A Retrospective Cohort Study Comparing Outcomes of Pediatric Intensive Care Patients after Changing from Higher to Permissive Blood Pressure Targets

New neurological morbidity post pediatric intensive care (PIC) poses substantial problems, with a need to understand the relationship of outcome to blood pressure (BP) targets. The aim of the study is to see whether a change from a higher BP targeted strategy to a permissive one improved outcomes for development of new neurological morbidity, length of stay (LOS), and PIC-acquired infection. A retrospective cohort analysis was undertaken, comparing outcomes before and after the change. The higher BP cohort targets were set using standardized age-based centiles. In the permissive cohort, lower BPs were allowed, dependent on physiological variables. Targeted treatment continued throughout the critical illness. New neurological morbidity was defined as any deterioration from baseline, attributable to the admission, measured by post discharge clinical and records review over a minimum period of 4 years. Results were analyzed with IBM SPSS Statistics v26. Of 123 admissions in the permissive and 214 admissions in the higher BP target cohorts, 88 (72%) and 188 (88%) survived without new neurological morbidity (permissive vs. higher cohort OR 0.348 [95% CI 0.197–0.613] p <0.001). Median LOS was 2 (interquartile [IQ] range 2–5) and 3 (IQ range 2–6) days for the permissive and higher cohorts, respectively (p = 0.127). Three (2.4%) and 7 (3.3%) admissions in the permissive and higher BP cohorts respectively suffered PIC-acquired infection (p = 0.666). A higher BP targeted strategy was associated with protection from new neurological morbidity as compared with a permissive strategy, supporting the need for prospective studies into BP targets.

An exploratory study of the experiences and challenges faced by advanced life support paramedics in the milieu of neonatal transfers

Background

The safe transfer of critically ill neonates is important for their survival. This calls for greater preparedness on the part of paramedics to effect these transfers safely.

Aim

To understand the experiences and the challenges faced by advanced life support (ALS) paramedics during neonatal transfers.

Setting

The study setting consisted of advanced life support paramedics from urban and rural areas in KwaZulu-Natal. It comprised of a network of district hospitals as well air and ground transfer facilities, both public and private.

Method

Using a qualitative research approach, the study sought the views of ALS paramedics who were involved in neonatal transfers in KwaZulu-Natal. A purposive sample of n = 8 ALS paramedics was selected. Data were collected using in-depth semi-structured interviews. The data were analysed through the process of thematic analysis.

Results

The study found that paramedics faced multiple complex challenges related to neonatal transfers. Poor pre-transfer preparation of the neonate, equipment related challenges, lack of clinical support available during transfers and pressure to effect inappropriate transfers were some of the challenges they faced. These challenges coupled with insufficient education and the lack of sub-speciality programmes to capacitate, rendered them unprepared to deal with neonatal transfers effectively.

Conclusion

Emergency medicine needs to provide greater attention towards preparing all stakeholders for successful neonatal transfers.

Contribution

The findings provide recommendations for a programme that will limit risks involved with, and support the inter-healthcare facility transfer of critically ill neonates in South Africa.