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Survey highlights risk to babies and children in intensive care units

2018-08-16
Recommendations to implement standardised monitoring of breathing in intensive care units have not been put into practice consistently following a 2011 landmark study


August 16, 2018, LONDON, UK. Press Dispensary. A new survey published today, Thursday 16 August 2018, in the journal Anaesthesia, highlights that variations in the practice of airway management in intensive care units across the UK are putting children and particularly newborn babies at risk. The PIC-NIC survey, led by doctors at the Royal United Hospitals Bath NHS Foundation Trust, found that lessons from a landmark study in 2011 have not been put into practice in all paediatric intensive care units (PICUs) and neonatal intensive care units (NICUs). Most respondents (98% of NICUs and 75% of PICUs) reported that they were unaware of the study (titled the 4th National Audit Project or NAP4).

The NAP4 study, by the Royal College of Anaesthetists (RCoA) and the Difficult Airway Society (DAS), studied major complications of airway management (establishing and maintaining a patient on a ventilator). It found that the absence of a simple method of monitoring breathing, called capnography, contributed to 74% of deaths from these events. The NAP4 authors recommended universal use of capnography in intensive care units together with changes in policy, equipment provision and training to improve airway safety. These recommendations have been largely adopted in adult intensive care units in the UK.

Key findings from the PIC-NIC survey team, who interviewed staff from all of the UK’s PICUs and 90% of the NICUs, include:

 The recommendations from NAP4 have not been widely implemented in NICUs. Despite capnography now being used in almost 100% of adult ICUs, as a direct result of the 2011 study, only 47% of NICUs have capnography available and it is rarely used.

 Some of the recommendations from NAP4 have been implemented in PICUs but not all. For example, 78% of PICUs and 34% NICUs do not formally identify patients with a difficult airway at staff handover. This is reflected by the relatively low number of units (40% of NICUs and 67% of PICUs) with protocols for high risk patients in place compared to 90% of adult ICUs.

 Of the 129 NICUs and 27 PICUs who responded to the survey, 34 of the NICUs and 5 of the PICUs reported death or serious harm in their unit as a result of complications of airway management in the last five years.

Speaking about the PIC-NIC survey findings, Dr Fiona Kelly, a consultant in Anaesthesia and Intensive Care Medicine at the Royal United Hospitals Bath NHS Foundation Trust, and one of the report authors, said: “The findings of this survey indicate that the NAP4 recommendations have been adopted into routine practice by many paediatric intensive care units, but into only a small number of neonatal intensive care units. There are many differences between adult, paediatric and especially neonatal practice but monitoring the breathing of a patient who is dependent on a ventilator is fundamental to safe practice in any ICU. Capnography, which detects exhaled carbon dioxide breath by breath, is a simple tool and can detect misplaced tubes or disconnections from a ventilator. It is of concern that this technology is only used in a few NICUs. This variation in practice, which is potentially putting lives at risk, merits further investigation.”

Prof Tim Cook, a Consultant in Anaesthesia and Intensive Care Medicine at the Royal United Hospital Bath NHS Foundation Trust, and another report author, said: “We recommend that lessons from adult ICUs are shared widely with our NICU and PICU colleagues and hope that this survey will prompt discussion about the feasibility of routine capnography monitoring. In particular we hope that the NICUs where capnography is already being used can share best practice with other colleagues to help implement this important technology more widely. In the case of low weight neonates, more research is needed to establish the utility of capnography and improve reliability of care. The current situation of half of UK NICUs using capnography and it not being available in the other half needs addressing.”

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Notes for editors

The survey is called: ‘United Kingdom Paediatric and Neonatal Intensive Care Airway Management: the ‘PIC-NIC survey’ and is published in the journal Anaesthesia on Thursday, 16 August and is available at: https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14359 .

Authors of the report are
K.E. Foy,(1) E. Mew,(1) T. M. Cook,(1) J. Bower,(1) P. Knight,(2) S. Dean,(2) K. Herneman,(3) B. Marden,(4) F. E. Kelly.(1)

1. Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals, Bath NHS Foundation Trust, UK
2. Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, UK
3. Department of Anaesthesia, Southmead Hospital, Bristol, UK
4. Neonatal Intensive Care Unit, Royal United Hospitals Bath NHS Foundation Trust, UK

About the journal Anaesthesia
Anaesthesia is the official journal of the Association of Anaesthetists of Great Britain and Ireland and is international in scope and comprehensive in coverage. It publishes original, peer-reviewed articles on all aspects of general and regional anaesthesia, intensive care and pain therapy. Its Impact Factor for 2018 is 5.4 and it is 3rd out of 31 (Anesthesiology) in the ISI Journal Citation Reports © Ranking.

About The Association of Anaesthetists
As the professional membership organisation for over 11,000 anaesthetists in the UK and Republic of Ireland, the Association of Anaesthetists promotes patient care and safety, and advances anaesthesia through education, publications, research and international work, as well as the professional aspects of the specialty. The Association maintains an active programme of support for anaesthesia worldwide, especially in low- and middle-income countries. Our motto in somno securitas (safe in sleep) encapsulates the major focus of the Association: safety in anaesthesia www.aagbi.org.

Technical details
Capnography
A capnograph measures how much carbon dioxide is present in the patient’s breath and helps confirm that the lungs are being adequately ventilated. They are an essential piece of monitoring and you can find them in areas such as operating rooms, recovery, critical care, wards, and ambulances.

For further information please contact
Amelia Lyons, Press Officer
AAGBI
Tel: 07989 748 477
Email:

Stephanie Addington, Marketing and Communications Manager
AAGBI
Tel: + 44 (0) 20 7631 8854
Email:

Survey: https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14359 .

Media contacts

Amelia Lyons, Press Officer
Tel: 07989 748 477
Email:

Stephanie Addington, Marketing and Communications Manager
AAGBI
Tel: + 44 (0) 20 7631 8854
Email:

Survey: https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14359 .

Keywords/tags
neonatal monitoring neonatal deaths intensive care paediatric intensive care neonatal intensive care capnography airway management ventilator monitoring Anaesthesia AAGBI anaesthetists association

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