Clinical and electrophysiological findings and long-term outcomes in paediatric patients with critical illness polyneuromyopathy

Knowledge, attitudes and practices regarding children with ICU-acquired weakness in pediatric intensive care unit among chinese medical staff: a cross-sectional survey

BACKGROUND

ICU-AW (Intensive Care Unit Acquired Weakness) is characterized by significant muscle weakness and can be caused by a variety of factors, including immobility, medication use, and underlying medical conditions.ICU-AW can affect critically ill children who have been hospitalized in the PICU for an extended period of time.The knowledge, attitude and practice level of ICU-AW of PICU medical staff directly affect the treatment of critically ill children with ICU-AW.The aim to this study was to explore the knowledge, attitudes, and practices of Chinese medical staff regarding critically ill children with intensive care unit-acquired weakness (ICU-AW) and related factors.

METHODS

A Knowledge, Attitudes, and Practices (KAP) Questionnaire regarding critically ill children with ICU-AW was distributed to a stratified sample of 530 pediatric intensive care unit (PICU) healthcare workers. The questionnaire consisted of 31 items-with scores of 45, 40, and 40 for each dimension and a total score of 125.

RESULTS

The mean total score of Chinese PICU healthcare workers for the KAP questionnaire regarding children with ICU-AW was 87.36 ± 14.241 (53-121), with mean total knowledge, attitudes, and practices scores of 30.35 ± 6.317, 30.46 ± 5.632, and 26.54 ± 6.454, respectively. The population distribution indicated that 50.56%, 46.04%, and 3.4% of healthcare workers had poor, average, and good scores, respectively. Multiple linear regression showed that gender, education, and hospital level classification influenced the KAP level of PICU healthcare workers regarding critically ill children with ICU-AW.

CONCLUSIONS

Overall, PICU healthcare workers in China have an average KAP level about ICU-AW, and the gender and education level of PICU healthcare workers, as well as the classification of hospitals where they work, predict the KAP status of healthcare workers regarding children with ICU-AW. Therefore, healthcare leaders should plan and develop specific training programs to improve the KAP level of PICU healthcare workers.

Klinische Neurophysiologie auf der pädiatrischen Intensivstation

Auf pädiatrischen Intensivstationen kommt es häufig zum Einsatz neurophysiologischer Untersuchungsmethoden. Bei akuten Enzephalopathien oder in Situationen, in denen ein hohes Risiko für epileptische Anfälle besteht, werden verschiedene Varianten des EEGs verwendet. Bei Hinweisen auf neuromuskuläre Erkrankungen sind die Neurographie, die evozierten Potentiale, und die Elektromyographie die entscheidenden diagnostischen Methoden. Im Falle erworbener Hirnschädigungen wie z. B. nach Reanimationsereignissen oder bei Schädel-Hirn-Traumata können sowohl das EEG, als auch die evozierten Potentiale zur Prognoseabschätzung verwendet werden. Die Umstände auf der Intensivstation erschweren bei all diesen Methoden die Durchführung und die Interpretation. Viele Patienten werden mit Medikamenten behandelt, die die Untersuchungsergebnisse beeinflussen (insbesondere Sedativa und Muskelrelaxantien). Elektronische Geräte, z. B. für die Beatmung der Patienten, können zum Auftreten deutlicher Artefakte bei den neurophysiologischen Untersuchungen führen. Im vorliegenden Artikel werden die Einsatzbereiche neurophysiologischer Methoden auf pädiatrischen Intensivstationen beschrieben und auf Details bei der Anwendung eingegangen.

Physical Functioning After Admission to the PICU: A Scoping Review

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Objectives:

To conduct a scoping review to 1) describe findings and determinants of physical functioning in children during and/or after PICU stay, 2) identify which domains of physical functioning are measured, 3) and synthesize the clinical and research knowledge gaps.

Data Sources:

A systematic search was conducted in PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library databases following the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews guidelines.

Study Selection:

Two investigators independently screened and included studies against predetermined criteria.

Data Extraction:

One investigator extracted data with review by a second investigator. A narrative analyses approach was used.

Data Synthesis:

A total of 2,610 articles were identified, leaving 68 studies for inclusion. Post-PICU/hospital discharge scores show that PICU survivors report difficulties in physical functioning during and years after PICU stay. Although sustained improvements in the long-term have been reported, most of the reported levels were lower compared with the reference and baseline values. Decreased physical functioning was associated with longer hospital stay and presence of comorbidities. A diversity of instruments was used in which mobility and self-care were mostly addressed.

CONCLUSIONS:

The results show that children perceive moderate to severe difficulties in physical functioning during and years after PICU stay. Longitudinal assessments during and after PICU stay should be incorporated, especially for children with a higher risk for poor functional outcomes. There is need for consensus on the most suitable methods to assess physical functioning in children admitted to the PICU.

Critical Illness Myopathy in a Child with SARS-CoV-2 Infection

A variety of symptoms affecting the nervous system and/or skeletal muscle have been described during the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic. Though largely unexplored in children, intensive care unit-acquired weakness (ICU-AW) is associated with significant comorbidities. No previous pediatric cases of ICU-AW associated with coronavirus disease 2019 have been reported. A 12-year-old boy with SARS-CoV-2 infection developed systemic inflammatory response syndrome. Seven days later, he developed severe muscle weakness, with a creatine kinase level of 402 U/L. Nerve conduction studies and electromyography revealed a myopathic pattern. Severe pediatric cases of SARS-CoV-2 infection may develop ICU-AW. Early diagnosis and rehabilitation may decrease comorbidity and improve quality of life.

Intensive Care Unit-Acquired Weakness in Children: A Prospective Observational Study Using Simplified Serial Electrophysiological Testing (PEDCIMP Study)

Background

To study the incidence and time of onset of intensive care unit—acquired weakness in a prospective cohort of children (2–12 years) by serial simplified electrophysiological assessment (Pediatric Critical Illness Myopathy Polyneuropathy study, PEDCIMP).

Methods

A single-center, prospective cohort study (Trial Registry Number: NCT02763709; PEDCIMP2016) was conducted at the pediatric intensive care unit of a tertiary care hospital in North India. A complete electrophysiological evaluation (4 motor nerves and 2 sensory nerves) was performed at baseline in children (2–12 years) admitted to the ICU with a pediatric risk of mortality (PRISM) of > 20 with more than 24-h stay. Following the entry evaluation, a minimal alternate day simplified electrophysiological testing of the unilateral common peroneal nerve and the sural nerve was assessed. A 25% reduction in compound muscle action potential (CMAP) and sensory nerve action potential from baseline was considered significant for ICUAW and was confirmed by complete electrophysiological re-evaluation.

Results

Of the total 481 children assessed for eligibility, 97 were enrolled. The median age of the cohort was 7 years. Sepsis (81%); need for vasoactive support (43%); multiorgan dysfunction (26%) were the common reasons for admission. Of the 433 eligible patient ICU days, 380 electrophysiological observations were done. A significant decrease of > 25% in CMAP of common peroneal nerve was not detected in any of the 380 observations. However, two children unfit for inclusion were diagnosed with ICUAW during the study period.

Conclusions

Children admitted with PRISM > 20 have a very low incidence of intensive care unit—acquired weakness by serial clinical and abbreviated electrophysiological evaluation.

Electronic supplementary material

The online version of this article (10.1007/s12028-020-01123-x) contains supplementary material, which is available to authorized users.

Peripheral nerve disease secondary to systemic conditions in children

This review is an overview of systemic conditions that can be associated with peripheral nervous system dysfunction. Children may present with neuropathic symptoms for which, unless considered, a causative systemic condition may not be recognized. Similarly, some systemic conditions may be complicated by comorbid peripheral neuropathies, surveillance for which is indicated. The systemic conditions addressed in this review are critical illness polyneuropathy, chronic renal failure, endocrine disorders such as insulin-dependent diabetes mellitus and multiple endocrine neoplasia type 2b, vitamin deficiency states, malignancies and reticuloses, sickle cell disease, neurofibromatosis, connective tissue disorders, bowel dysmotility and enteropathy, and sarcoidosis. In some disorders presymptomatic screening should be undertaken, while in others there is no benefit from early detection of neuropathy. In children with idiopathic peripheral neuropathies, systemic disorders such as celiac disease should be actively excluded. While management is predominantly focused on symptomatic care through pain control and rehabilitation, some neuropathies improve with effective control of the underlying etiology and in a small proportion a more targeted approach is possible. In conclusion, peripheral neuropathies can be associated with a diverse range of medical conditions and unless actively considered may not be recognized and inadequately managed.

Neurophysiological study of critical illness polyneuropathy and myopathy in mechanically ventilated children; additional aspects in paediatric critical illness comorbidities

BACKGROUND AND PURPOSE

Critical illness polyneuropathy and myopathy (CIP/CIM) is being increasingly recognized as a significant clinical problem in critically ill children especially if they have spent long periods in the intensive care unit. So the aim was to determine the frequency of CIP/CIM amongst mechanically ventilated children and to analyse the associated risk factors and drawbacks frequently encountered in this cohort.

METHODS

The study included 105 patients admitted to the paediatric intensive care unit who underwent mechanical ventilation for ≥7 days. These patients were screened daily for awakening. Patients with severe muscle weakness on day 7 post-awakening underwent nerve conduction studies and electromyography. Accordingly, the patients were classified as CIP/CIM patients if they had abnormal neurophysiology studies or control patients if normal neurophysiology studies were obtained. Their clinical and laboratory profiles had been recorded as well.

RESULTS

Overall, of 105 patients who achieved satisfactory awakening, 34 patients (32.4%) developed CIP/CIM mostly of the axonal polyneuropathy pattern (27.6%) whilst 71 control patients (67.6%) showed normal electrophysiological studies. The mean duration of mechanical ventilation was significantly longer in patients with CIP/CIM compared to control patients (P = 0.001). The study also revealed that 62.1% of our CIP/CIM patients failed weaning trials and finally died. CIP/CIM was significantly associated with decreased platelets, elevated liver enzymes and prolonged prothrombin time. Acidosis, low serum calcium and albumin levels and higher blood glucose were also found to be more significant in CIP/CIM patients compared to control patients.

CONCLUSION

Critically ill children frequently develop CIP/CIM, mostly of axonal polyneuropathy pattern, which compromises rehabilitation and recovery and is associated with a number of comorbidities.

Physical and occupational therapy utilization in a pediatric intensive care unit

PURPOSE

To characterize the use of physical therapy (PT) and occupational therapy (OT) consultation in our pediatric intensive care unit (PICU).

MATERIALS AND METHODS

We studied children aged 1week-18years admitted to a tertiary care PICU for ≥3days. Patient characteristics, details of PT and OT sessions and adverse events were collected. A multivariable logistic regression was performed to determine factors associated with receipt of PT and OT consultation with propensity analysis followed by a regression for factors associated with outcome.

RESULTS

Of 138 children studied, 40 (29%) received PT and OT consultation. Services were initiated 6.9±10.0 (mean±standard deviation) days after PICU admission. Range of motion (83%) was the most common therapy provided and 28% of patients were ambulated. Sixty-four of 297 (21.5%) sessions were deferred and 7 (2.4%) sessions were terminated early due to physiologic instability with no serious adverse events. Children who received PT and OT were older, more likely to require neuromuscular blocking agents, and had lower pre-PICU POPC scores (all p<0.05).

CONCLUSIONS

Data are needed to inform on the efficacy of rehabilitative therapies initiated in the ICU to improve outcome for critically ill children.

Intensive care unit acquired weakness in children: Critical illness polyneuropathy and myopathy

BACKGROUND AND AIMS

Intensive care unit acquired weakness (ICUAW) is a common occurrence in patients who are critically ill. It is most often due to critical illness polyneuropathy (CIP) or to critical illness myopathy (CIM). ICUAW is increasingly being recognized partly as a consequence of improved survival in patients with severe sepsis and multi-organ failure, partly related to commonly used agents such as steroids and muscle relaxants. There have been occasional reports of CIP and CIM in children, but little is known about their prevalence or clinical impact in the pediatric population. This review summarizes the current understanding of pathophysiology, clinical presentation, diagnosis and treatment of CIP and CIM in general with special reference to published literature in the pediatric age group.

SUBJECTS AND METHODS

Studies were identified through MedLine and Embase using relevant MeSH and Key words. Both adult and pediatric studies were included.

RESULTS

ICUAW in children is a poorly described entity with unknown incidence, etiology and unclear long-term prognosis.

CONCLUSIONS

Critical illness polyneuropathy and myopathy is relatively rare, but clinically significant sequelae of multifactorial origin affecting morbidity, length of intensive care unit (ICU) stay and possibly mortality in critically ill children admitted to pediatric ICU.