Early Mobilization after Pediatric Liver Transplantation

Implementing early rehabilitation and mobilisation for children in UK paediatric intensive care units: the PERMIT feasibility study

Background

Early rehabilitation and mobilisation encompass patient-tailored interventions, delivered within intensive care, but there are few studies in children and young people within paediatric intensive care units.

Objectives

To explore how healthcare professionals currently practise early rehabilitation and mobilisation using qualitative and quantitative approaches; co-design the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual of early rehabilitation and mobilisation interventions, with primary and secondary patient-centred outcomes; explore feasibility and acceptability of implementing the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual within three paediatric intensive care units.

Design

Mixed-methods feasibility with five interlinked studies (scoping review, survey, observational study, codesign workshops, feasibility study) in three phases.

Setting

United Kingdom paediatric intensive care units.

Participants

Children and young people aged 0-16 years remaining within paediatric intensive care on day 3, their parents/guardians and healthcare professionals.

Interventions

In Phase 3, unit-wide implementation of manualised early rehabilitation and mobilisation.

Main outcome measures

Phase 1 observational study: prevalence of any early rehabilitation and mobilisation on day 3. Phase 3 feasibility study: acceptability of early rehabilitation and mobilisation intervention; adverse events; acceptability of study design; acceptability of outcome measures.

Data sources

Searched Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PEDro, Open grey and Cochrane CENTRAL databases.

Review methods

Narrative synthesis.

Results

In the scoping review we identified 36 full-text reports evaluating rehabilitation initiated within 7 days of paediatric intensive care unit admission, outlining non-mobility and mobility early rehabilitation and mobilisation interventions from 24 to 72 hours and delivered twice daily. With the survey, 124/191 (65%) responded from 26/29 (90%) United Kingdom paediatric intensive care units; the majority considered early rehabilitation and mobilisation a priority. The observational study followed 169 patients from 15 units; prevalence of any early rehabilitation and mobilisation on day 3 was 95.3%. We then developed a manualised early rehabilitation and mobilisation intervention informed by current evidence, experience and theory. All three sites implemented the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual successfully, recruited to target (30 patients recruited) and followed up the patients until day 30 or discharge; 21/30 parents consented to complete additional outcome measures.

Limitations

The findings represent the views of National Health Service staff but may not be generalisable. We were unable to conduct workshops and interviews with children, young people and parents to support the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual development due to pandemic restrictions.

Conclusions

A randomised controlled trial is recommended to assess the effectiveness of the manualised early rehabilitation and mobilisation intervention.

Future work

A definitive cluster randomised trial of early rehabilitation and mobilisation in paediatric intensive care requires selection of outcome measure and health economic evaluation.

Study registration

The study is registered as PROSPERO CRD42019151050. The Phase 1 observational study is registered Clinicaltrials.gov NCT04110938 (Phase 1) (registered 1 October 2019) and the Phase 3 feasibility study is registered NCT04909762 (Phase 3) (registered 2 June 2021).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/21/06) and is published in full in Health Technology Assessment; Vol. 27, No. 27. See the NIHR Funding and Awards website for further award information.

Nonpulmonary Treatments for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

To provide an updated review of the literature on nonpulmonary treatments for pediatric acute respiratory distress syndrome (PARDS) from the Second Pediatric Acute Lung Injury Consensus Conference.

DATA SOURCES

MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost).

STUDY SELECTION

Searches were limited to children with PARDS or hypoxic respiratory failure focused on nonpulmonary adjunctive therapies (sedation, delirium management, neuromuscular blockade, nutrition, fluid management, transfusion, sleep management, and rehabilitation).

DATA EXTRACTION

Title/abstract review, full-text review, and data extraction using a standardized data collection form.

DATA SYNTHESIS

The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-five studies were identified for full-text extraction. Five clinical practice recommendations were generated, related to neuromuscular blockade, nutrition, fluid management, and transfusion. Thirteen good practice statements were generated on the use of sedation, iatrogenic withdrawal syndrome, delirium, sleep management, rehabilitation, and additional information on neuromuscular blockade and nutrition. Three research statements were generated to promote further investigation in nonpulmonary therapies for PARDS.

CONCLUSIONS

These recommendations and statements about nonpulmonary treatments in PARDS are intended to promote optimization and consistency of care for patients with PARDS and identify areas of uncertainty requiring further investigation.

Improving Mobility Practices of Critically Ill Children

INTRODUCTION

This quality improvement project aimed to improve mobility practices in a pediatric intensive care unit.

METHOD

Three interventions were implemented: a staff-developed mobility progression guideline (including patient mobility phase identification using animal images), physical therapy (PT), and occupational therapy (OT) referrals for all patients with expected hospitalizations of more than 3 days, and the use of activity goal posters. The frequency of mobility activities performed, the number of PT and OT referrals and nurses' confidence in mobilizing patients were compared before and after project implementation.

RESULTS

Improvements occurred in the median number of daily mobility activities per patient encounter (1.5-4.0), number of PT and OT referrals (43% and 61% increase, respectively), and nurses' confidence in mobilizing patients (69% of clinical nurses agreed their confidence in mobilizing patients improved after protocol implementation).

DISCUSSION

Implementation of an interprofessional mobility quality improvement project improved mobility practices in the pediatric intensive care unit.

2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility

RATIONALE

A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available.

OBJECTIVE

To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility.

DESIGN

The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to.

METHODS

Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence.

RESULTS

The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements.

CONCLUSIONS

The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.

Nurse-driven early rehabilitation protocol for critically ill children

BACKGROUND

Physical impairment is a major morbidity in children surviving intensive care. The main objective of this study was to evaluate the effectiveness of a nurse-driven protocol in the early mobilization of critically ill children in terms of reduction of motor dysfunction, pediatric intensive care unit stays, and ventilator days. The secondary objective was to evaluate safety, in terms of injury, dislodgement of medical devices, and cardiorespiratory instability attributable to the intervention.

METHODS

The early rehabilitation intervention was initiated in July 2020. This retrospective interrupted time-series study was divided into the pre-implementation phase (January-June 2020) and the post-implementation phase (July-December 2020). The motor function domain of the Functional Status Scale was used to define the motor dysfunction after pediatric intensive care unit discharge.

RESULTS

Twenty-five children were allocated in each group. The median age of the whole cohort was 11.5 months and approximately 58% of the population was male. The baseline characteristics of both groups were not statistically significant. There was a statistically significant reduction in motor dysfunction after protocol implementation (64.0% vs 36.0%; P = 0.044) with an absolute risk reduction of 28%. The number needed to treat was 3.6 children. There were no statistically significant differences in the median ventilator days, length of stay in the intensive care unit, and hospital length of stay. No complications were found.

CONCLUSIONS

A nurse-driven protocol for the early mobilization of critically ill children was feasible and could be effective in reducing post-intensive care motor dysfunction.

Caregiver perceptions of an early mobility and communication protocol in the pediatric ICU

PURPOSE

Early mobility (EM) and patient communication have known benefits for critically ill patients, but perceived barriers exist, notably related to family and caregiver concerns. Caregiver perceptions of an EM and communication therapy protocol in the pediatric intensive care unit (PICU) were assessed.

METHODS

Caregivers of PICU patients at a free-standing academic children's hospital completed a survey using a Likert-type agreement scale on their perceptions surrounding the safety of EM, benefits of EM and communication, and barriers to EM and communication services.

RESULTS

Forty caregivers completed the survey. Most agreed or strongly agreed that EM helped their child get stronger (76%), improved their child's mood (57%), helped them to be involved in their child's care (86%), and improved their child's overall experience (78%). Most disagreed with statements relating to EM causing fear or pain (57%). Caregivers agreed that communication therapy improved overall ICU experience (75%). Free-text comments emphasized meaningful relationships with rehabilitation and unit staff.

CONCLUSION

Caregivers perceived EM and communication interventions as enriching to their child's ICU experience and the majority did not perceive that EM caused fear or pain.

Building a culture of early mobilization in the pediatric intensive care unit-a nuts and bolts approach

The culture of sedation and immobilization in the pediatric intensive care unit (PICU) is associated with PICU-acquired weakness, delirium, and poor functional, neurocognitive and psychosocial outcomes. A structured approach to introducing physical activity, as early as possible after PICU admission, may prevent these complications and optimize the holistic outcomes of critically ill children. Changing culture and introducing new clinical practice in PICU is complex, but can be approached systematically, using a "nuts and bolts" approach targeting the basic, practical considerations and essential required elements or components. Extending the construction analogy, this article reviews the relevant literature to describe the essential elements required to build and sustain a successful and safe early mobility program in the PICU. Effective early mobilization requires individual patient assessment and goal setting, using a collaborative inter-disciplinary, patient- and family-centered approach, to ensure mobility goals and physical activities are appropriate for the patient's age, condition/s, premorbid function, strength, endurance and developmental level. Early mobility activities for the pediatric age spectrum include active or active-assisted range of motion exercises, neurodevelopmental play, use of mobility devices, in-bed exercises, transfers, sitting or standing tolerance, crawling, pre-gait activities, ambulation and activities of daily living, with a focus on play as function. Although there are few complete contraindications to early mobilization, appropriate precautions and preparation should be taken to mitigate potential safety concerns. Although there are many perceived barriers to early mobilization in the PICU, at the level of patient, provider, institution and knowledge translation; these are not objectively associated with increased risk during mobilization and can be overcome through an engaged process of practice change by all members of the interprofessional clinical team. Early mobility programs could be initiated in PICU as systematic quality improvement initiatives, with established processes to optimize structural, process and system elements and to provide continual feedback, measurement, benchmarking and collaboration; to ultimately impact on measurable patient outcomes. Early, graded, and individually prescribed mobilization should be considered as part of the standard PICU "package of care" for all critically ill and injured children, in order to improve their functional status and quality of life after PICU discharge.

Development and Implementation of Pediatric ICU-based Mobility Guidelines: A Quality Improvement Initiative

Supplemental Digital Content is available in the text.

Critical illness results in physical impairments which may be mitigated by intensive care unit (ICU)-based early mobility. This initiative aimed to develop and implement ICU-based mobility guidelines for critically ill children.

Early Mobilization in a PICU: A Qualitative Sustainability Analysis of PICU Up!

OBJECTIVES

To identify staff-reported factors and perceptions that influenced implementation and sustainability of an early mobilization program (PICU Up!) in the PICU.

DESIGN

A qualitative study using semistructured phone interviews to characterize interprofessional staff perspectives of the PICU Up! program. Following data saturation, thematic analysis was performed on interview transcripts.

SETTING

Tertiary-care PICU in the Johns Hopkins Hospital, Baltimore, MD.

SUBJECTS

Interprofessional PICU staff.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Fifty-two staff members involved in PICU mobilization across multiple disciplines were interviewed. Three constructs emerged that reflected the different stages of PICU Up! program execution: 1) factors influencing the implementation process, 2) staff perceptions of PICU Up!, and 3) improvements in program integration. Themes were developed within these constructs, addressing facilitators for PICU Up! implementation, cultural changes for unitwide integration, positive impressions toward early mobility, barriers to program sustainability, and refinements for more robust staff and family engagement.

CONCLUSIONS

Three years after implementation, PICU Up! remains well-received by staff, positively influencing role satisfaction and PICU team dynamics. Furthermore, patients and family members are perceived to be enthusiastic about mobility efforts, driving staff support. Through an ongoing focus on stakeholder buy-in, interprofessional engagement, and bundled care to promote mobility, the program has become part of the culture in the Johns Hopkins Hospital PICU. However, several barriers remain that prevent consistent execution of early mobility, including challenges with resource management, sedation decisions, and patient heterogeneity. Characterizing these staff perceptions can facilitate the development of solutions that use institutional strengths to grow and sustain PICU mobility initiatives.

Barreiras e facilitadores da mobilização precoce na unidade de terapia intensiva pediátrica: revisão sistemática

RESUMO O objetivo desta revisão sistemática foi identificar as barreiras e facilitadores para a implementação da mobilização precoce em unidades de terapia intensiva pediátrica. Realizou-se uma busca sistemática baseada em estudos que abordassem barreiras e/ou facilitadores para mobilização precoce em crianças e adolescentes. Foram incluídos estudos publicados até junho de 2019 nas bases de dados MEDLINE®, Physiotherapy Evidence Database, Literatura Latino-Americana e do Caribe em Ciências da Saúde, Cochrane Library, Scientific Electronic Library Online. A seleção e a avaliação da qualidade metodológica foram realizadas por dois revisores independentes. Dados que pudessem ser identificados como barreiras e/ou facilitadores foram extraídos para análise. Foram encontrados 358 registros nas bases de dados, dos quais foram incluídos 13 artigos. Foram citadas 18 barreiras, sendo as mais citadas o número insuficiente de profissionais, e insegurança da equipe. Dos 11 facilitadores citados, os mais frequentes foram treinamento/educação da equipe multidisciplinar e a instituição de diretriz/consenso. Existem muitas barreiras a serem quebradas para que a mobilização precoce seja efetiva, porém alguns facilitadores já são conhecidos e podem ser implementados, tornando viável a sua implementação para a população pediátrica.

Measurement and reporting of physical rehabilitation interventions in pediatric critical care: a scoping review

Purpose: To describe and evaluate physical rehabilitation research in critically ill children, including physical rehabilitation intervention reporting.Methods: We searched five electronic databases to 31 December 2018 for prospective physical rehabilitation studies conducted in pediatric intensive care units (PICU). Screening was conducted independently in duplicate. Study characteristics, outcomes, and interventions were extracted from included studies. Quality of study reporting was assessed using standardized tools. Completeness of physical rehabilitation intervention reporting was assessed using the Consensus on Exercise Reporting Template (CERT).Results: We included 20 studies enrolling a total of 2644 patients. Median (Q1,Q3) sample size was 57 (44,104). Seven studies (35%) were randomized controlled trials. Eleven studies (55%) evaluated respiratory interventions, most commonly multicomponent chest physiotherapy (73%). Nine studies (45%) evaluated physical activity interventions, most commonly progressive mobility (56%). The majority of stated outcomes (92.5%) were limited to the PICU setting. Median [Q1,Q3] quality of study reporting was good (77.2% [66.7%,87.4%]), and completeness of physical rehabilitation intervention reporting was moderate (61.9% [45.9%,71.5%]).Conclusion: Physical rehabilitation studies in critically ill children were small, and focused on evaluating respiratory-based interventions and short-term PICU-based outcomes. Reporting of physical rehabilitation interventions was suboptimal. Use of CERT may improve design and reporting in future studies.Implications for rehabilitationWhile physical rehabilitation research in critically ill children is a growing field, there are currently few studies evaluating physical rehabilitation interventions in this population.Physical rehabilitation studies to date have been small, focused on evaluating respiratory-based interventions and short-term outcomes limited to the PICU setting.The reporting of physical rehabilitation interventions in this population is suboptimal, making it challenging for clinicians to reproduce interventions and appraise their efficacy or safety.

Early mobilization protocols for critically ill pediatric patients: systematic review

OBJECTIVE

To describe the existing early mobilization protocols in pediatric intensive care units.

METHODS

A systematic literature review was performed using the databases MEDLINE®, Embase, SciELO, LILACS and PeDRO, without restrictions of date and language. Observational and randomized and nonrandomized clinical trials that described an early mobilization program in patients aged between 29 days and 18 years admitted to the pediatric intensive care unit were included. The methodological quality of the studies was evaluated using the Newcastle-Ottawa Scale, Methodological Index for Non-Randomized Studies and the Cochrane Collaboration.

RESULTS

A total of 8,663 studies were identified, of which 6 were included in this review. Three studies described the implementation of an early mobilization program, including activities such as progressive passive mobilization, positioning, and discussion of mobilization goals with the team, in addition to contraindications and interruption criteria. Cycle ergometer and virtual reality games were also used as resources for mobilization. Four studies considered the importance of the participation of the multidisciplinary team in the implementation of early mobilization protocols.

CONCLUSION

In general, early mobilization protocols are based on individualized interventions, depending on the child's development. In addition, the use of a cycle ergometer may be feasible and safe in this population. The implementation of institutional and multidisciplinary protocols may contribute to the use of early mobilization in pediatric intensive care units; however, studies demonstrating the efficacy of such intervention are needed.

Benefits of Early Mobilization After Pediatric Liver Transplantation

OBJECTIVE

To evaluate the impact of early mobilization after pediatric liver transplantation in the PICU.

DESIGN

A 70-month retrospective before-after study.

SETTING

Medical and surgical PICU with 20 beds at a tertiary children's hospital.

PATIENTS

Seventy-five patients 2-18 years old who underwent liver transplantation and could walk before surgery.

INTERVENTION

We meticulously planned and implemented an early mobilization intervention, a multifaceted framework for early mobilization practice in the PICU focusing on a multidisciplinary team approach.

MEASUREMENTS AND MAIN RESULTS

There was a significant increase in the proportion of patients who received physical therapy in the PICU (66% vs 100%; p < 0.001), especially within the first 48 hours after transplantation (9% vs 78%; p < 0.001). Furthermore, the time spent for physical therapy per eligible patient and per eligible PICU day increased (8.1 min [interquartile range, 0-10.6 min] vs 17.4 min [13.2-26.6 min]; p < 0.001). Compared with patients in the pre-early mobilization period, patients in the post-early mobilization period were able to walk again for more than 50 yards without a rolling walker earlier (28 [16-66] vs 23 [19-31] postoperative days; p = 0.015 by the Gray test), and the length of hospital stay of the post-early mobilization group was shorter than that of the pre-early mobilization group (55 [37-99] vs 40 [31-54] postoperative days; p = 0.012).

CONCLUSIONS

Through implementation of early mobilization for pediatric patients who underwent liver transplantation, the duration from liver transplantation to regaining the ability to walk again without a rolling walker became shorter. Early mobilization intervention was beneficial for pediatric patients who underwent liver transplantation and could walk before surgery.