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Clinical surveillance provides essential data on changes in a patient's condition. The common method for performing this surveillance is the assessment of vital signs. Despite the importance of these signs, research has found that vital signs are not rigorously assessed in clinical practice. Respiratory rate, arguably the most important vital sign, is the most neglected. Poor understanding might contribute to nurses incorrectly valuing oxygen saturation more than respiratory rate. Nurses need to understand the importance of respiratory rate assessment as a vital sign and the benefits and limitations of pulse oximetry as a clinical tool. By better understanding pulse oximetry and respiratory rate assessment, nurses might be more inclined to conduct rigorous vital signs' assessment. Research is needed to understand why many nurses do not appreciate the importance of vital signs' monitoring.

Clinical surveillance provides essential data on changes in a patient's condition. The common method for performing this surveillance is the assessment of vital signs. Despite the importance of these signs, research has found that vital signs are not rigorously assessed in clinical practice. Respiratory rate, arguably the most important vital sign, is the most neglected. Poor understanding might contribute to nurses incorrectly valuing oxygen saturation more than respiratory rate. Nurses need to understand the importance of respiratory rate assessment as a vital sign and the benefits and limitations of pulse oximetry as a clinical tool. By better understanding pulse oximetry and respiratory rate assessment, nurses might be more inclined to conduct rigorous vital signs' assessment. Research is needed to understand why many nurses do not appreciate the importance of vital signs' monitoring.

Raoultella planticola (R. planticola) is a Gram-negative, aerobic, rod bacteria found in water and soil that has been on rare occasions associated with clinical infections. However, in recent years, there has been both an increase in the frequency and severity of R. planticola infections. We present the first case of Meckel's diverticulum perforation and peritonitis in a child associated with R. planticola infection and a systematic review of the paediatric literature. At present, in the paediatric population, R. planticola presents good susceptibility to a variety of antibiotics with the exception of ampicillin.Copyright © 2019 The Authors

Raoultella planticola (R. planticola) is a Gram-negative, aerobic, rod bacteria found in water and soil that has been on rare occasions associated with clinical infections. However, in recent years, there has been both an increase in the frequency and severity of R. planticola infections. We present the first case of Meckel's diverticulum perforation and peritonitis in a child associated with R. planticola infection and a systematic review of the paediatric literature. At present, in the paediatric population, R. planticola presents good susceptibility to a variety of antibiotics with the exception of ampicillin.Copyright © 2019 The Authors

Introduction: Acute wrap failure post fundoplication is a rare but recognized complication and can be due to patient factors, disease factors and surgical factors. Herniation of the stomach into the thorax can mimic a pneumothorax clinically and radiologically and thus lead to bad outcomes for patients. Presentation of case: We report the case of a 20-year-old male who presented to the emergency department with progressively worsening upper abdominal pain, nausea and vomiting followed by acute onset dyspnoea, six days post a laparoscopic repair of a small hiatus hernia and a Nissen fundoplication. His chest x-ray was consistent with that of a left sided pneumothorax and was therefore, appropriately resuscitated and treated with an intercostal catheter (ICC). A subsequent CT scan of the chest revealed a left gastrothorax. The patient was taken to theatre for the surgical reduction of the paraoesophageal hernia. Discussion(s): Patients with a recent history of anti-reflux surgery, who present with a pneumothorax and respiratory distress or a tension pneumothorax should always be treated with an ICC. However, follow up imaging with a CT scan is essential to confirm diagnosis. Good control of post- operative nausea and vomiting is essential in avoiding wrap failure and ensuing complications. Conclusion(s): A high index of suspicion for a gastrothorax mimicking a pneumothorax is important in the setting of recent anti-reflux surgery.Copyright © 2018 The Author(s)

Introduction: Acute wrap failure post fundoplication is a rare but recognized complication and can be due to patient factors, disease factors and surgical factors. Herniation of the stomach into the thorax can mimic a pneumothorax clinically and radiologically and thus lead to bad outcomes for patients. Presentation of case: We report the case of a 20-year-old male who presented to the emergency department with progressively worsening upper abdominal pain, nausea and vomiting followed by acute onset dyspnoea, six days post a laparoscopic repair of a small hiatus hernia and a Nissen fundoplication. His chest x-ray was consistent with that of a left sided pneumothorax and was therefore, appropriately resuscitated and treated with an intercostal catheter (ICC). A subsequent CT scan of the chest revealed a left gastrothorax. The patient was taken to theatre for the surgical reduction of the paraoesophageal hernia. Discussion(s): Patients with a recent history of anti-reflux surgery, who present with a pneumothorax and respiratory distress or a tension pneumothorax should always be treated with an ICC. However, follow up imaging with a CT scan is essential to confirm diagnosis. Good control of post- operative nausea and vomiting is essential in avoiding wrap failure and ensuing complications. Conclusion(s): A high index of suspicion for a gastrothorax mimicking a pneumothorax is important in the setting of recent anti-reflux surgery.Copyright © 2018 The Author(s)

Background: Adrenaline is the standard treatment for anaphylaxis but appropriate administration remains challenging, and iatrogenic overdose is easily overlooked. Despite the established importance of pediatric blood pressure measurement, its use remains inconsistent in clinical practice. Case presentation: We report a case of adrenaline overdose in a 9-year-old white boy with anaphylaxis, where signs of adrenaline overdose were indistinguishable from progressive shock until blood pressure measurement was taken. Conclusion(s): The consequences of under-dosing adrenaline in anaphylaxis are well-recognized, but the converse is less so. Blood pressure measurement should be a routine part of pediatric assessment as it is key to differentiating adrenaline overdose from anaphylactic shock.Copyright © 2017 The Author(s).

Background: Adrenaline is the standard treatment for anaphylaxis but appropriate administration remains challenging, and iatrogenic overdose is easily overlooked. Despite the established importance of pediatric blood pressure measurement, its use remains inconsistent in clinical practice. Case presentation: We report a case of adrenaline overdose in a 9-year-old white boy with anaphylaxis, where signs of adrenaline overdose were indistinguishable from progressive shock until blood pressure measurement was taken. Conclusion(s): The consequences of under-dosing adrenaline in anaphylaxis are well-recognized, but the converse is less so. Blood pressure measurement should be a routine part of pediatric assessment as it is key to differentiating adrenaline overdose from anaphylactic shock.Copyright © 2017 The Author(s).

Background: Bronchiolitis imposes the largest health care burden on non-elective paediatric hospital admissions worldwide, with up to 15 % of cases requiring admission to intensive care. A number of previous studies have failed to show benefit of pharmaceutical treatment in respect to length of stay, reduction in PICU admission rates or intubation frequency. The early use of non-invasive respiratory support devices in less intensive scenarios to facilitate earlier respiratory support may have an impact on outcome by avoiding progression of the disease process. High Flow Nasal Cannula (HFNC) therapy has emerged as a new method to provide humidified air flow to deliver a non-invasive form of positive pressure support with titratable oxygen fraction. There is a lack of high-grade evidence on use of HFNC therapy in bronchiolitis. Methods/Design: Prospective multi-centre randomised trial comparing standard treatment (standard subnasal oxygen) and High Flow Nasal Cannula therapy in infants with bronchiolitis admitted to 17 hospitals emergency departments and wards in Australia and New Zealand, including 12 non-tertiary regional/metropolitan and 5 tertiary centres. The primary outcome is treatment failure; defined as meeting three out of four pre-specified failure criteria requiring escalation of treatment or higher level of care; i) heart rate remains unchanged or increased compared to admission/enrolment observations, ii) respiratory rate remains unchanged or increased compared to admission/ enrolment observations, iii) oxygen requirement in HFNC therapy arm exceeds FiO2 >= 40 % to maintain SpO2 >= 92 % (or >=94 %) or oxygen requirement in standard subnasal oxygen therapy arm exceeds > 2L/min to maintain SpO2 >= 92 % (or >=94 %), and iv) hospital internal Early Warning Tool calls for medical review and escalation of care. Secondary outcomes include transfer to tertiary institution, admission to intensive care, length of stay, length of oxygen treatment, need for non-inva

Background: Bronchiolitis imposes the largest health care burden on non-elective paediatric hospital admissions worldwide, with up to 15 % of cases requiring admission to intensive care. A number of previous studies have failed to show benefit of pharmaceutical treatment in respect to length of stay, reduction in PICU admission rates or intubation frequency. The early use of non-invasive respiratory support devices in less intensive scenarios to facilitate earlier respiratory support may have an impact on outcome by avoiding progression of the disease process. High Flow Nasal Cannula (HFNC) therapy has emerged as a new method to provide humidified air flow to deliver a non-invasive form of positive pressure support with titratable oxygen fraction. There is a lack of high-grade evidence on use of HFNC therapy in bronchiolitis. Methods/Design: Prospective multi-centre randomised trial comparing standard treatment (standard subnasal oxygen) and High Flow Nasal Cannula therapy in infants with bronchiolitis admitted to 17 hospitals emergency departments and wards in Australia and New Zealand, including 12 non-tertiary regional/metropolitan and 5 tertiary centres. The primary outcome is treatment failure; defined as meeting three out of four pre-specified failure criteria requiring escalation of treatment or higher level of care; i) heart rate remains unchanged or increased compared to admission/enrolment observations, ii) respiratory rate remains unchanged or increased compared to admission/ enrolment observations, iii) oxygen requirement in HFNC therapy arm exceeds FiO2 >= 40 % to maintain SpO2 >= 92 % (or >=94 %) or oxygen requirement in standard subnasal oxygen therapy arm exceeds > 2L/min to maintain SpO2 >= 92 % (or >=94 %), and iv) hospital internal Early Warning Tool calls for medical review and escalation of care. Secondary outcomes include transfer to tertiary institution, admission to intensive care, length of stay, length of oxygen treatment, need for non-inva

Background: Bronchiolitis imposes the largest health care burden on non-elective paediatric hospital admissions worldwide, with up to 15 % of cases requiring admission to intensive care. A number of previous studies have failed to show benefit of pharmaceutical treatment in respect to length of stay, reduction in PICU admission rates or intubation frequency. The early use of non-invasive respiratory support devices in less intensive scenarios to facilitate earlier respiratory support may have an impact on outcome by avoiding progression of the disease process. High Flow Nasal Cannula (HFNC) therapy has emerged as a new method to provide humidified air flow to deliver a non-invasive form of positive pressure support with titratable oxygen fraction. There is a lack of high-grade evidence on use of HFNC therapy in bronchiolitis. Methods/Design: Prospective multi-centre randomised trial comparing standard treatment (standard subnasal oxygen) and High Flow Nasal Cannula therapy in infants with bronchiolitis admitted to 17 hospitals emergency departments and wards in Australia and New Zealand, including 12 non-tertiary regional/metropolitan and 5 tertiary centres. The primary outcome is treatment failure; defined as meeting three out of four pre-specified failure criteria requiring escalation of treatment or higher level of care; i) heart rate remains unchanged or increased compared to admission/enrolment observations, ii) respiratory rate remains unchanged or increased compared to admission/ enrolment observations, iii) oxygen requirement in HFNC therapy arm exceeds FiO2 >= 40 % to maintain SpO2 >= 92 % (or >=94 %) or oxygen requirement in standard subnasal oxygen therapy arm exceeds > 2L/min to maintain SpO2 >= 92 % (or >=94 %), and iv) hospital internal Early Warning Tool calls for medical review and escalation of care. Secondary outcomes include transfer to tertiary institution, admission to intensive care, length of stay, length of oxygen treatment, need for non-inva

A failure to adequately respond to hypoxia has been implicated in the Sudden Infant Death Syndrome (SIDS). Preterm infants are at increased risk for SIDS, thus we compared ventilatory and arousal responses to mild hypoxia [15% oxygen (O2)] in preterm and term infants. Eight preterm and 15 term infants were serially studied with daytime polysomnography during which nasal airflow was monitored by pneumotachograph at 2-5 weeks, 2-3 and 5-6 months. At each age, in both groups, hypoxia induced a significant decrease in oxygen saturation (SpO2) during both active sleep (AS) and quiet sleep (QS). Infants invariably aroused in AS; and in QS either aroused or failed to arouse. In preterm infants arousal latency in AS was longer than in term infants (P < 0.05) at 2-5 weeks. Compared with term infants, preterm infants reached significantly lower SpO2 levels at 2-5 weeks in both AS and QS non-arousing tests and at 2-3 months in QS. A biphasic hypoxic ventilatory response was observed in QS non-arousing tests in both groups of infants at all three ages. We conclude that the greater desaturation during a hypoxic challenge combined with the longer arousal latency in preterm infants could contribute to greater risk for SIDS. © 2008 European Sleep Research Society.

In infants most previous studies of the hypoxic ventilatory response (HVR) have been conducted only during quiet sleep (QS) and arousal responses have not been considered. Our aim was to quantify the maturation of the HVR in term infants during both active sleep (AS) and QS over the first 6 months of life. Daytime polysomnography was performed on 15 healthy term infants at 2-5 weeks, 2-3 and 5-6 months after birth and infants were challenged with hypoxia (15% O2, balance N2). Tests in AS always resulted in arousal; in QS tests infants either aroused or did not arouse. A biphasic HVR was observed in non arousing tests at all three ages studied. The fall in SpO 2 was more rapid in arousal tests at all three ages. At 2-5 weeks, in non-arousing QS tests, there was a greater fall in respiratory frequency (f) despite a smaller fall in SpO2 compared with 2-3 and 5-6 months. When infants aroused there was no difference in the HVR between sleep states or with postnatal age. However, when infants failed to arouse from QS, arterial desaturation was less in the younger infants despite a poorer HVR. We suggest that arousal in response to hypoxia, particularly in AS, is a vital survival mechanism throughout the first 6 months of life. © 2007 European Sleep Research Society.

Responses to cool ambient temperature were tested with reference to the sleep-wakefulness cycle in six chronically instrumented newborn lambs which were exposed to warm (20-25degreeC) and cool (10-15degreeC) ambient temperatures (T(a)) in fifteen studies. We measured cardio-respiratory variables (cardiac output, heart rate, stroke volume, arteriovenous O2 difference and O2 consumption) together with body temperature (T(b)) during behavioural states of quiet wakefulness (QW), quiet sleep (QS) and rapid-eye-movement sleep (REM). In cool T(a), significant increases (P<0.05) occurred in cardiac output, O2 uptake and O2 consumption in QW (10 +/- 3%, 23 +/- 4% and 35 +/- 6%, respectively, mean +/- S.E.M.) and QS (12 +/- 3%, 21 +/- 7% and 35 +/- 8%, respectively), but these responses were absent in REM. Increases in heart rate (6 +/- 2%) and stroke volume (6 +/- 3%) were present during QS, but not during REM. In REM, T(b) was dependent upon the prevailing T(a), increasing in the warm T(a) and tending to decrease in the cool T(a). In cool T(a), REM sleep epochs were shorter and more frequent with no changes in total REM time. These changes were not seen in QS. Thus, the behavioural state determines both the thermogenic and the associated cardio-respiratory responses to cool stress in lambs. The consequences of disrupted thermogenesis during REM sleep include dependence of T(b) upon the prevailing ambient temperature, and abbreviation of the REM epoch by arousal, possibly as a defence against falls in T(b) in cool T(a).

The objective of this study was to demonstrate the efficacy, safety and patient acceptability of the use of intranasal sufentanil for cancer-associated breakthrough pain. This was a prospective, open label, observational study of patients in three inpatient palliative care units in Australia. Patients on opioids with cancer-associated breakthrough pain and clinical evidence of opioid responsiveness to their breakthrough pain were given intranasal (IN) Sufentanil via a GO MedicalTM patient controlled IN analgesia device. The main outcome measures were pain scores, need to revert to previous breakthrough opioid after 30 min, number of patients who chose to continue using IN sufentanil, and adverse effects. There were 64 episodes of use of IN sufentanil for breakthrough pain in 30 patients. There was a significant reduction in pain scores at 15 (P < 0.0001) and 30 min (P < 0.0001). In only 4/64 (6%) episodes of breakthrough pain did the participants choose to revert to their prestudy breakthrough medication. Twenty-three patients (77%) rated IN sufentanil as better than their prestudy breakthrough medication. The incidence of adverse effects was low and most were mild. Our study showed that IN sufentanil can provide relatively rapid onset, intense but relatively short lasting analgesia and in the palliative care setting it is an effective, practical, and safe option for breakthrough pain. © 2009 SAGE Publications.

In infants most previous studies of the hypoxic ventilatory response (HVR) have been conducted only during quiet sleep (QS) and arousal responses have not been considered. Our aim was to quantify the maturation of the HVR in term infants during both active sleep (AS) and QS over the first 6 months of life. Daytime polysomnography was performed on 15 healthy term infants at 2-5 weeks, 2-3 and 5-6 months after birth and infants were challenged with hypoxia (15% O2, balance N2). Tests in AS always resulted in arousal; in QS tests infants either aroused or did not arouse. A biphasic HVR was observed in non arousing tests at all three ages studied. The fall in SpO 2 was more rapid in arousal tests at all three ages. At 2-5 weeks, in non-arousing QS tests, there was a greater fall in respiratory frequency (f) despite a smaller fall in SpO2 compared with 2-3 and 5-6 months. When infants aroused there was no difference in the HVR between sleep states or with postnatal age. However, when infants failed to arouse from QS, arterial desaturation was less in the younger infants despite a poorer HVR. We suggest that arousal in response to hypoxia, particularly in AS, is a vital survival mechanism throughout the first 6 months of life. © 2007 European Sleep Research Society.

A failure to adequately respond to hypoxia has been implicated in the Sudden Infant Death Syndrome (SIDS). Preterm infants are at increased risk for SIDS, thus we compared ventilatory and arousal responses to mild hypoxia [15% oxygen (O2)] in preterm and term infants. Eight preterm and 15 term infants were serially studied with daytime polysomnography during which nasal airflow was monitored by pneumotachograph at 2-5 weeks, 2-3 and 5-6 months. At each age, in both groups, hypoxia induced a significant decrease in oxygen saturation (SpO2) during both active sleep (AS) and quiet sleep (QS). Infants invariably aroused in AS; and in QS either aroused or failed to arouse. In preterm infants arousal latency in AS was longer than in term infants (P < 0.05) at 2-5 weeks. Compared with term infants, preterm infants reached significantly lower SpO2 levels at 2-5 weeks in both AS and QS non-arousing tests and at 2-3 months in QS. A biphasic hypoxic ventilatory response was observed in QS non-arousing tests in both groups of infants at all three ages. We conclude that the greater desaturation during a hypoxic challenge combined with the longer arousal latency in preterm infants could contribute to greater risk for SIDS. © 2008 European Sleep Research Society.

Responses to cool ambient temperature were tested with reference to the sleep-wakefulness cycle in six chronically instrumented newborn lambs which were exposed to warm (20-25degreeC) and cool (10-15degreeC) ambient temperatures (T(a)) in fifteen studies. We measured cardio-respiratory variables (cardiac output, heart rate, stroke volume, arteriovenous O2 difference and O2 consumption) together with body temperature (T(b)) during behavioural states of quiet wakefulness (QW), quiet sleep (QS) and rapid-eye-movement sleep (REM). In cool T(a), significant increases (P<0.05) occurred in cardiac output, O2 uptake and O2 consumption in QW (10 +/- 3%, 23 +/- 4% and 35 +/- 6%, respectively, mean +/- S.E.M.) and QS (12 +/- 3%, 21 +/- 7% and 35 +/- 8%, respectively), but these responses were absent in REM. Increases in heart rate (6 +/- 2%) and stroke volume (6 +/- 3%) were present during QS, but not during REM. In REM, T(b) was dependent upon the prevailing T(a), increasing in the warm T(a) and tending to decrease in the cool T(a). In cool T(a), REM sleep epochs were shorter and more frequent with no changes in total REM time. These changes were not seen in QS. Thus, the behavioural state determines both the thermogenic and the associated cardio-respiratory responses to cool stress in lambs. The consequences of disrupted thermogenesis during REM sleep include dependence of T(b) upon the prevailing ambient temperature, and abbreviation of the REM epoch by arousal, possibly as a defence against falls in T(b) in cool T(a).

The objective of this study was to demonstrate the efficacy, safety and patient acceptability of the use of intranasal sufentanil for cancer-associated breakthrough pain. This was a prospective, open label, observational study of patients in three inpatient palliative care units in Australia. Patients on opioids with cancer-associated breakthrough pain and clinical evidence of opioid responsiveness to their breakthrough pain were given intranasal (IN) Sufentanil via a GO MedicalTM patient controlled IN analgesia device. The main outcome measures were pain scores, need to revert to previous breakthrough opioid after 30 min, number of patients who chose to continue using IN sufentanil, and adverse effects. There were 64 episodes of use of IN sufentanil for breakthrough pain in 30 patients. There was a significant reduction in pain scores at 15 (P < 0.0001) and 30 min (P < 0.0001). In only 4/64 (6%) episodes of breakthrough pain did the participants choose to revert to their prestudy breakthrough medication. Twenty-three patients (77%) rated IN sufentanil as better than their prestudy breakthrough medication. The incidence of adverse effects was low and most were mild. Our study showed that IN sufentanil can provide relatively rapid onset, intense but relatively short lasting analgesia and in the palliative care setting it is an effective, practical, and safe option for breakthrough pain. © 2009 SAGE Publications.