Nancy M. Tofil, M.D., M.Ed., is a Professor of Pediatrics at the University of Alabama at Birmingham and the Division Director of Pediatric Critical Care at Children’s of Alabama Hospital. She is also the medical director of the Pediatric Simulation Center, which focuses on interdisciplinary learning and skill practice in the context of real-life scenarios. Dr. Tofil also serves as the Senior Associate Program Director for the Pediatric Residency Training Program.
I spoke with Dr. Tofil about a recent study published in the International Journal of Pediatric Research and Reviews. In this study Dr. Tofil and her colleagues at Children’s of Alabama investigated the impact of using the LifeFlow® Fluid Infuser in children with shock or hypotension presenting to the Emergency Department. Here are her thoughts on the study, its key findings and future research plans.
1) What drove you to want to do this retrospective study on fluid resuscitation in children? As pediatric critical care physician, I am well aware that resuscitation is important, as is being timely about that resuscitation. Our Emergency Department started using LifeFlow in 2017 and found it allowed us to complete fluid resuscitation earlier. This inspired me to want to understand the benefits the ED was seeing related to successful resuscitation with LifeFlow – what were the outcomes and how does that translate to the PICU?
2) Were there challenges with this study? Interestingly, because the staff were so pro-LifeFlow they did not want to subject patients to a control group. We also discovered that documentation is generally poor in a critical situation. We identified gaps in our own process with assessing and managing vital signs pre- and post- fluids and have since implemented improvements.
3) What were your key learnings? Most impressive to me is that we had a history of using push-pull method with syringes that are designed for single-use only. It’s quite easy to see how the barrel can become contaminated with each subsequent depression, leading to multiple contamination opportunities. If you were to use push-pull in a sterile manner you would require a new syringe for each depression, resulting in higher costs. LifeFlow offers a closed-system design to protect against contamination. Separately we suspect that more patients with shock were able to go to our step-down unit and not require PICU admission, but further research is necessary to prove this definitively.
4) Were there any surprises in your findings? There were a couple of patients whose vital signs did not appear to show an improvement after fluid boluses. Sometimes, as the patient is worsening, you are giving fluids and they still downgrading. We’ve recognized the value of a fluid challenge in identifying fluid responsiveness in a given patient; providing fluids and then assessing vital signs for improvement. LifeFlow makes this easier in terms of this rapid titration, but we have to be diligent about process, including reassessment.
5) I understand that you are working on a follow-up study. How will this study be different? We will have a similar approach but with more rigor to the documentation. In particular, we are more vigilantly documenting start and stop times for volume resuscitation. We are also looking to add LifeFlow PLUS for blood usage in a small cohort. Interestingly, the study team is encountering a similar issue of resistance to a control group – our clinicians believe in LifeFlow and want to see it used where it applies.
6) How has use of LifeFlow impacted care in your facility? I have found it’s much more predictable – we can identify the amount of fluid delivered in the right timeframe. LifeFlow is now routine at our institution and included in our sepsis order sets. That has probably helped the whole gamut of folks who need it. There is also more of a safety factor than I realized as it relates to the contamination issue.
7) Can you tell me about the CODE video you developed that integrates LifeFlow? Five years ago our simulation team created a video to train our nurses on how to approach resuscitation of critically ill patients. We were in need of an update so we recently reshot it and this time included LifeFlow as part of our treatment protocol [Fig 1. – Screen Shot of CODE video]. We have found this type of tutorial to be very helpful for ensuring consistency in treatment and approach.
Fig 1. Screen shot of Children’s of Alabama CODE Training Video including LifeFlow.