Pediatric Critical Care Outcomes: State of the Science

Health Care Resource Use and Costs After Hospitalization With Multiple Organ Dysfunction in Children

Importance

Multiple organ dysfunction (MOD) is a leading cause of in-hospital child mortality. For survivors, posthospitalization health care resource use and costs are unknown.

Objective

To evaluate longitudinal health care resource use and costs after hospitalization with MOD in infants (aged <1 year) and children (aged 1-18 years).

Design, Setting, and Participants

This retrospective cohort study used nationwide data from 2004 to 2019 from Optum's deidentified Clinformatics Data Mart Database, an insurance claims database. Infants and children from birth to age 18 years with an index hospitalization between January 1, 2005, and December 31, 2018, were included. Infants (age <1 year) and children (age 1-18 years) with MOD (MOD cohort) or without MOD (non-MOD cohort) were separately identified, and cohorts were propensity score weighted to balance demographics and pre-index hospitalization characteristics, including health care use and comorbidities. The data were analyzed between January 7, 2022, and September 8, 2023.

Main Outcomes and Measures

Weighted generalized estimating equations were used to evaluate differences between cohorts in rehospitalizations, emergency department visits, and health care costs up to 5 years after the index hospitalization.

Results

During the study period, 9671 children in the MOD cohort were compared with 1 691 793 children in the non-MOD cohort in the weighted sample. Infants comprised 67.4% of the MOD cohort (mean [SD] age at index hospitalization, 0.1 [0.8] years; 51.2% male) and 87% of the non-MOD cohort (mean [SD] age at index hospitalization, 0.1 [0.8] years; 50.8% male), and children comprised 32.5% of the MOD cohort (mean [SD] age at index hospitalization, 11.6 [5.7] years; 50.7% female) and 13.0% of the non-MOD cohort (mean [SD] age at index hospitalization, 11.5 [5.5] years; 51.3% female). The infant MOD cohort had more emergency department visits, with an adjusted incidence rate ratio of 1.76 (95% CI, 1.56-1.97) at 30 days; this difference persisted for years 1 through 5. Children had a similar pattern except at 30 days among those who acquired new organ-supportive technology during the index hospitalization. Among infants, the MOD cohort had more rehospitalizations, with an adjusted incidence rate ratio of 12.45 (95% CI, 11.40-13.59) at 30 days; this difference persisted for years 1 through 5. A similar pattern was observed among children. Annual health care costs were higher for the MOD cohort in year 1 (infants: mean [SD], $80 133 [$6543] vs $5183 [$19] [P < .001]; children: mean [SD], $54 113 [$17 544] vs $10 935 [$95] [P < .001]) and in all years through year 5.

Conclusions and Relevance

In this cohort study of nearly 1.7 million children, survivors of MOD accrued substantial ongoing health care resource use and cost burden after the index hospitalization. These findings suggest that follow-up care of survivors of MOD should include economic well-being alongside measures of clinical health.

Pediatric Post-Intensive Care Syndrome and Current Therapeutic Options

Post-intensive care syndrome (PICS) impacts most pediatric critical care survivors. PICS spans physical, cognitive, emotional, and social health domains and is increasingly recognized in survivorship literature. Children pose unique challenges in identifying and treating PICS given the inherent population heterogeneity in pediatric samples with biological differences across ages and neurodevelopmental stages, unique disease pathophysiology, strong environmental influences on disease and recovery, and lack of standardized measurements to identify morbidities or track response to intervention. Emerging literature and the recent development of specialized multidisciplinary clinics highlight opportunities for intervention across PICS domains in inpatient and outpatient settings.

Characterization of Awareness and Depth of Blockade During Neuromuscular Blockade Infusions in Critically Ill Children

OBJECTIVE

The Society of Critical Care Medicine released the first guideline for the prevention and -management of pain, agitation, neuromuscular blockade, and delirium in critically ill pediatric patients but offered conditional recommendations for sedation practices and monitoring during neuromuscular blockade. This study aimed to characterize sedation practices, patient awareness, and depth of blockade with neuromuscular blocking agent (NMBA) infusion administration in a single pediatric and cardiac intensive care unit.

METHODS

This retrospective chart review of critically ill pediatric patients queried orders for continuous infusion NMBA. Analgosedation agent(s), dose, and dose changes were assessed, along with depth of blockade monitoring via Train of Four (TOF) and awareness via Richmond Agitation and Sedation Scale (RASS).

RESULTS

Thirty-one patients were included, of which 27 (87%) had a documented sedation agent infusing at time of NMBA initiation and 17 patients (54%) were receiving analgesia. The most common agents used were rocuronium (n = 28), dexmedetomidine (n = 23), and morphine (n = 14). RASS scores were captured in all patients; however, 9 patients (29%) had recorded positive scores and 1 patient (3%) never achieved negative scores. TOF was only captured for 11 patients (35%), with majority of the scores being 0 or 4.

CONCLUSIONS

Majority of the study population did not receive recommended depth of blockade monitoring via TOF. Similarly, RASS scores were not consistent with deep sedation in half of the patients. The common use of dexmedetomidine as a single sedation agent calls into question the appropriateness of current sedation practices during NMBA continuous infusions.

Association of bilaterally suppressed EEG amplitudes and outcomes in critically ill children

Background and objectives

Amplitude-integrated EEG (aEEG) is used to assess electrocortical activity in pediatric intensive care if (continuous) full channel EEG is unavailable but evidence regarding the meaning of suppressed aEEG amplitudes in children remains limited. This retrospective cohort study investigated the association of suppressed aEEG amplitudes in critically ill children with death or decline of neurological functioning at hospital discharge.

Methods

Two hundred and thirty-five EEGs derived from individual patients <18 years in the pediatric intensive care unit at the University Hospital Essen (Germany) between 04/2014 and 07/2021, were converted into aEEGs and amplitudes analyzed with respect to age-specific percentiles. Crude and adjusted odds ratios (OR) for death, and functional decline at hospital discharge in patients with bilateral suppression of the upper or lower amplitude below the 10th percentile were calculated. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were assessed.

Results

The median time from neurological insult to EEG recording was 2 days. PICU admission occurred due to neurological reasons in 43% and patients had high overall disease severity. Thirty-three (14%) patients died and 68 (29%) had a functional decline. Amplitude suppression was observed in 48% (upper amplitude) and 57% (lower amplitude), with unilateral suppression less frequent than bilateral suppression. Multivariable regression analyses yielded crude ORs between 4.61 and 14.29 and adjusted ORs between 2.55 and 8.87 for death and functional decline if upper or lower amplitudes were bilaterally suppressed. NPVs for bilaterally non-suppressed amplitudes were above 95% for death and above 83% for pediatric cerebral performance category Scale (PCPC) decline, whereas PPVs ranged between 22 and 32% for death and 49-52% for PCPC decline.

Discussion

This study found a high prevalence of suppressed aEEG amplitudes in critically ill children. Bilaterally normal amplitudes predicted good outcomes, whereas bilateral suppression was associated with increased odds for death and functional decline. aEEG assessment may serve as an element for risk stratification of PICU patients if conventional EEG is unavailable with excellent negative predictive abilities but requires additional information to identify patients at risk for poor outcomes.

Post-Intensive Care Sequelae in Pediatrics-Results of an Early Rehabilitation Implementation Study

OBJECTIVES

To compare post-PICU discharge functioning, health-related quality of life (HRQL), and parental stress before and after the implementation of an early rehabilitation bundle.

DESIGN AND SETTING

Prospective cohort substudy within an early rehabilitation implementation program, conducted at the PICUs at McMaster Children's Hospital and London Health Sciences, London, Ontario, Canada.

INTERVENTIONS

A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization. Patients with an anticipated 48-hour PICU length of stay were approached for consent to participate.

PATIENTS

Critically ill children with an anticipated 48-hour PICU length of stay were approached for consent to participate.

MEASUREMENTS AND MAIN RESULTS

Patient-/proxy-reported outcome measures were assessed at baseline, PICU discharge, and 1 and 3 months post-PICU discharge using: 1) Pediatric Evaluation of Disability Inventory Computer Adaptive Test to assess physical, social, cognitive, and responsibility/caregiver domains of functioning; 2) KIDSCREEN to assess HRQL; and 3) the Pediatric Inventory for Parents to assess caregiver stress. A total of 117 participants were enrolled. Patient demographic characteristics were similar in the pre- and post-intervention groups. Following bundle implementation, 30 of 47 respondents (63.8%) experienced functional decline and 18 of 45 (40%) experienced low HRQL at PICU discharge. Eighteen of 36 (50%) at 1 month and 14 of 38 (36.8%) at 3 months experienced either persistent functional decline and/or low HRQL; 2.8% and 2.6% at 1- and 3-month follow-up, respectively, experienced both persistent functional decline and low HRQL. There were no significant differences in the rates of persistent functional decline, low HRQL, or caregiver stress scores post-bundle compared with pre-rehabilitation bundle implementation.

CONCLUSIONS

We were unable to adequately determine the efficacy of a rehabilitation bundle on patient-centered outcomes as this substudy was not powered for these outcomes. Our results did reveal that persistent low functioning is common in PICU survivors, more common than low HRQL, while experiencing both functional decline and low HRQL was uncommon.

Abnormal DNA methylation within HPA-axis genes years after paediatric critical illness

BACKGROUND

Critically ill children suffer from impaired physical/neurocognitive development 2 years later. Glucocorticoid treatment alters DNA methylation within the hypothalamus-pituitary-adrenal (HPA) axis which may impair normal brain development, cognition and behaviour. We tested the hypothesis that paediatric-intensive-care-unit (PICU) patients, sex- and age-dependently, show long-term abnormal DNA methylation within the HPA-axis layers, possibly aggravated by glucocorticoid treatment in the PICU, which may contribute to the long-term developmental impairments.

RESULTS

In a pre-planned secondary analysis of the multicentre PEPaNIC-RCT and its 2-year follow-up, we identified differentially methylated positions and differentially methylated regions within HPA-axis genes in buccal mucosa DNA from 818 former PICU patients 2 years after PICU admission (n = 608 no glucocorticoid treatment; n = 210 glucocorticoid treatment) versus 392 healthy children and assessed interaction with sex and age, role of glucocorticoid treatment in the PICU and associations with long-term developmental impairments. Adjusting for technical variation and baseline risk factors and correcting for multiple testing (false discovery rate < 0.05), former PICU patients showed abnormal DNA methylation of 26 CpG sites (within CRHR1, POMC, MC2R, NR3C1, FKBP5, HSD11B1, SRD5A1, AKR1D1, DUSP1, TSC22D3 and TNF) and three DNA regions (within AVP, TSC22D3 and TNF) that were mostly hypomethylated. These abnormalities were sex-independent and only partially age-dependent. Abnormal methylation of three CpG sites within FKBP5 and one CpG site within SRD5A1 and AKR1D1 was partly attributable to glucocorticoid treatment during PICU stay. Finally, abnormal methylation within FKBP5 and AKR1D1 was most robustly associated with long-term impaired development.

CONCLUSIONS

Two years after critical illness in children, abnormal methylation within HPA-axis genes was present, predominantly within FKBP5 and AKR1D1, partly attributable to glucocorticoid treatment in the PICU, and explaining part of the long-term developmental impairments. These data call for caution regarding liberal glucocorticoid use in the PICU.

Pediatric intensive care unit admissions network-rationale, framework and method of operation of a nationwide collaborative pediatric intensive care research network in Germany

The Pediatric Intensive Care Unit Admissions (PIA) network aims to establish a nationwide database in Germany to gather epidemiological, clinical, and outcome data on pediatric critical illness. The heterogeneity of pediatric patients in intensive care units (PICU) poses challenges in obtaining sufficient case numbers for reliable research. Multicentered approaches, such as patient registries, have proven effective in collecting large-scale data. However, Germany lacks a systematic registration system for pediatric intensive care admissions, hindering epidemiological and outcome assessments. The PIA network intends to address these gaps and provide a framework for clinical and epidemiological research in pediatric intensive care. The network will interconnect PICUs across Germany and collect structured data on diagnoses, treatment, clinical course, and short-term outcomes. It aims to identify areas for improvement in care, enable disease surveillance, and potentially serve as a quality control tool. The PIA network builds upon the existing infrastructure of the German Pediatric Surveillance Unit ESPED and utilizes digitalized data collection techniques. Participating units will complete surveys on their organizational structure and equipment. The study population includes patients aged ≥28 days admitted to participating PICUs, with a more detailed survey for cases meeting specific criteria. Data will be collected by local PIA investigators, anonymized, and entered into a central database. The data protection protocol complies with regulations and ensures patient privacy. Quarterly data checks and customized quality reports will be conducted to monitor data completeness and plausibility. The network will evaluate its performance, data collection feasibility, and data quality. Eligible investigators can submit proposals for data analyses, which will be reviewed and analyzed by trained statisticians or epidemiologists. The PIA network aims to improve pediatric intensive care medicine in Germany by providing a comprehensive understanding of critical illness, benchmarking treatment quality, and enabling disease surveillance.