In this teaching exercise, the goal is to demonstrate how an application of principles of physiology can reveal the basis for a severe degree of acidaemia (pH 6.81, bicarbonate <3 mmol/l (P(HCO(3))), PCO(2) 8 mmHg), why it was tolerated for a long period of time, and the issues for its therapy in an 8-year-old female with diabetic ketoacidosis. The relatively low value for the anion gap in plasma (19 mEq/l) suggested that its cause was both a direct and an indirect loss of NaHCO(3). Professor McCance suggested that ileus due to hypokalaemia might cause this direct loss of NaHCO(3), and that an excessive excretion of ketoacid anions without NH(4)(+) in the urine accounted for the indirect loss of NaHCO(3). In addition, he suspected that another factor also contributing to the severity of the acidaemia was a low input of alkali. He was also able to explain why there was a 16-h delay before there was a rise in the P(HCO(3)) once therapy began. The missing links in this interesting story, including a possible basis for the hypokalaemia, emerge during the discussion between the medical team and Professor McCance.

This review will outline the role of visiting cardiac surgical teams in low-and middle-income countries drawing on the collective experience of the authors in a wide range of locations. Requests for assistance can emerge from local programmes at a beginner or advanced stage. However, in all circumstances, careful pre-trip planning is necessary in conjunction with clinical and non-clinical local partners. The clinical evaluation, surgical procedures, and postoperative care all serve as a template for collaboration and education between the visiting and local teams in every aspect of care. Education focusses on both common and patient-specific issues. Case selection must appropriately balance the clinical priorities, safety, and educational objectives within the time constraints of trip duration. Considerable communication and practical challenges will present, and clinicians may need to make significant adjustments to their usual practice in order to function effectively in a resource-limited, unfamiliar, and multilingual environment. The effectiveness of visiting trips should be measured and constantly evaluated. Local and visiting teams should use data-driven evaluations of measurable outcomes and critical qualitative evaluation to repeatedly re-assess their interim goals. Progress invariably takes several years to achieve the final goal: an autonomous self-governing, self-financed, cardiac programme capable of providing care for children with complex CHD. This outcome is consistent with redundancy for the visiting trips model at the site, although fraternal, professional, and academic links will invariably remain for many years.

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The incidence of cerebral edema during therapy of diabetic ketoacidosis (DKA) in children remains unacceptably high-this suggests that current treatment may not be ideal and that important risk factors for the development of cerebral edema have not been recognized. We suggest that there are two major sources for an occult generation of osmole-free water in these patients: first, fluid with a low concentration of electrolytes that was retained in the lumen of the stomach when the patient arrived in hospital; second, infusion of glucose in water at a time when this solution can be converted into water with little glucose. In a retrospective chart review of 30 patients who were admitted with a diagnosis of DKA and a blood sugar > 900 mg/dL (50 mmol/L), there were clues to suggest that some of the retained fluid in the stomach was absorbed. To minimize the likelihood of creating a dangerous degree of cerebral edema in patients with DKA, it is important to define the likely composition of fluid retained in the stomach on admission, to look for signs of absorption of some of this fluid during therapy, and to be especially vigilant once fat-derived brain fuels have disappeared, because this is the time when glucose oxidation in the brain should increase markedly, generating osmole-free water.

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Introduction: Human errors occur during resuscitation despite individual knowledge of resuscitation guidelines. Poor teamwork has been implicated as a major source of such error; therefore interprofessional resuscitation teamwork training is essential. Hypothesis: A one-day team training course for pediatric interprofessional resuscitation team members improves adherence to PALS guidelines, team efficiency and teamwork in a simulated clinical environment. Methods: A prospective interventional study was conducted at 4 children’s hospitals in Canada with pediatric resuscitation team members (n=300, 51 teams). Educational intervention was a one-day simulation-based team training course involving interactive lecture, group discussions and 4 simulated resuscitation scenarios followed by debriefing. First scenario of the day was conducted prior to any training. Final scenario of the day was the same scenario, with modified patient history. Scenarios included standardized distractors designed to elicit and challenge specific teamwork behaviors. Primary outcome measure was change (before and after training) in adherence to PALS guidelines, as measured by the Clinical Performance Tool (CPT). Secondary outcome measures: change in times to initiation of chest compressions and defibrillation; and teamwork performance, as measured by the Clinical Teamwork Scale (CTS). Correlation between CPT and CTS scores was analyzed. Results: Teams significantly improved CPT scores (67.3% to 79.6%, P< 0.0001), time to initiation of chest compressions (60.8 sec to 27.1 sec, P<0.0001), time to defibrillation (164.8 sec to 122.0 sec, P<0.0001) and CTS scores (56.0% to 71.8%, P<0.0001). Significantly more teams defibrillated under AHA target of 2 minutes (10 vs. 27, P<0.01). A strong correlation was found between CPT and CTS (r=0.530, P<0.0001). Conclusions: Participation in a simulation-based team training educational intervention significantly improved surrogate measures of clinical performance, time to initiation of key clinical tasks, and teamwork during simulated pediatric resuscitation. A strong correlation between clinical and teamwork performance suggests that effective teamwork optimizes clinical performance of resuscitation teams.

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Despite improvements in surgical technique and medical management, single-ventricle lesions remain one of the most challenging congenital heart anomalies to treat, and mortality rates are high. Most infants who have single-ventricle palliation undergo a sequence of surgeries to optimize pulmonary and systemic blood flow. The first surgery to separate pulmonary and systemic blood flow is the bidirectional cavopulmonary shunt. This article describes single-ventricle lesions and gives a basic overview of outcomes and strategies to improve interstage mortality. Preoperative investigations that evaluate stage II candidacy are reviewed along with surgical approaches and postoperative physiology. Although mortality rates are low and decreasing in patients with bidirectional cavopulmonary shunts, morbidity is still a challenge. Nurses must understand the pertinent anatomy and physiology and recognize postoperative complications early in order to reduce morbidity. Postoperative complications, management, outcomes and nursing care are discussed.