of 0.79 (κ=0.73, FNR=0.08) when compared to gold standard PSG assessment. The relatively high CCR, and low FNR indicate that a OSA severity system based on dual RIP and oximetry is feasible for application as a pre-PSG screening tool.

Noninvasive activity-based control of an implantable rotary blood pump: comparative software simulation study.

A control algorithm for an implantable centrifugal rotary blood pump (RBP) based on a noninvasive indicator of the implant recipient's activity level has been proposed and evaluated in a software simulation environment. An activity level index (ALI)-derived from a noninvasive estimate of heart rate and the output of a triaxial accelerometer-forms the noninvasive indicator of metabolic energy expenditure. Pump speed is then varied linearly according to the ALI within a defined range. This ALI-based control module operates within a hierarchical multiobjective framework, which imposes several constraints on the operating region, such as minimum flow and minimum speed amplitude thresholds. Three class IV heart failure (HF) cases of varying severity were simulated under rest and exercise conditions, and a comparison with other popular RBP control strategies was performed. Pump flow increases of 2.54, 1.94, and 1.15 L/min were achieved for the three HF cases, from rest to exercise. Compared with constant speed control, this represents a relative flow change of 30.3, 19.8, and -15.4%, respectively. Simulations of the proposed control algorithm exhibited the effective intervention of each constraint, resulting in an improved flow response and the maintenance of a safe operating condition, compared with other control modes.

Parameter-optimized model of cardiovascular-rotary blood pump interactions.

A lumped parameter model of human cardiovascular-implantable rotary blood pump (iRBP) interaction has been developed based on experimental data recorded in two healthy pigs with the iRBP in situ. The model includes descriptions of the left and right heart, direct ventricular interaction through the septum and pericardium, the systemic and pulmonary circulations, as well as the iRBP. A subset of parameters was optimized in a least squares sense to faithfully reproduce the experimental measurements (pressures, flows and pump variables). Our fitted model compares favorably with our experimental measurements at a range of pump operating points. Furthermore, we have also suggested the importance of various model features, such as the curvilinearity of the end systolic pressure-volume relationship, the Starling resistance, the suction resistance, the effect of respiration, as well as the influence of the pump inflow and outflow cannulae. Alterations of model parameters were done to investigate the circulatory response to rotary blood pump assistance under heart failure conditions. The present model provides a valuable tool for experiment designs, as well as a platform to aid in the development and evaluation of robust physiological pump control algorithms.

A survey of pediatric caudal extradural anesthesia practice.

BACKGROUND: Caudal extradural blockade is one of the most commonly performed procedures in pediatric anesthesia. However, there is little information available on variations in clinical practice. OBJECTIVES: To perform a survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland who undertake caudal anesthesia. METHODS: An 'online' World Wide Web questionnaire collected information on various aspects of clinical practice. The survey ran from April to June 2008. RESULTS: There were 366 questionnaires completed. The majority of respondents had >5 years of pediatric experience and performed up to ten caudal extradural procedures a month. The commonest device used was a cannula (69.7%) with 68.6% using a 22G device. There was a trend toward the use of a cannula in those anesthetists with <15 years experience, while those with >15 years experience tended to use a needle. Most anesthetists (91.5%) did not believe that there was a significant risk of implantation of dermoid tissue into the caudal extradural space. The majority used a combination of clinical methods to confirm correct placement. Only 27 respondents used ultrasound. The most popular local anesthetics were bupivacaine (43.4%) and levobupivacaine (41.7%). The most common additives were clonidine (42.3%) and ketamine (37.5%). The caudal catheter technique was used by 43.6%. Most anesthetists (74%) wear gloves for a single shot caudal injection. CONCLUSIONS: This survey provides a snapshot of current practice and acts a useful reference for the development of enhanced techniques and new equipment in the future.

Reliable suction detection for patients with rotary blood pumps.

All rotary blood pumps (RBPs) are prone to the harmful effects of ventricular collapse or "suction events" because of over-pumping, because they are inherently preload insensitive devices, yet RBP controllers do not comprise a clinically reliable suction detector. We therefore investigated the clinical performance of seven expertly selected time domain indices of suction based on the observed positive spike induced in the RBP impeller speed waveform. Using expert panel classifications, a balanced set of 404 five-second speed snapshots of normal and suction events was created from the impeller speed 25 Hz data in 12 VentrAssist implant patients. Initially, suction index threshold levels were set differently for each patient, giving best sensitivity 95% and specificity 99%. However, analysis of paired combinations of suction indices with fixed thresholds identified one pair giving an acceptable sensitivity of 99.5% and specificity 97.5%; the low number of high speed data samples relative to the speed snapshot mean and maximum OR the largest increase in successive speed maxima. The additional precondition of RBP speed amplitude exceeding a low threshold level allows its more general application to patients with low cardiac contractility. This gives a suction detector with high clinical utility; requiring three index threshold settings only.

Noninvasive average flow and differential pressure estimation for an implantable rotary blood pump using dimensional analysis.

Accurate noninvasive average flow and differential pressure estimation of implantable rotary blood pumps (IRBPs) is an important practical element for their physiological control. While most attempts at developing flow and differential pressure estimate models have involved purely empirical techniques, dimensional analysis utilizes theoretical principles of fluid mechanics that provides valuable insights into parameter relationships. Based on data obtained from a steady flow mock loop under a wide range of pump operating points and fluid viscosities, flow and differential pressure estimate models were thus obtained using dimensional analysis. The algorithm was then validated using data from two other VentrAssist IRBPs. Linear correlations between estimated and measured pump flow over a flow range of 0.5 to 8.0 L/min resulted in a slope of 0.98 ( R(2) = 0.9848). The average flow error was 0.20 +/- 0.14 L/min (mean +/- standard deviation) and the average percentage error was 5.79%. Similarly, linear correlations between estimated and measured pump differential pressure resulted in a slope of 1.027 ( R(2) = 0.997) over a pressure range of 60 to 180 mmHg. The average differential pressure error was 1.84 +/- 1.54 mmHg and the average percentage error was 1.51%.

Noninvasive pulsatile flow estimation for an implantable rotary blood pump.

A noninvasive approach to the task of pulsatile flow estimation in an implantable rotary blood pump (iRBP) has been proposed. Employing six fluid solutions representing a range of viscosities equivalent to 20-50% blood hematocrit (HCT), pulsatile flow data was acquired from an in vitro mock circulatory loop. The entire operating range of the pump was examined, including flows from -2 to 12 L/min. Taking the pump feedback signals of speed and power, together with the HCT level, as input parameters, several flow estimate models were developed via system identification methods. Three autoregressive with exogenous input (ARX) model structures were evaluated: structures I and II used the input parameters directly; structure II incorporated additional terms for HCT; and the third structure employed as input a non-pulsatile flow estimate equation. Optimal model orders were determined, and the associated models yielded minimum mean flow errors of 5.49% and 0.258 L/min for structure II, and 5.77% and 0.270 L/min for structure III, when validated on unseen data. The models developed in this study present a practical method of accurately estimating iRBP flow in a pulsatile environment.

A dynamic lumped parameter model of the left ventricular assisted circulation.

A lumped parameter model of the cardiovascular system (CVS) and its interaction with an implantable rotary blood pump (iRBP) is presented. The CVS model consists of the heart, the systemic and the pulmonary circulations. The pump model is made up of three differential equations, i.e. the motor equation, the torque equation and the hydraulic equation. Qualitative comparison with data from ex vivo porcine experiments suggests that the model is able to simulate different physiologically significant pumping states with varying pump speed set points. The combined CVS-iRBP model is suitable for use as a tool for investigating changes in the circulatory system parameters in the presence of the pump, and for testing control algorithms.

Classification of physiologically significant pumping states in an implantable rotary blood pump: patient trial results.

An integral component in the development of a control strategy for implantable rotary blood pumps is the task of reliably detecting the occurrence of left ventricular collapse due to overpumping of the native heart. Using the noninvasive pump feedback signal of impeller speed, an approach to distinguish between overpumping (or ventricular collapse) and the normal pumping state has been developed. Noninvasive pump signals from 10 human pump recipients were collected, and the pumping state was categorized as either normal or suction, based on expert opinion aided by transesophageal echocardiographic images. A number of indices derived from the pump speed waveform were incorporated into a classification and regression tree model, which acted as the pumping state classifier. When validating the model on 12,990 segments of unseen data, this methodology yielded a peak sensitivity/specificity for detecting suction of 99.11%/98.76%. After performing a 10-fold cross-validation on all of the available data, a minimum estimated error of 0.53% was achieved. The results presented suggest that techniques for pumping state detection, previously investigated in preliminary in vivo studies, are applicable and sufficient for use in the clinical environment.