Measuring Physical Function in the PICU: Development and Testing of a Children's Version (Age 2-18 yr) of the Chelsea Critical Care Physical Assessment Tool.

OBJECTIVES: To adapt and develop a reliable and easily administered outcome measure of physical and respiratory function in critically ill children in the PICU. DESIGN: Modified Delphi study to adapt the Chelsea Critical Care Physical Assessment (CPAx) tool for use in children 2-18 years old, with subsequent prospective testing in a single-center cohort. SETTING: Single-center tertiary PICU. SUBJECTS: Delphi process in 27 panelists (including physiotherapists, occupational therapists, and pediatric intensivists from seven countries from January 2018 to March 2018). Cohort study in 54 patients admitted to PICU for greater than 24 hours over a 3-month period (April 2018 to June 2018), with median age 5.5 years (interquartile range [IQR], 3-12.75 yr), 33 of 54 male, and 38 of 54 invasively ventilated. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Three Delphi iterations were required to reach greater than or equal to 80% consensus in all the children's CPAx (cCPAx) items. In the subsequent cohort study, six physiotherapists used the cCPAx tool and scored 54 participants, with a total 106 observations. The median cCPAx tool score was 14.50 (IQR, 3-25) out of a possible total of 50. Inter-rater reliability for 30 randomly selected participants was excellent (intraclass correlation coefficient, 0.998). Completion rate of cCPAx in the 54 patients occurred in 78 of 106 occasions (74%). CONCLUSIONS: The cCPAx tool content that was developed using Delphi methodology provided a feasible and clinically relevant tool for use in assessing physical morbidity in PICU patients 2-18 years old. Overall, the cCPAx scores were low, demonstrating low levels of physical function and high levels of immobility during PICU care.

Surgeon's practices and beliefs in Australia and New Zealand regarding the donor site wound for paediatric skin grafts.

AIM: Children's burns care in Australasia is performed by paediatric surgeons and by plastic surgeons. The aim was to determine practices regarding the donor site wound (DSW), and to explore any differences by training scheme or nature of unit (paediatric vs. mixed). METHODS: Online survey of Australasian burns surgeons. RESULTS: Forty surgeons responded. 23/40 paediatric surgeons, 23/40 worked in a stand-alone children's burns unit. All used powered dermatomes. Alginates were the most common DSW dressing. Idealised dressings favour patient factors over cost. Plastic, and mixed-practice, surgeons use a broader range of dermatome settings in children >1 year. Mixed practice surgeons use thicker settings. All surgeons see pain as a common DSW problem. Paediatric surgeons recognise itch as a problem. CONCLUSIONS: While there are differences related to training scheme and the mix of patients being treated, there is a broader commonality of practice.

Prospective randomised controlled trial of Algisite™ M, Cuticerin™, and Sorbact® as donor site dressings in paediatric split-thickness skin grafts.

BACKGROUND: This is a parallel three-arm prospective randomised controlled trial (RCT) comparing Algisite™ M, Cuticerin™, and Sorbact® as donor site dressings in paediatric split-thickness skin grafts (STSG). All three were in current use within the Pegg Leditschke Children's Burn centre (PLCBC), the largest paediatric burns centre in Queensland, Australia. Our objective was to find the best performing dressing, following on from previous trials designed to rationalise dressings for the burn wound itself. METHODS: All children for STSG, with thigh donor sites, were considered for enrolment in the trial. Primary outcome measures were days to re-epithelialisation, and pain. Secondary measures were cost, itch, and scarring at 3 and 6 months. Patients and parents were blinded to group assignment. Blinding of assessors was possible with the dressing in situ, with partial blinding following first dressing change. Blinded photographic assessments of re-epithelialisation were used. Scar assessment was blinded. Covariates for analysis were sex, age, and graft thickness (as measured from a central biopsy). RESULTS: There were 101 patients randomised to the Algisite™ M (33), Cuticerin™ (32), and Sorbact® (36) arms between April 2015 and July 2016. All were analysed for time to re-epithelialisation. Pain scores were not available for all time points in all patients. There were no significant differences between the three arms regarding pain, or time to re-epithelialisation. There were no significant differences for the secondary outcomes of itch, scarring, or cost. Regression analyses demonstrated faster re-epithelialisation in younger patients and decreased donor site scarring at 3 and 6 months with thinner STSG. There were no adverse effects noted. CONCLUSIONS: There are no data supporting a preference for one trial dressing over the others, in donor site wounds (DSW) in children. Thinner skin grafts lead to less donor site scarring in children. Younger patients have faster donor site wound healing. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ACTRN12614000380695).Royal Children's Hospital Human Research Ethics Committee (HREC/14/QRCH/36).University of Queensland Medical Research Ethics Committee (#2014000447).

Paediatric horse-related trauma.

AIM: This retrospective cohort study reported on the epidemiology of horse-related injuries for patients presenting to the only tertiary paediatric trauma hospital in Queensland. The secondary outcome was to examine the use of helmets and adult supervision. Traumatic brain injury (TBI) was examined in relation to helmet use. Morbidity and mortality were also recorded. METHODS: Included were all patients presenting with any horse-related trauma to the Royal Children's Hospital in Brisbane from January 2008 to August 2014. Data were retrospectively collected on patient demographics, hospital length of stay (LOS), mechanism of injury (MOI), safety precautions taken, diagnoses and surgical procedures performed. RESULTS: Included in the analysis were 187 incidents involving 171 patients. Most patients were aged 12-14 years (36.9%) and female (84.5%). The most common MOI were falls while riding horses (97.1%). Mild TBI (24.6%) and upper limb fractures (20.9%) were common injuries sustained. Patients who wore helmets had significantly reduced hospital LOS and severity of TBI when compared with those who did not wear helmets (P < 0.001 and P = 0.028, respectively). Morbidity was reported in 7.5% of patients. There were three deaths in Queensland. CONCLUSION: Helmet use is recommended for non-riders when handling horses, in addition to being a compulsory requirement whilst horse riding. Prompts in documentation may assist doctors to record the use of safety attire and adult supervision. This will allow future studies to further investigate these factors in relation to clinical outcomes.

3D photography is a reliable method of measuring infantile haemangioma volume over time.

BACKGROUND: Infantile haemangiomas are common lesions of infancy. With the development of novel treatments utilised to accelerate their regression, there is a need for a method of assessing these lesions over time. Volume is an ideal assessment method because of its quantifiable nature. This study investigated whether 3D photography is a valid tool for measuring the volume of infantile haemangiomas over time. METHOD: Thirteen children with infantile haemangiomas presenting to the Vascular Anomalies Clinic, Royal Children's Hospital/Lady Cilento Children's Hospital treated with propranolol were included in the study. Lesion volume was assessed using 3D photography at presentation, one month and three months follow up. Intrarater reliability was determined by retracing all images several months after the initial mapping. Interrater reliability of the 3D camera software was determined by two investigators, blinded to each other's results, independently assessing infantile haemangioma volume. RESULTS: Lesion volume decreased significantly between presentation and three-month follow-up (p<0.001). Volume intra- and interrater reliability were excellent with ICC 0.991 (95% CI 0.982, 0.995) and 0.978 (95% CI 0.955, 0.989), respectively. CONCLUSION: This study demonstrates images taken with the 3D LifeViz™ camera and lesion volume calculated with Dermapix® software is a reliable method for assessing infantile haemangioma volume over time.

Hot Beverage Scalds in Australian Children: Still Simmering 10 Years On.

The objectives of this study are to describe the proportion, mechanism, severity, and outcomes of hot beverage scald injuries in children presenting at a major burns centre in 2013 and to compare these results with data collected at the same centre 10 years before. A cross-sectional trend analysis was performed to determine the differences in proportion, mechanism, severity, and outcomes of hot beverage scalds in 0-year to 14-year old children presenting to the Stuart Pegg Paediatric Burns Centre, Royal Children's Hospital, Brisbane, Australia, between January 1 and December 31, 2013 and compare these data to presentations at the same burns centre between 1999 and 2002. Of the 759 children treated for burns and scald injuries at Stuart Pegg Paediatric Burns Centre in 2013, 133 (18%) were caused by hot beverages. Although there has been no change in the proportion, injury mechanism or age groups affected in the past 10 years, there has been a significant change in the number of children being admitted to hospital (52% vs 11% in 2013, P < .001), requiring split skin grafts (18% vs 5% in 2013, P < .05), and long-term scar management (26% vs 11% in 2013, P < .05). The decrease in admissions, skin grafts, and scar management requirements can be attributed to several factors; moving from silver sulfadiazine to silver-impregnated dressings at SPBBC from 2003, changes in excision and skin grafting practices, modified referral patterns, a move to non-inpatient care for minor burns, and the increased application of first aid. However, what has not changed is hot beverage scalds remain the leading cause of childhood burns making it a major pediatric public health issue.

Efficacy and safety of normal saline instillation: a systematic review.

OBJECTIVE: To investigate the efficacy and safety of the technique of instillation of normal saline prior to suction of airways in intubated patients. DATA SOURCES: Databases searched included: MEDLINE, CINAHL, EMBASE, Cochrane Controlled Trials Register and Full text clinicians' health journals @ Ovid from the earliest time to March 2009. Citation tracking of relevant primary and review articles. REVIEW METHODS: All randomised controlled trials, crossover trials, quasi- and full systematic reviews were screened. From 65 articles screened, 17 articles (two quasi-systematic reviews and 15 empirical studies) met the eligibility criteria and were included for data extraction. The outcomes in the reviewed studies included oxygenation, lung mechanics, sputum yield, dyspnoea, tube patency and ventilator-associated pneumonia. Effect sizes and 95% confidence intervals were calculated. RESULTS: Studies were mainly of low methodological quality due to factors such as lack of assessor blinding and within-group-only statistics. Overall, there was a positive effect favouring the use of saline to increase sputum yield (d=0.50, 95% confidence interval 0.10 to 0.90). Due to heterogeneity of methodology, it was not possible to perform meta-analyses on haemodynamics, oxygenation, tube patency and ventilator-associated pneumonia. Overall, while a decrease was found in oxygen saturation measured by pulse oximetry (SpO(2)) following instillation of normal saline compared with no saline, this was of limited clinical significance. CONCLUSIONS: The results of this review reflect the poor quality of available articles on instillation of normal saline prior to suction of artificial airways. There is little evidence of benefit but also minimal evidence of safety risks. Controlled trials of better quality and more clinically relevant outcomes need to be performed before this technique is either accepted or rejected.

Effect of multiple physiotherapy sessions on functional outcomes in the initial postoperative period after primary total hip replacement: a randomized controlled trial.

UNLABELLED: Stockton KA, Mengersen KA. Effect of multiple physiotherapy sessions on functional outcomes in the initial postoperative period after primary total hip replacement: a randomized controlled trial. OBJECTIVE: To determine whether increasing physiotherapy input from once to twice per day will result in earlier achievement of functional milestones (ie, independence in mobility and transfers) and decreased length of stay (LOS) in patients undergoing a primary total hip replacement. DESIGN: Randomized controlled trial. SETTING: Metropolitan private hospital. PARTICIPANTS: Patients (N=57) with primary total hip replacement were randomly assigned to the twice daily (treatment, n=30) and once daily (control, n=27) groups. Patients who chose to attend hydrotherapy were excluded from the randomization process; however, they gave consent for outcome measures to be collected for comparison with the randomized groups. INTERVENTIONS: The control group received usual care, and the treatment group received twice-daily physiotherapy from day 1 after surgery to discharge. MAIN OUTCOME MEASURES: The Iowa Level of Assistance at postoperative days 3 and 6 and LOS. RESULTS: This study demonstrates that patients who received twice-daily land-based physiotherapy after primary total hip replacement attained earlier achievement of functional milestones than patients that received once-daily physiotherapy. A statistically significant (P=.041) but not clinically significant difference was evident in the Iowa Level of Assistance score at day 3. There was no difference between the groups in Iowa Level of Assistance measures on day 6 or on LOS. CONCLUSIONS: Patients who received twice-daily physiotherapy showed a trend toward earlier achievement of functional milestones; however, this finding did not translate to decreased LOS.