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Kim S, Steffen K, Gottschalk-Henneberry L, Miros J, Leger K, Robichaux-Viehoever A, Taca K, Aravamuthan B. Standardized clinical data capture to describe cerebral palsy. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.08.09.24311474. [PMID: 39211855 PMCID: PMC11361210 DOI: 10.1101/2024.08.09.24311474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Objective To describe a standardized methodology for capturing clinically valuable information on young people with cerebral palsy (CP) from caregivers and clinicians during routine clinical care. Methods We developed a caregiver-facing intake form and clinician-facing standardized note template and integrated both into routine clinical care at a tertiary care CP center ( https://bit.ly/CP-Intake-Methodology ). We extracted this caregiver and clinician-entered data on people with an ICD10 diagnosis of CP seen between 3/22/23 and 12/28/23. We used this data to describe how CP manifests in this group and which medical features affected the odds of walking, oral feeding, and speech by age 5. Results Of 686 visits, 663 (97%) had caregiver- and clinician-entered data and 633 had a clinician-confirmed CP diagnosis (mean age 9.1, 53.4% Male, 78.5% White). It was common to have quadriplegia (288/613, 47.0%), both spasticity and dystonia (257/632, 40.7%), walk independently (368/633, 58.1%), eat all food and drink safely by mouth (288/578, 55.9%), and produce understandable speech (249/584, 42.6%). Cortical grey matter injury and duration of initial critical care unit stay affected the odds of walking, oral feeding, and speech (binary logistic regression, p<0.001). Conclusions We comprehensively captured caregiver and clinician-entered data on 97% of people seen in a tertiary care CP Center and used this data to determine medical features affecting the odds of three functional outcomes. By sharing our methodology, we aim to facilitate replication of this dataset at other sites and grow our understanding of how CP manifests in the US. Article summary Using caregiver and clinician-entered data on people seen in a tertiary-care CP center, we determined medical features affecting the odds of three functional outcomes. What’s known on this subject Detailed CP characterization can be limited if using population-based registries and retrospective chart review alone, including limited data on recently validated functional classification systems for CP. What this study adds We comprehensively captured caregiver and clinician-entered data on 97% of people seen in our CP Center to describe how CP manifests and show that cortical injury and initial ICU stay duration affect the odds of walking, oral feeding, and speech. Contributors Statement Susie Kim helped design the study, aggregated data, carried out data analyses, and critically reviewed and revised the manuscript.Kelsey Steffen helped conceptualize and design the study and critically reviewed and revised the manuscript.Lauren Gottschalk, Jennifer Miros, Katie Leger, Amy Viehoever, and Karen Taca helped design the study and critically reviewed and revised the manuscript.Bhooma Aravamuthan conceptualized and designed the study, supervised data collection and analysis, drafted the initial manuscript, and critically reviewed and revised the manuscript.
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Hardin BG, McCarter A, Hamrick SEG. A Delirium Prevention and Management Initiative: Implementing a Best Practice Recommendation for the NICU. Neonatal Netw 2024; 43:19-34. [PMID: 38267090 DOI: 10.1891/nn-2023-0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Medically complex infants experiencing NICU stays can be difficult to manage, exhibiting refractory agitation, disengagement, or both-all signs of delirium, which can present in a hypoactive, hyperactive, or mixed form. Though documented in other settings, delirium is under-recognized in NICUs. Pediatric studies show that a high percentage of patients with delirium are under the age of 12 months. Delirium is associated with increased ventilation days, hospital days, and costs. It negatively affects neurodevelopment and social interaction. Studies show that pediatric nurses are unprepared to recognize delirium. Our nurse-led multidisciplinary group created a best practice recommendation (BPR) focused on detecting delirium and minimizing risk through thoughtful sedation management, promotion of sleep hygiene and mobility, and facilitation of meaningful caregiver presence. Occasionally, medications, including melatonin and risperidone, are helpful. In 2019, we introduced this BPR to reduce delirium risk in our NICU. Practice changes tied to this initiative correlate with a significant reduction in delirium scores and risk including exposure to deliriogenic medications. A multidisciplinary care bundle correlates with decreased delirium screening scores in NICU patients.
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Riggs BJ, Carpenter JL. Pediatric Neurocritical Care: Maximizing Neurodevelopmental Outcomes Through Specialty Care. Pediatr Neurol 2023; 149:187-198. [PMID: 37748977 DOI: 10.1016/j.pediatrneurol.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/27/2023] [Accepted: 08/04/2023] [Indexed: 09/27/2023]
Abstract
The field of pediatric neurocritical care (PNCC) has expanded and evolved over the last three decades. As mortality from pediatric critical care illness has declined, morbidity from neurodevelopmental disorders has expanded. PNCC clinicians have adopted a multidisciplinary approach to rapidly identify neurological injury, implement neuroprotective therapies, minimize secondary neurological insults, and establish transitions of care, all with the goal of improving neurocognitive outcomes for their patients. Although there are many aspects of PNCC and adult neurocritical care (NCC) medicine that are similar, elemental difference between adult and pediatric medicine has contributed to a divergent evolution of the respective fields. The low incidence of pediatric critical care illness, the heterogeneity of neurological insults, and the limited availability of resources all shape the need for a PNCC clinical care model that is distinct from the established paradigm adopted by the adult neurocritical care community at large. Considerations of neurodevelopment are fundamental in pediatrics. When neurological injury occurs in a child, the neurodevelopmental stage at the time of insult alters the impact of the neurological disease. Developmental variables contribute to a range of outcomes for seemingly similar injuries. Despite the relative infancy of the field of PNCC, early reports have shown that implementation of a specialized PNCC service elevates the quality and safety of care, promotes education and communication, and improves outcomes for children with acute neurological injuries. The multidisciplinary approach of PNCC clinicians and researchers also promotes a culture that emphasizes the importance of quality improvement and education initiatives, as well as development of and adherence to evidence-based guidelines and family-focused care models.
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Affiliation(s)
- Becky J Riggs
- Division of Pediatric Critical Care Medicine, Oregon Health & Science University, Portland, Oregon.
| | - Jessica L Carpenter
- Division of Pediatric Neurology, University of Maryland Medical Center, Baltimore, Maryland
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Xia Y, Liu M, Fan J, Qiu Y, Zhang X, Zheng Z, Shi S. Risk factors of postoperative neurodevelopmental abnormalities in neonates with critical congenital heart disease. Zhejiang Da Xue Xue Bao Yi Xue Ban 2023; 52:110-116. [PMID: 37283124 PMCID: PMC10407982 DOI: 10.3724/zdxbyxb-2022-0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 12/07/2022] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To investigate the risk factors of postoperative neuro-developmental abnormalities in neonates with critical congenital heart disease (CCHD). METHODS Clinical data of 50 neonates with CCHD admitted in the Cardiac Intensive Care Unit, The Children's Hospital, Zhejiang University School of Medicine from November 2020 to December 2021 were retrospectively analyzed. Neurological assessment was performed with cranial ultrasonography, CT/MRI, video electroencephalogram and clinical symptoms before and after surgical treatment for all patients, and neurodevelopmental abnormalities were documented. Binary logistic stepwise regression was used to analyze risk factors of postoperative new-onset neurodysplasia in children with CCHD, and the predictive value of the risk factors on postoperative neurodevelopmental abnormalities were evaluated using the receiver operating characteristic (ROC) curve. RESULTS Neurodevelopmental abnormalities were detected in 22 cases (44.0%) and not detected in 28 cases (56.0%) before surgery. There were no significant differences in gender, birth weight, age at admission, gestational age, preoperative SpO2 level, prematurity, cyanotic congenital heart disease, and ventilator support between the two groups (all P>0.05). After surgery, there were 22 cases (44.0%) with new-onset neurological abnormalities and 28 cases (56.0%) without new-onset abnormalities. Multivariate logistic regression analysis showed that postoperative 24 h peak lactic acid (OR=1.537, 95%CI: 1.170-2.018, P<0.01) and postoperative length of ICU stay (OR=1.172, 95%CI:1.031-1.333, P<0.05) were independent risk factors for postoperative new-onset neurodevelopmental abnormalities. The area under ROC curve (AUC) of the postoperative 24 h peak lactic acid for predicting the new-onset neurological abnormalities after operation was 0.829, with cut-off value of 4.95 mmol/L. The diagnostic sensitivity and specificity were 90.0% and 64.3%, respectively. The AUC of postoperative length of ICU stay for predicting the new-onset neurological abnormalities after operation was 0.712, with cut-off value of 18.0 d. The diagnostic sensitivity and specificity were 50.0% and 96.4%, respectively. The AUC of the combination of the two indicators was 0.917, the diagnostic sensitivity and specificity were 95.5% and 64.3%, respectively. CONCLUSIONS The incidence of neurodysplasia in neonatal CCHD is high, and new neurological abnormalities may occur after surgery. The postoperative 24 h peak lactic acid and postoperative length of ICU stay are risk factors for new-onset neurodysplasia after surgery. The combination of the two indicators has good predictive value for neurodevelopmental outcomes after surgery in CCHD infants.
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Affiliation(s)
- Yuanyuan Xia
- Cardiac Intensive Care Unit, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Regional Medical Center for Children, Hangzhou 310052, China.
| | - Mingnan Liu
- Cardiac Intensive Care Unit, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Regional Medical Center for Children, Hangzhou 310052, China
| | - Jiajie Fan
- Cardiac Intensive Care Unit, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Regional Medical Center for Children, Hangzhou 310052, China
| | - Yunxiang Qiu
- Cardiac Intensive Care Unit, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Regional Medical Center for Children, Hangzhou 310052, China
| | - Xianghong Zhang
- Cardiac Intensive Care Unit, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Regional Medical Center for Children, Hangzhou 310052, China
| | - Zhijie Zheng
- Cardiac Intensive Care Unit, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Regional Medical Center for Children, Hangzhou 310052, China
| | - Shanshan Shi
- Cardiac Intensive Care Unit, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Regional Medical Center for Children, Hangzhou 310052, China.
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Stenkjaer RL, Herling SF, Egerod I, Weis J, van Dijk M, Kudchadkar SR, Ramelet AS, Ista E. Development of a non-pharmacologic delirium management bundle in paediatric intensive care units. Nurs Crit Care 2022; 27:867-876. [PMID: 35726841 PMCID: PMC10084175 DOI: 10.1111/nicc.12809] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Non-pharmacologic interventions might be effective to reduce the incidence of delirium in pediatric intensive care units (PICU). AIM To explore expert opinions and generate informed consensus decisions regarding the content of a non-pharmacologic delirium bundle to manage delirium in PICU patients. STUDY DESIGN A two-round online Delphi study was conducted from February to April 2021. PICU experts (nurses, physicians, researchers, physical therapists, play specialists, and occupational therapists) located in Europe, North America, South America, Asia, and Australia participated. RESULTS We developed a questionnaire based on the outcomes of a comprehensive literature search in the domains: 1) cognition support; 2) sleep support; and 3) physical activity support. Under these domains, we listed 11 strategies to promote support with 61 interventions. Participants rated the feasibility of each intervention on a 9-point Likert scale (ranging from 1 strongly disagree to 9 strongly agree). A disagreement index and panel median were calculated to determine the level of agreement among experts. In the second round, participants reassessed the revised statements and ranked the interventions in each domain in order of importance for age groups: 0-2, 3-5, and 6-18 years of age. During the first Delphi round, 53 of 74 (72%) questionnaires were completed, and in the second round 45 of 74 (61%) were completed. Five of the highest ranked interventions across the age groups were: 1) developing a daily routine, 2) adjusting light exposure according to the time of day, 3) scheduling time for sleep, 4) providing eyeglasses and hearing aids if appropriate, 5) encouraging parental presence. CONCLUSIONS Based on expert consensus, we developed an age-specific non-pharmacologic delirium bundle of interventions to manage delirium in PICU patients. RELEVANCE TO CLINICAL PRACTICE An age-specific Non-Pharmacological Delirium bundle is now ready to be tested in the PICU and will hopefully reduce pediatric delirium.
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Affiliation(s)
- Rikke Louise Stenkjaer
- Department of Neonatology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Ingrid Egerod
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Janne Weis
- Department of Neonatology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Monique van Dijk
- Department of Pediatric Surgery, Pediatric Intensive care, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sapna Ravi Kudchadkar
- Anesthesiology & Critical Care Medicine, Pediatrics, and Physical Medicine & Rehabilitation, Associate Vice Chair for Research, ACCM, Johns Hopkins University School of Medicine, Charlotte Bloomberg Children's Center, Baltimore, Maryland, USA
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare (IUFRS), University of Lausanne, Lausanne, Switzerland.,Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Erwin Ista
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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de Sonnaville ESV, Kӧnigs M, van Leijden O, Knoester H, van Woensel JBM, Oosterlaan J. Intelligence outcome of pediatric intensive care unit survivors: a systematic meta-analysis and meta-regression. BMC Med 2022; 20:198. [PMID: 35642037 PMCID: PMC9158152 DOI: 10.1186/s12916-022-02390-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 04/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Long-term morbidity after pediatric intensive care unit (PICU) admission is a growing concern. Both critical illness and accompanying PICU treatments may impact neurocognitive development as assessed by its gold standard measure; intelligence. This meta-analysis and meta-regression quantifies intelligence outcome after PICU admission and explores risk factors for poor intelligence outcome. METHODS PubMed, Embase, CINAHL and PsycINFO were searched for relevant studies, published from database inception until September 7, 2021. Using random-effects meta-analysis, we calculated the standardized mean difference in full-scale intelligence quotient (FSIQ) between PICU survivors and controls across all included studies and additionally distinguishing between PICU subgroups based on indications for admission. Relation between demographic and clinical risk factors and study's FSIQ effect sizes was investigated using random-effects meta-regression analysis. RESULTS A total of 123 articles was included, published between 1973 and 2021, including 8,119 PICU survivors and 1,757 controls. We found 0.47 SD (7.1 IQ-points) lower FSIQ scores in PICU survivors compared to controls (95%CI -0.55 to -0.40, p < .001). All studied PICU subgroups had lower FSIQ compared to controls (range 0.38-0.88 SD). Later year of PICU admission (range 1972-2016) and longer PICU stay were related to greater FSIQ impairment (R2 = 21%, 95%CI -0.021 to -0.007, p < .001 and R2 = 2%, 95%CI -0.027 to -0.002, p = .03, respectively), whereas male sex and higher rate of survivors were related to smaller FSIQ impairment (R2 = 5%, 95%CI 0.001 to 0.014, p = .03 and R2 = 11%, 95%CI 0.006 to 0.022, p < .001, respectively). Meta-regression in PICU subgroups showed that later year of PICU admission was related to greater FSIQ impairment in children admitted after cardiac surgery and heart- or heart-lung transplantation. Male sex was related to smaller FSIQ impairment in children admitted after cardiac surgery. Older age at PICU admission and older age at follow-up were related to smaller FSIQ impairment in children admitted after heart- or heart-lung transplantation. CONCLUSIONS PICU survivors, distinguished in a wide range of subgroups, are at risk of intelligence impairment. Length of PICU stay, female sex and lower rate of survivors were related to greater intelligence impairment. Intelligence outcome has worsened over the years, potentially reflecting the increasing percentage of children surviving PICU admission.
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Affiliation(s)
- Eleonore S V de Sonnaville
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Intensive Care, Amsterdam Reproduction and Development research institute, Meibergdreef 9, Amsterdam, The Netherlands. .,Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatrics, Amsterdam UMC Follow-Me Program & Emma Neuroscience Group, Amsterdam Reproduction and Development research institute, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Marsh Kӧnigs
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatrics, Amsterdam UMC Follow-Me Program & Emma Neuroscience Group, Amsterdam Reproduction and Development research institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - Ouke van Leijden
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatrics, Amsterdam UMC Follow-Me Program & Emma Neuroscience Group, Amsterdam Reproduction and Development research institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - Hennie Knoester
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Intensive Care, Amsterdam Reproduction and Development research institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - Job B M van Woensel
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Intensive Care, Amsterdam Reproduction and Development research institute, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jaap Oosterlaan
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatrics, Amsterdam UMC Follow-Me Program & Emma Neuroscience Group, Amsterdam Reproduction and Development research institute, Meibergdreef 9, Amsterdam, The Netherlands
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