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Background Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children. Methods Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document. Results Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C). Conclusions Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

Background Cardiovascular instability is common in critically ill children. There is a scarcity of published high-quality studies to develop meaningful evidence-based hemodynamic monitoring guidelines and hence, with the exception of management of shock, currently there are no published guidelines for hemodynamic monitoring in children. The European Society of Paediatric and Neonatal Intensive Care (ESPNIC) Cardiovascular Dynamics section aimed to provide expert consensus recommendations on hemodynamic monitoring in critically ill children. Methods Creation of a panel of experts in cardiovascular hemodynamic assessment and hemodynamic monitoring and review of relevant literature—a literature search was performed, and recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. The AGREE statement was followed to prepare this document. Results Of 100 suggested recommendations across 12 subgroups concerning hemodynamic monitoring in critically ill children, 72 reached “strong agreement,” 20 “weak agreement,” and 2 had “no agreement.” Six statements were considered as redundant after rephrasing of statements following the first round of voting. The agreed 72 recommendations were then coalesced into 36 detailing four key areas of hemodynamic monitoring in the main manuscript. Due to a lack of published evidence to develop evidence-based guidelines, most of the recommendations are based upon expert consensus. Conclusions These expert consensus-based recommendations may be used to guide clinical practice for hemodynamic monitoring in critically ill children, and they may serve as a basis for highlighting gaps in the knowledge base to guide further research in hemodynamic monitoring.

We compared the long-term outcomes of pediatric kidney transplants from DCD and DBD donors over a 33-year period in the USA. Data were retrieved and analysed on kidney transplants from deceased donors in paediatric recipients in 1994–2020 from the OPTN. Data were compared between those receiving kidney transplants from DBD and DCD donors. There were 11,071 paediatric kidney transplants from deceased donors including 350 from DCD donors. DCD transplants were more likely to have delayed allograft function (20.1% vs. 11.9%, p < 0.01). However, there was no significant difference in allograft or patient survival between transplants from DBD and DCD donors at 10 years (56% vs. 55%, p = 0.76 and 90% vs. 91%, p = 0.89). We describe the largest cohort of pediatric DCD kidney transplant recipients in the literature. We showed that despite higher rates of delayed allograft function in DCD transplants, long-term outcomes were not significantly different. Kidney transplants from DCD donors are a viable option and should be offered to children comparable to DBD kidneys as their long-term outcomes do not differ. DCD transplantation is illegal in some countries, however, it offers an opportunity to increase the number of transplants for children; this data should be considered in ongoing policy discussions.

IntroductionClinical ethics support services (CESS) have been developing worldwide with growing interest in evaluating their quality. Paediatric-specific CESSs (p-CESS) have received little attention, and evidence from adult services might not be generalisable. Evidence on service models and practices is crucial to inform further research and debate on quality evaluation and minimum standards for p-CESSs. We aim to systematically identify, appraise and synthesise evidence for p-CESS structures, processes and outcomes.Methods and analysisWe will conduct a mixed-studies systematic review including peer-reviewed empirical studies published in English or Spanish language providing data on the evaluation and/or impact on any aspect of p-CESS. We will search seven electronic databases: MEDLINE, Philosopher’s Index, EMBASE, PsycINFO, LILACS, Web of Science and CINHAL, without filters applied. Search terms will be related to “clinical ethics support” AND “paediatrics” AND “structure/process/outcome”. Reference and citation list of included studies will be handsearched. A 10% random sample of retrieved titles/abstracts and all full texts will be independently dual-screened. We will conduct narrative and thematic synthesis for quantitative and qualitative data, respectively, following sequential explanatory synthesis guided by Donabedian’s framework of structure, process and outcomes. Quality will be assessed using the Mixed-Methods Appraisal Tool (2018). The review will be reported using the adapted Preferred Reporting Items for Systematic Reviews and Meta-Analyses for reporting systematic reviews of qualitative and quantitative evidence template. Stakeholders will be involved twice in the review process; prior to data extraction and synthesis and after preliminary results.Ethics and disseminationAs a systematic review of published data, no ethical approval is necessary. Results will be published in a relevant academic peer-reviewed journal.PROSPERO registration numberCRD42021280978.

Heart transplant for adults following Donation after Circulatory Death (DCD) is well established in many parts of the world, including the United Kingdom (UK). Small child DCD hearts have now been recovered in the UK and internationally utilising novel technologies. Despite these recent advances, extension of this practice to pediatric cardiac transplantation has been slow and difficult despite the severe shortage of donors for children leading to a high number of deaths annually of children waiting for heart transplant. This is in direct contrast with the thriving UK programme of adult DCD heart transplant and pediatric DCD donation for non-cardiac organs. There has been insufficient action in addressing this inequality thus far. Barriers to development of a pediatric cardiac DCD programme are multifaceted: ethical concerns, technological paucity, financial and logistical hurdles. We describe the background, live issues, current developments and how we are driving resources toward a sustainable DCD programme for small children in the UK to provide valuable insights to other countries of the elements and principles at play. This is a call to responsible bodies to take urgent and achievable actions to establish an equitable paediatric DCD cardiac programme for donors, recipients and their families.

Many diseases, especially rare ones, have not gained the attention or support needed to attract dedicated research interest to be able to develop successful medicines. There is, thus, a significant unmet clinical need, not all of which is (or indeed can be) addressed through the evaluation of investigational treatments introduced within the confines of clinical trials. People with severe life-threatening conditions who are not eligible to participate in any ongoing clinical trials may be able to try investigational medicines through schemes facilitating early use of or expanded access to innovative medicines. Here, we focus on the issue of equity in such programmes. Standard metrics of clinical need which inform operational decisions about equity in resource allocation primarily rely on social goods which have already been evaluated, providing evidence to support the standard assessment of patient ‘capacity to benefit’ from given medical interventions. Notions of equity have only relatively recently been discussed within research and innovation generally and within the ethics of clinical trials in particular. Considerations of equity, however, require an overview of all these different patient pathways. We suggest that a new formal method to assess eligibility for early use of or expanded access to innovative medicines be used to capture both the severity of the condition and capacity for scientific or social value alongside clinical trials.

BackgroundJournal Clubs are well recognised and valuable training resources in the practice of evidence-based medicine.1 Given the increasing complexity and frequency of ethical dilemmas experienced in clinical practice, developing critical appraisal skills for ethics literature is needed.2AimTo describe the experience of, and feedback on, the first year of a Paediatric Ethics Journal Club offered to clinical departments at a tertiary children’s hospital.MethodsDuring 2022 the Paediatric Bioethics Centre offered a paediatric journal club sessions to all departments aiming to offer an avenue for dialogue on ethically challenging topics and to expand the bioethics centre’s engagement within the institution. Date, time and article(s) were arranged according to each department’s preferences. After each session, attendees were sent an online, voluntary, and anonymous electronic 10-item survey.Results8 JC session were held during 2020: One each for the Paediatric, Cardiac and Neonatal intensive Care Units (ICU) and for Radiology, Palliative Care, Genetics, Transplant and Neuro-disability teams. From a total of 130 attendees, (mean 16, range 10–25), we received 31 complete survey responses (23.8% response rate). All respondents rated the session quality as excellent or good (n=31, 100%), and considered the session was extremely/very (n=28) or somewhat (n=5) relevant to their work. All said they would like more ethics JC sessions, with 27 (87%) very likely to recommend it to a colleague. Ensuring broader access to the target article before the session, and promoting wider multidisciplinary attendance, were the main suggestions for improvement.ConclusionWe describe the introduction of Paediatric Bioethics Journal clubs to our children’s hospital. They proved a well-received educational activity and feedback from participants, although moderate response rate, was overall very positive. Strengthening advertising to promote greater and more diverse participation is needed.ReferencesAweid B, Haider Z, Wehbe M, Hunter A. Educational benefits of the online journal club: A systematic review. Med Teach. 2022 Jan;44(1):57–62.Jansen M, Ellerton P. How to read an ethics paper. Journal of Medical Ethics 2018;44:810–813.

Background To explore the impact of the transition from a traditional face-to-face course delivering essential contents in pediatric critical care to a hybrid format consisting of an online pre-course self-directed learning, an online facilitated discussion, and a face-to-face edition. Methods Attendees and faculty were surveyed after the face-to-face course and the hybrid version to evaluate the effectiveness and satisfaction of participants with the course. Results Fifty-seven students attended multiple formats of the Pediatric Basic Course between January 2020 and October 2021 in Udine, Italy. We compared course evaluation data from the 29 attendees of the face-to-face course with the 28 of the hybrid edition. Data collected included participant demographics, participant self-assessed pre and post-course ‘‘confidence’’ with a range of pediatric intensive care-related activities, and their satisfaction with elements of the course. There were no statistical differences in participant demographics or pre and post-course confidence scores. Overall satisfaction with the face-to-face course was marginally higher, 4.59 vs. 4.25/5, but did not reach significance. Pre-recorded lectures which could be viewed several times, were highlighted as a positive for the hybrid course. Residents found no significant differences comparing the two courses in rating the lectures and the technical skills stations. Hybrid course facilities (online platform and uploaded material) were reported to be clear, accessible, and valuable by 87% of attendees. After six months, they still find the course relevant to their clinical practice (75%). Candidates considered the respiratory failure and mechanical ventilation modules the most relevant modules. Conclusions The Pediatric Basic Course helps residents strengthen their learning and identify areas to improve their knowledge. Both face-to-face and hybrid model versions of the course improved attendees’ knowledge and perceived confidence in managing the critically ill child.

AimsOne important PBC function is to provide ethics education for members, hospital staff & other students. Educational activities are open to national and international healthcare students and workers. No standardised guidance exists Re how to run or evaluate such activities, though national UKCEN core competencies provide an ethics curriculum.The objective of this work is to describe the evolution of PBC educational activities over the pandemic period 2019-22.MethodsPBC educational activities database reviewResultsThe PBC provides training to its members, hospital staff, trainees and students, as well as external educational activities. These include:• PBC members - monthly 1-hour Bioethics Educational Forum with local/regional speakers evolved with videoconferencing to involve national/international speakers. Similarly, annual PBC Away Day now has more international speakers with positive feedback, tempered slightly by loss of team bonding. Each (of 10) new associate-member presents at bespoke 1-hour monthly online sessions, supported by mentor, unchanged by pandemic.• Hospital staff, trainees & students – vary in methods and scope, i.e., standalone sessions and ethics/law lectures embedded in other courses. e.g., 8 Weekly Autumn ethics interactive lectures open to hospital AND sessions on request to tackle moral injury. Feedback surprisingly positive, though efficacy not formally assessed.• External educational activities - include annual Medical Student Bioethics Day with lectures, workshops & abstract presentations; a one-week Paediatric Ethics & Law MSc Module and ad-hoc seminars/conferences to address timely hot topics (i.e., 2019 ‘Recent Court Judgements: should we change clinical practice?’ & 2020 ‘Role of Faith & Non in Society’s Pandemic Emergence’) Again, broader speaker pool facilitated, very positive feedback scores maintained online.The pandemic brought both challenge and opportunity. Educational activities were adapted to the online format, raising concerns about the loss of face-to-face discussion and interaction. However, videoconferencing allowed greater participation of national/international ethics experts and delegates. Informal and formal feedback from participants was entirely positive regarding the change; however, educators found entire day sessions arduous– these evolved to shorter sessions/fewer per teacher.ConclusionRemote learning offers new opportunities for ethics education/training activities. Further work should be done to evaluate not just participants’ and educators’ experience but to compare the efficacy of different modes of training.