Slow and Steady: A Systematic Review of ICU Care Models Relevant to Pediatric Chronic Critical Illness

[Etiology composition and prognosis of pediatric chronic critical illness in a pediatric intensive care unit]

OBJECTIVES

To explore the etiology composition and outcomes of pediatric chronic critical illness (PCCI) in the pediatric intensive care unit (PICU).

METHODS

The children who were hospitalized in the PICU of Dongguan Children's Hospital Affiliated to Guangdong Medical University and met the diagnostic criteria for PCCI from January 2017 to December 2022 were included in the study. The etiology of the children was classified based on their medical records and discharge diagnoses. Relevant clinical data during hospitalization were collected and analyzed.

RESULTS

Among the 3 955 hospitalized children in the PICU from January 2017 to December 2022, 321 cases (8.12%) met the diagnostic criteria for PCCI. Among the 321 cases, the most common etiology was infection (71.3%, 229 cases), followed by unintentional injury (12.8%, 41 cases), postoperation (5.9%, 19 cases), tumors/immune system diseases (5.0%, 16 cases), and genetic and chromosomal diseases (5.0%, 16 cases). Among the 321 cases, 249 cases (77.6%) were discharged after improvement, 37 cases (11.5%) were discharged at the request of the family, and 35 cases (10.9%) died in the hospital. Among the deaths, infection accounted for 74% (26/35), unintentional injury accounted for 17% (6/35), tumors/immune system diseases accounted for 6% (2/35), and genetic and chromosomal diseases accounted for 3% (1/35). From 2017 to 2022, the proportion of PCCI in PICU diseases showed an increasing trend year by year (P<0.05). Among the 321 children with PCCI, there were 148 infants and young children (46.1%), 57 preschool children (17.8%), 54 school-aged children (16.8%), and 62 adolescents (19.3%), with the highest proportion in the infant and young children group (P<0.05). The in-hospital mortality rates of the four age groups were 14.9% (22/148), 8.8% (5/57), 5.6% (3/54), and 8.1% (5/62), respectively. The infant and young children group had the highest mortality rate, but there was no statistically significant difference among the four groups (P>0.05).

CONCLUSIONS

The proportion of PCCI in PICU diseases is increasing, and the main causes are infection and unintentional injury. The most common cause of death in children with PCCI is infection. The PCCI patient population is mainly infants and young children, and the in-hospital mortality rate of infant and young children with PCCI is relatively high.

Slow and Steady: Optimizing Intensive Care Unit Treatment Weans for Children with Chronic Critical Illness

Pediatric chronic critical illness (PCCI) is characterized by prolonged and recurrent hospitalizations, multiorgan conditions, and use of medical technology. Our prior work explored the mismatch between intensive care unit (ICU) acute care models and the chronic needs of patients with PCCI. The objective of this study was to examine whether the number and frequency of treatment weans in ICU care were associated with clinical setbacks and/or length of stay for patients with PCCI. A retrospective chart review of the electronic medical record for 300 pediatric patients with PCCI was performed at the neonatal intensive care unit, pediatric intensive care unit, and cardiac intensive care unit of two urban children's hospitals. Daily patient care data related to weans and setbacks were collected for each ICU day. Data were analyzed using multilevel mixed multiple logistic regression analysis and a multilevel mixed Poisson regression. The patient-week level adjusted regression analysis revealed a strong correlation between weans and setbacks: three or more weekly weans yielded an odds ratio of 3.35 (95% confidence interval [CI] = 2.06–5.44) of having one or more weekly setback. There was also a correlation between weans and length of stay, three or more weekly weans were associated with an incidence rate ratio of 1.09 (95% CI = 1.06–1.12). Long-stay pediatric ICU patients had more clinical setbacks and longer hospitalizations if they had more than two treatment weans per week. This suggests that patients with PCCI may benefit from a slower pace of care than is traditionally used in the ICU. Future research to explore the causative nature of the correlation is needed to improve the care of such challenging patients.

Persistent Critical Illness in Newborns

The problem of persistent critical illness (PCI) in newborns is poorly understood. The epidemiology of this pathological condition in newborns has not been precisely established, however, it is known that PCI is considered a predictor of an unfavorable outcome in any pathology and proceeds more severely then in adults and children. Long-term outcomes of PCI in surviving newborns are associated with subsequent asthenia, cognitive impairment, chronic fatigue syndrome, a high incidence of disability, complex physiological abnormalities, and chronic organ dysfunction from which they rarely recover.Nutritional, respiratory and hemodynamic supports are key components of neonatal PCI therapy. The physiology of a newborn is different from that of an adult patient; therefore, inotropic therapy in this category of patients requires special approaches. In the past few years, in addition to dopamine, dobutamine and adrenaline, newborns have been prescribed milrinone, norepinephrine, vasopressin, and levosimendan as hemodynamic support. The clinical potential of these drugs in neonates is still under evaluation but there is some evidence for their benefits for use in PCI.

Factors influencing the length of stay among patients admitted to a tertiary pediatric intensive care unit in Saudi Arabia

This study aimed to assess the variables contributing to the length of stay in the pediatric intensive care unit. This study utilized a retrospective design by analyzing data from the Virtual Pediatric Systems web-based database. The study was conducted in a tertiary hospital-King Fahad Medical City in Riyadh, Saudi Arabia-from January 1, 2014 to December 31, 2019. The patients were admitted to intensive care with complex medical and surgical diseases. The variables were divided into quantitative and qualitative parameters, including patient data, Pediatric Risk of Mortality III score, and complications. Data from 3,396 admissions were analyzed. In this cohort, the median and mean length of stay were 2.8 (interquartile range, 1.08-7.04) and 7.43 (standard deviation, 14.34) days, respectively. The majority of long-stay patients-defined as those staying longer than 30 days-were less than 12 months of age (44.79%), had lower growth parameters (p < 0.001), and had a history of admission to pediatric intensive care units. Moreover, the majority of long-stay patients primarily suffered from respiratory diseases (51.53%) and had comorbidities and complications during their stay (p < 0.001). Multivariate analysis of all variables revealed that central line-associated bloodstream infections (p < 0.001), external ventricular drain insertion (p < 0.005), tracheostomy (p < 0.001), and use of mechanical ventilation (p < 0.001) had the most significant associations with a longer stay in the pediatric intensive care unit. The factors associated with longer stays included the admission source, central nervous system disease comorbidity, and procedures performed during the stay. Factors such as respiratory support were also associated with prolonged intensive care unit stays.

Chronic Illness in Pediatric Critical Care

Children and Youth with Special Healthcare Needs (CYSHCN), children with medical complexity (CMC), and children with chronic, critical illness (CCI) represent pediatric populations with varying degrees of medical dependance and vulnerability. These populations are heterogeneous in underlying conditions, congenital and acquired, as well as intensity of baseline medical needs. In times of intercurrent illness or perioperative management, these patients often require acute care services in the pediatric intensive care (PICU) setting. This review describes epidemiologic trends in chronic illness in the PICU setting, differentiates these populations from those without significant baseline medical requirements, reviews models of care designed to address the intersection of acute and chronic illness, and posits considerations for future roles of PICU providers to optimize the care and outcomes of these children and their families.