Children with chronic conditions in pediatric intensive care units located in predominantly French-speaking regions: Prevalence and implications on rehabilitation care need and utilization

Mortality following admission to the paediatric intensive care unit: A Swedish longitudinal cohort study

AIM

This study aimed to compare outcomes post-admission to a Swedish paediatric intensive care unit (PICU) in children with complex chronic conditions (CCC) and without CCC.

METHODS

In this observational registry-based study, consecutive admissions to the Astrid Lindgren Children's Hospital PICU from 1 January 2008 to 31 December 2016 were analysed. Data on demographics, predicted death rates (PDR), admission diagnoses and causes of death were collected. Mortality was recorded up to 15 years after admission and compared between groups.

RESULTS

Patients with CCC constituted 64.6% (n = 3026) of PICU admissions and 83.5% (n = 111) of PICU deaths. The crude mortality rate in PICU was 2.84% overall. CCC-patients were 2.83 times more likely to die in PICU compared to non-CCC (OR 2.83; 95% CI: 1.78-4.49). Mortality increased in the CCC-cohort up to 5 years after PICU discharge, while non-CCC patients generally survived if they survived in PICU. Of the patients who died in PICU, the median PDR was 22.9% for CCC-patients and 66.5% in the non-CCC cohort.

CONCLUSION

Children with CCC accounted for most admissions and deaths in PICU. Despite lower severity of illness scores upon admission, CCC patients were nearly three times more likely to die in PICU compared to non-CCC patients.

Speech-language pathologist involvement in the paediatric intensive care unit

PURPOSE

To measure the prevalence of speech-language pathologist (SLP) involvement and associated trends for critically ill children in United States (US) paediatric intensive care units (PICU) through secondary analysis of the Prevalence of Acute Rehab for Kids in the PICU (PARK-PICU) study data.

METHOD

A secondary analysis of cross-sectional point prevalence study conducted over 1 day in 82 US PICUs. Data collected included SLP presence, patients' age, length of stay, medical interventions, aetiology, admission data, Glasgow Coma Scale scores, staffing involvement, and family presence.

RESULT

Among 961 patients, 82 were visited by an SLP on the study day for a prevalence of 8.5%. Most visits were for children <3 years old. The odds of SLP involvement were lower for children who were 7-12 years old (vs. age 0-2; adjusted odds ratio [aOR] 0.28; 95% CI 0.1-0.8), were mechanically ventilated via endotracheal tube (vs. room air; aOR 0.02; 95% CI 0.005-0.11), or had mild or severe disability (mild vs. no disability; aOR 0.34; 95% CI 0.16-0.76 and severe vs. no disability; aOR 0.39; 95% CI 0.17-0.90). Concurrent physical and/or occupational therapy involvement was associated with higher odds of SLP involvement (aOR 3.6; 95% CI 2.1-6.4).

CONCLUSION

SLP involvement is infrequent in US PICUs. PICU teams should be educated about the scope of SLP practice, to support communication and oral feeding needs during early recovery from critical illness.

Withholding life support for children with severe neurological impairment: Prevalence and predictive factors prior to admission in the PICU

BACKGROUND

Our study aimed to evaluate the prevalence and predictive factors of withholding life support for children suffering from severe neurological impairment before admission to the pediatric intensive care unit (PICU).

METHOD

Children under 18 years of age with severe neurological impairment, who were hospitalized between January 2006 and December 2016, were included in this retrospective study. They were allocated to a withholding group or a control group, depending on whether life support was withheld or not, before admission to the PICU.

RESULTS

Overall, 119 patients were included. At admission to the PICU, the rate of withholding life support was 10 % (n = 12). Predictive factors were: (1) a previous stay in the PICU (n = 11; 92 %, p<0.01, odds ratio [OR]: 14 [2-635], p = 0.001); (2) the need for respiratory support (n = 5; 42 %, p = 0.01, OR: 6 [1-27], p = 0.01); (3) the need for feeding support (n = 10; 83 %, p = 0.01, OR: 10 [2-100], p = 0.001); and (4) a higher functional status score (FSS: 16 [12.5-19] vs. 10 [8-13], p<0.01).

CONCLUSION

The withholding of life support for children suffering from severe neurological impairment appeared limited in our pediatric department. The main predictor was at least one admission to the PICU, which raised the question of the pediatrician's role in the decision to withhold life support.

[Early mobilization in critically ill pediatric patient with ventilatory support. Experience of a high complexity center]

In the pediatric intensive care units (PICU) from our region, early mobilization (EM) in patients requiring ventilatory support is an underreported activity. For this reason, we emphasize the need for epidemiological research that allows us to know the characteristics of this relevant activity in the evolution of critically ill patients. Objective: describe the population, time of onset and frequency which MT is performed in patients who received ventilatory support in a PICU of a public pediatric hospital of Latin America. Materials and methods: descriptive, retrospective, observational study, conducted in a 17-bed medical-surgical PICU of a pediatric hospital in Argentina, between July 1 and December 31, 2019. All patients under 18 years of age requiring invasive mechanical ventilation (IMV) and/or noninvasive mechanical ventilation (NIV) for at least 24hs were included. Results: 196 patients were admitted to the study, of which 124 (63.3%) received IMV and 72 (37.7%) NIV only. During their stay in PICU 143 (73%) subjects received MT and of these, 89 (62%) started MT within the first 3 days of hospitalization. In the MT group 93 (65%) required IMV and 50 (35%) NIV. All patients who were tracheostomized in PICU received MT. Conclusion: Early mobilization in pediatric critically ill patients was feasible and early in more than 70% of the population studied. Neither age, nor weight, nor ventilatory support were barriers or limiting factors for its implementation.

Prevalence and functional status of children with complex chronic conditions in Brazilian PICUs during the COVID-19 pandemic

OBJECTIVE

The proportion of children with complex chronic conditions is increasing in PICUs around the world. We determined the prevalence and functional status of children with complex chronic conditions in Brazilian PICUs during the COVID-19 pandemic.

METHODS

The authors conducted a point prevalence cross-sectional study among fifteen Brazilian PICUs during the COVID-19 pandemic. The authors enrolled all children admitted to the participating PICUs with complex chronic conditions on three different days, four weeks apart, starting on April 4^th, 2020. The authors recorded the patient's characteristics and functional status at admission and discharge days.

RESULTS

During the 3 study days from March to June 2020, the authors enrolled 248 patients admitted to the 15 PICUs; 148 had CCC (prevalence of 59.7%). Patients had a median of 1 acute diagnosis and 2 chronic diagnoses. The use of resources/devices was extensive. The main mode of respiratory support was conventional mechanical ventilation. Most patients had a peripherally inserted central catheter (63.1%), followed by a central venous line (52.5%), and 33.3% had gastrostomy or/and tracheostomy. The functional status score was significantly better at discharge compared to admission day due to the respiratory status improvement.

CONCLUSIONS

The prevalence of children with CCC admitted to the Brazilian PICUs represented 59.7% of patients during the COVID-19 pandemic. The functional status of these children improved during hospitalization, mainly due to the respiratory component.

The Differences in Viral Etiologies between Children with and without Severe Disability Admitted to the Pediatric Intensive Care Unit with Acute Respiratory Illness

Objectives The objectives of this study were to evaluate the differences in the viral etiologies and variability in the clinical course between children with and without severe disability (SD) admitted to the pediatric intensive care unit (PICU) with acute respiratory illness (ARI).

Methods The medical records of patients admitted to our PICU between June 2017 and July 2019 were retrospectively reviewed for viral etiology and clinical course.

Results Forty-eight of 136 patients included in the study had SD. The rates of requiring positive pressure ventilation (43.5% vs. 20.5%) or inotropic support (39.9% vs. 15.9%), and the median length of stay (11 [10] vs. 5 [8]) were significantly higher in children with SD (p < 0.01, each). Influenza infection was significantly higher in children with SD (20.8% vs. 2.3%; p < 0.01) whereas respiratory syncytial virus (RSV) infection was more common in children without SD (47.7% vs. 4.2%; p < 0.01). There was no statistically significant difference in terms of other viruses between study groups.

Conclusion In this present study, influenza was an important pathogen for children with SD, while RSV was the main cause of ARI-associated PICU admission in children without SD. By focusing on increasing the rate of immunization against influenza in children with SD and their caregivers the burden of influenza-associated PICU admissions could be decreased.

Daily Practice of Mechanical Ventilation and Weaning in Turkish PICUs: A Multicenter Prospective Survey

OBJECTIVES

To investigate conventional mechanical ventilation weaning characteristics of patients requiring conventional mechanical ventilation support for greater than 48 hours within the PICU.

DESIGN

The prospective observational multicenter cohort study was conducted at 15 hospitals. Data were being collected from November 2013 to June 2014, with two designated researchers from each center responsible for follow-up and data entry.

SETTING

Fifteen tertiary PICUs in Turkey.

PATIENTS

Patients between 1 month and 18 years old requiring conventional mechanical ventilation for greater than 48 hours were included. A single-center was not permitted to surpass 20% of the total sample size. Patients with no plans for conventional mechanical ventilation weaning were excluded.

INTERVENTIONS

Conventional mechanical ventilation MEASUREMENTS AND MAIN RESULTS:: Pertinent variables included PICU and patient demographics, including clinical data, chronic diseases, comorbid conditions, and reasons for intubation. Conventional mechanical ventilation mode and weaning data were characterized by daily ventilator parameters and blood gases. Patients were monitored until hospital discharge. Of the 410 recruited patients, 320 were included for analyses. A diagnosis of sepsis requiring intubation and high initial peak inspiratory pressures correlated with a longer weaning period (mean, 3.65 vs 1.05-2.17 d; p < 0.001). Conversely, age, admission Pediatric Risk of Mortality III scores, days of conventional mechanical ventilation before weaning, ventilator mode, and chronic disease were not related to weaning duration.

CONCLUSIONS

Pediatric patients requiring conventional mechanical ventilation with a diagnosis of sepsis and high initial peak inspiratory pressures may require longer conventional mechanical ventilation weaning prior to extubation. Causative factors and optimal weaning for this cohort needs further consideration.

Prevalence of Children With Complex Chronic Conditions in PICUs of Argentina: A Prospective Multicenter Study

OBJECTIVES

To determine the prevalence of children with complex chronic conditions in PICUs in Argentina. To describe the demographic profile, clinical course and outcomes in PICU of children with complex chronic condition in comparison to previously healthy children.

DESIGN

Prospective, observational multicenter study.

SETTING

Nineteen PICUs located in Argentina belonging to public and private institutions.

PATIENTS

All children admitted to the participating PICUs between March 1, 2015, and February 28, 2016.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

We analyzed 3,483 PICU admissions. The prevalence of complex chronic condition was 48.06% (95% CI, 46.39-49.72). Cardiovascular complex chronic condition was predominant (22.24% [421/1,893]), followed by neuromuscular complex chronic condition (18.75% [355/1,893]) and malignant disease 17.7% (335/1,893). Technologic dependence was present in 22.22% of the patients (372 of 1,674). Predominant admission diagnosis was postoperative (36.6%) and respiratory disease (28.32%). Children with complex chronic condition had higher mortality than previously healthy patients (odds ratio, 2.74; 95% CI, 2.01-3.73). The risk of prolonged stay (≥ 26 d) was also higher (odds ratio, 1.44; 95% CI, 1.10-1.89). Rate utilization of the following devices was higher in patients with complex chronic condition: mechanical ventilation (odds ratio, 1.35; 95% CI, 1.12-1.63), central venous catheter (odds ratio, 1.24; 95% CI, 1.04-1.48), and arterial monitoring (odds ratio, 1.33; 95% CI, 1.09-1.63).

CONCLUSIONS

We observed a high prevalence of patients with complex chronic condition in this sample of argentine PICUs. These patients presented higher mortality and resource use than previously healthy children. This information is valuable to understand the impact that patients with complex chronic condition have on PICU performance and enables proper planning of care.

Is transcutaneous electrical muscle stimulation an alternative for preventing acquired muscle weakness in the pediatric intensive care unit? A scoping review

BACKGROUND

Transcutaneous electrical muscle stimulation (TEMS) has been progressively used as add-on therapy to reduce muscle atrophy in adults unable to carry out active mobilization in the intensive care unit (ICU). There are no studies addressing TEMS in the pediatric ICU. Therefore, we decided to develop a scoping review, a type of knowledge synthesis, which unlike systematic review, identify gaps in the literature to aid the planning and commissioning of future research.

OBJECTIVE

To provide current perspectives on the application of TEMS for combating pediatric intensive care unit acquired weakness (PICUAW).

METHODS

Online databases were used to identify papers published 2006-2016, from which we selected those used musculoskeletal and cardiorespiratory performance as a primary or secondary outcome variable in participants under 18 years.

RESULTS

The publications reported six clinical trials from 218 outpatients with 9.5 ± 8 years old. There were differences in current modulation and duration of TEMS sessions, with a predominance of high intensity and short duration in which a muscle contraction is triggered. The main use of TEMS was in pediatric neurological disorders. TEMS was more effective when compared with SHAM on spasticity, bone mineral density, disability, and gait. One study regarding spine injury showed improvement in VO₂ (P = 0.035) when combined cycling with TEMS.

CONCLUSION

TEMS was an effective and safe treatment for musculoskeletal impairments and cardiorespiratory performance in children with neurological disorders. Although the physiopathology is different in outpatients, an individualized protocol with TEMS might be promising for preventing PICUAW. Its effectiveness, however, deserves further investigation.

The role of the neuropediatrician in pediatric intensive care unit: Diagnosis, therapeutics and major participation in collaborative multidisciplinary deliberations about life-sustaining treatments' withdrawal

BACKGROUND

In Pediatric Intensive Care Unit (PICU) two types of population require the intervention of neuropediatricians (NP): chronic brain diseases' patients who face repetitive and prolonged hospitalizations, and patients with acute brain failure facing the risk of potential neurologic sequelae, and both conditions may result in a limitation of life-sustaining treatments (LLST) decision.

OBJECTIVE

To assess NP's involvement in LLST decisions within the PICU of a tertiary hospital.

METHOD

Retrospective study of medical reports of patients hospitalized during 2014 in the Necker-Hospital PICU. Patients were selected using keywords ("cardiorespiratory arrest", "death", "withdrawal of treatment", "palliative care", "acute brain failure", or "chronic neurological disease"), and/or if they were assessed by a NP during the hospitalization. Demographic and medical data were analysed, including the NP's assessment and data about Collaborative Multidisciplinary Deliberation (CMD) to discuss potential LLST.

RESULTS

Among 1160 children, 274 patients were included and 142 (56%) were assessed by a NP during their hospitalization for diagnosis (n = 55) and/or treatment (n = 95) management. NP was required for 59%-100% of patients with neurological acute failure, and for 14-44% of patients with extra neurological failure. A LLST decision was taken after a CMD for 27 (9.8%) of them, and a NP was involved in 19/27 (70%) of these decisions that occurred during the hospitalization (n = 19) or before (n = 8).12 patients died thereafter the LLST decision (40% of the 30 dead patients).

CONCLUSION

NP are clearly involved in the decision-process of LLST for patients admitted in PICU, claiming for close collaboration to improve current practices and the quality of the care provided to children.

Early Mobilization in Critically Ill Children: A Systematic Review

OBJECTIVE

To characterize how early mobilization is defined in the published literature and describe the evidence on safety and efficacy on early mobilization in critically ill children.

STUDY DESIGN

Systematic search of randomized and nonrandomized studies assessing early mobilization-based physical therapy in critically ill children under 18 years of age in MEDLINE, Embase, CINAHL, CENTRAL, the National Institutes of Health, Evidence in Pediatric Intensive Care Collaborative, Physiotherapy Evidence Database, and the Mobilization-Network. We extracted data to identify the types of mobility-based interventions and definitions for early, as well as barriers, feasibility, adverse events, and efficacy outcomes (mortality, morbidities, and length of stay).

RESULTS

Of 1199 titles found, we included 11 studies (2 pilot trials and 9 observational studies) and 1 clinical practice guideline in the analyses. Neurodevelopmentally appropriate increasing mobility levels have been described for critically ill children, and "early" mobilization was defined as either a range (within 48-72 hours) from admission to the pediatric intensive care unit or when clinical safety criteria are met. Current evidence suggests that early mobilization is safe and feasible and institutional practice guidelines significantly increase the frequency of rehabilitation consults, improve the proportion of patients who receive early mobilization, and reduce the time to mobilization. However, there were inconsistencies in populations and interventions across studies, and imprecision and risk of bias in included studies that precluded us from pooling data to evaluate the efficacy outcomes of early mobilization.

CONCLUSIONS

The definition of early mobilization varies, but seems to be feasible and safe in critically ill children. The efficacy for early mobilization in this population is yet undetermined because of the low certainty of the evidence available.

Children with life-limiting conditions in paediatric intensive care units: a national cohort, data linkage study

OBJECTIVE

To determine how many children are admitted to paediatric intensive care unit (PICU) with life-limiting conditions (LLCs) and their outcomes.

DESIGN

National cohort, data-linkage study.

SETTING

PICUs in England.

PATIENTS

Children admitted to a UK PICU (1 January 2004 and 31 March 2015) were identified in the Paediatric Intensive Care Audit Network dataset. Linkage to hospital episodes statistics enabled identification of children with a LLC using an International Classification of Diseases (ICD10) code list.

MAIN OUTCOME MEASURES

Random-effects logistic regression was undertaken to assess risk of death in PICU. Flexible parametric survival modelling was used to assess survival in the year after discharge.

RESULTS

Overall, 57.6% (n=89 127) of PICU admissions and 72.90% (n=4821) of deaths in PICU were for an individual with a LLC.The crude mortality rate in PICU was 5.4% for those with a LLC and 2.7% of those without a LLC. In the fully adjusted model, children with a LLC were 75% more likely than those without a LLC to die in PICU (OR 1.75 (95% CI 1.64 to 1.87)).Although overall survival to 1 year postdischarge was 96%, children with a LLC were 2.5 times more likely to die in that year than children without a LLC (OR 2.59 (95% CI 2.47 to 2.71)).

CONCLUSIONS

Children with a LLC accounted for a large proportion of the PICU population. There is an opportunity to integrate specialist paediatric palliative care services with paediatric critical care to enable choice around place of care for these children and families.

Practice Recommendations for Early Mobilization in Critically Ill Children

Prolonged immobility is associated with significant short- and long-term morbidities in critically ill adults and children. The majority of critically ill children remain immobilized while in the pediatric intensive care unit (PICU) due to limited awareness of associated morbidities, lack of comfort and knowledge on how to mobilize critically ill children, and the lack of pediatric-specific practice guidelines. The objective of this article was to develop consensus practice recommendations for safe, early mobilization (EM) in critically ill children. A group of 10 multidisciplinary experts with clinical and methodological expertise in physical rehabilitation, EM, and pediatric critical care collaborated to develop these recommendations. First, a systematic review was conducted to evaluate existing evidence on EM in children. Using an iterative process, the working document was circulated electronically to panel members until the group reached consensus. The group agreed that the overall goals of mobilization are to reduce PICU morbidities and optimize recovery. EM should therefore not be instituted in isolation but as part of a rehabilitation care bundle. Mobilization should not be delayed, but its appropriateness and safety should be assessed early. Increasing levels of physical activity should be individualized for each patient with the goal of achieving the highest level of functional mobility that is developmentally appropriate, for increasing durations, daily. We developed a system-based set of clinical safety criteria and a checklist to ensure the safety of mobilization in critically ill children. Although there is a paucity of pediatric evidence on the efficacy of EM, there is ample evidence that prolonged bed rest is harmful and should be avoided. These EM practice recommendations were developed to educate clinicians, encourage safe practices, reduce PICU-acquired morbidities, until future pediatric research provides evidence on effective rehabilitation interventions and how best to implement these in critically ill children.

Needs and unmet needs for rehabilitation services: a scoping review

BACKGROUND

There is a global demand for rehabilitation services but to date little attention has been paid to rehabilitation as part of the health agenda, especially in low- and middle-income countries. The objective of the scoping review was to get an overview of the needs and unmet needs for rehabilitation services described in the literature.

MATERIALS AND METHODS

Electronic search was performed in PubMed and REHABDATA for studies published between 2000 and 2017.

RESULTS

Eighty-six articles met the inclusion criteria. Results revealed a profound need for rehabilitation among different user groups with non-communicable diseases and injuries across countries. However, this need considerably outstripped the provision of services, which left many people with substantial unmet needs for rehabilitation. The main reasons for the unmet needs for rehabilitation were the absence of or unequal geographical distribution of services within a country, lack of transportation, and unaffordability of the services.

CONCLUSIONS

There are substantial unmet needs for rehabilitation and numerous barriers to accessing services. Efforts need to focus on building the capacity for rehabilitation research predominantly in low- and middle-income countries. The comprehensive data that this review provides is useful for raising awareness for the need of rehabilitation at policy level. Implications for rehabilitation There is a profound need for rehabilitation services due to the ageing population and growing prevalence of non-communicable diseases. This scoping review shows that the need for rehabilitation considerably outstrips the provision of services. There are substantial unmet needs for rehabilitation and numerous barriers to accessing services. Concerted global action to scale up quality rehabilitation services is needed, especially in low- and middle-income countries.

Early Exercise in Critically Ill Youth and Children, a Preliminary Evaluation: The wEECYCLE Pilot Trial

OBJECTIVES

To determine the feasibility of conducting a full trial evaluating the efficacy of early mobilization using in-bed cycling as an adjunct to physiotherapy, on functional outcomes in critically ill children.

DESIGN

Single center, pilot, randomized controlled trial.

SETTING

Twelve-bed tertiary care, medical-surgical PICU at McMaster Children's Hospital, Hamilton, ON, Canada.

PATIENTS

Children 3-17 years old who were limited to bed-rest with an expected PICU stay of at least 48 hours. Patients were excluded if they were at their baseline level of function, already mobilizing out of bed or expected to do so within 24 hours.

INTERVENTIONS

Patients were randomized in a 2:1 ratio to early mobilization using in-bed cycling in addition to usual care physiotherapy (cycling arm) or to usual care physiotherapy alone (control). Usual care was according to institutional practice guidelines. The primary outcome was feasibility and safety.

MEASUREMENTS AND MAIN RESULTS

Thirty patients were enrolled (20 to the cycling and 10 to control) over a 12-month period, at a 93.7% consent rate. The median (interquartile range) time from PICU admission to mobilization was 1.5 days (1-3) in the cycling arm and 2.5 days (2-7) in the control arm. Total duration of mobilization therapy in PICU was 210 (152-380) and 136 minutes (42-314 min) in cycling and control arms, respectively. Total number of PICU days mobilized was 5.0 (3-6) with cycling and 2.5 (2-4.8) with usual care. No adverse events occurred in either arm. The main threat to feasibility of mobilization was the availability of physiotherapists or research personnel.

CONCLUSIONS

Early mobilization is safe and feasible in the PICU. In-bed cycling may facilitate greater duration and intensity of mobilization, in critically ill children. A full-scale randomized controlled trial is warranted to evaluate the efficacy of this intervention on PICU-acquired morbidities and functional outcomes in this population.

Development and implementation of an early mobility program for mechanically ventilated pediatric patients

PURPOSE

Early mobility (EM) is being used in adult ICUs in an effort to treat and prevent intensive care unit acquired weakness (ICU-AW) and Post-Intensive Care Syndrome (PICS). Data supports children suffer from ICU-AW and PICS as well. Our objective was to create and implement an EM protocol for pediatric patients receiving invasive mechanical ventilation.

METHODS

A multidisciplinary EM committee was formed to create and implement an EM protocol in a quarternary care PICU. A quality database was used to prospectively monitor patient tolerance of EM sessions and for serious adverse events, defined as unplanned extubation, hemodynamic instability, loss of central venous line, loss of arterial line, displacement of ECMO cannula, or cardiopulmonary arrest.

RESULTS

Between December 2013 and October 2016, 74 patients received EM for a total of 130 unique sessions. No serious adverse events occurred. Two patients had an oxygen desaturation episode during mobility that resolved with ventilator modifications, and one patient had nasogastric tube displacement during mobility.

CONCLUSIONS

Early mobility is attainable in a quaternary care PICU population without serious adverse events, using a multidisciplinary approach and appropriate staff education. Further research is needed to understand the physical and neurocognitive benefits of EM in children.

Moral Distress in PICU and Neonatal ICU Practitioners: A Cross-Sectional Evaluation

OBJECTIVES

To measure the level of moral distress in PICU and neonatal ICU health practitioners, and to describe the relationship of moral distress with demographic factors, burnout, and uncertainty.

DESIGN

Cross-sectional survey.

SETTING

A large pediatric tertiary care center.

SUBJECTS

Neonatal ICU and PICU health practitioners with at least 3 months of ICU experience.

INTERVENTIONS

A 41-item questionnaire examining moral distress, burnout, and uncertainty.

MEASUREMENTS AND MAIN RESULTS

The main outcome was moral distress measured with the Revised Moral Distress Scale. Secondary outcomes were frequency and intensity Revised Moral Distress Scale subscores, burnout measured with the Maslach Burnout Inventory depersonalization subscale, and uncertainty measured with questions adapted from Mishel's Parent Perception of Uncertainty Scale. Linear regression models were used to examine associations between participant characteristics and the measures of moral distress, burnout, and uncertainty. Two-hundred six analyzable surveys were returned. The median Revised Moral Distress Scale score was 96.5 (interquartile range, 69-133), and 58% of respondents reported significant work-related moral distress. Revised Moral Distress Scale items involving end-of-life care and communication scored highest. Moral distress was positively associated with burnout (r = 0.27; p < 0.001) and uncertainty (r = 0.04; p = 0.008) and inversely associated with perceived hospital supportiveness (r = 0.18; p < 0.001). Nurses reported higher moral distress intensity than physicians (Revised Moral Distress Scale intensity subscores: 57.3 vs 44.7; p = 0.002). In nurses only, moral distress was positively associated with increasing years of ICU experience (p = 0.02) and uncertainty about whether their care was of benefit (r = 0.11; p < 0.001) and inversely associated with uncertainty about a child's prognosis (r = 0.03; p = 0.03).

CONCLUSIONS

In this single-center, cross-sectional study, we found that moral distress is present in PICU and neonatal ICU health practitioners and is correlated with burnout, uncertainty, and feeling unsupported.

The Impact of Chronic Health Conditions on Length of Stay and Mortality in a General PICU

OBJECTIVES

Each year approximately 20,000 children are admitted to PICUs across the United Kingdom. It is highlighted in several international studies that 40-70% of children admitted to PICUs have at least one chronic health condition that leads to increased length of stay and higher mortality rates. The prevalence of chronic health conditions in children admitted to U.K. PICUs is unknown. The purpose of this study was to use existing clinical data to explore the prevalence and impact of chronic health conditions on length of stay and mortality in a tertiary U.K. PICU.

DESIGN

Single-centre retrospective observational cohort study.

SETTING

Single, tertiary referral PICU.

PATIENTS

One thousand one hundred ninety-seven children 0-18 years old admitted between March 1, 2009, and February 28, 2013.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data were derived from the unit's data submitted to the Paediatric Intensive Care Audit Network, the U.K. national PICU dataset. Data included demographics, diagnosis, Pediatric Index of Mortality-2 score, PICU interventions, PICU outcomes, chronic health condition etiologies, admission, and discharge dates and times. In total, 554 of 1,197 (46.3%) had at least one chronic health condition. Of 554, 371 patients (67.1%) presented with a single chronic health condition, 126 (22.6%) with two chronic health conditions, and 57 (10.3%) with at least three chronic health conditions to a maximum of four chronic health conditions. There was a statistically significant difference in length of stay in those with a chronic health condition compared with those without (medians, 4 vs 3 d [interquartile range, 1-7 d]; Mann-Whitney U test, p < 0.001). The length of stay also increased significantly according to the number of chronic health conditions (Kruskal-Wallis test, p < 0.001). Mortality was significantly different between those with and without chronic health conditions (8.8% vs 5.4%; chi-square test, p = 0.024). Having two or at least three chronic health conditions significantly increased mortality compared with no chronic health conditions (odds ratio, 2.3 [CI, 1.2-4.55]; p = 0.013 and 2.95 [CI, 1.28-6.8]; p = 0.011), respectively.

CONCLUSIONS

The increasing number of chronic healthcare conditions is associated with length of stay and mortality.

Pediatric Critical Care Resource Use by Children with Medical Complexity

OBJECTIVES

To examine the proportionate use of critical care resources among children of differing medical complexity admitted to pediatric intensive care units (ICUs) in tertiary-care children's hospitals.

STUDY DESIGN

This is a retrospective, cross-sectional study of all children (<19 years of age) admitted to a pediatric ICU between January 1, 2012, and December 31, 2013, in the Pediatric Health Information Systems database. Using the Pediatric Medical Complexity Algorithm, we assigned patients to 1 of 3 categories: no chronic disease, noncomplex chronic disease (NC-CD), or complex chronic disease (C-CD). Baseline demographics, hospital costs, and critical care resource use were stratified by these groups and summarized.

RESULTS

Of 136 133 children with pediatric ICU admissions, 53.0% were categorized as having C-CD. At the individual-encounter level, ICU resource use was greatest among patients with C-CD compared with children with NC-CD and no chronic disease. At the hospital level, patients with C-CD accounted for more than 75% of all examined ICU resources, including ventilation days, ICU costs, extracorporeal membrane oxygenation runs, and arterial and central venous catheters. Children with a progressive condition accounted for one-half of all ICU resources. In contrast, patients with no chronic disease and NC-CD accounted for less than one-quarter of all ICU therapies.

CONCLUSION

Children with medical complexity disproportionately use the majority of ICU resources in children's hospitals. Efforts to improve quality and provide cost-effective care should focus on this population.

Is it taking longer to die in paediatric intensive care in England and Wales?

INTRODUCTION

All-cause infant and childhood mortality has decreased in the UK over the last 30 years. Advances in paediatric critical care have increased survival in paediatric intensive care units (PICUs) but may have affected how and when children die in PICU. We explored factors affecting length of stay (LOS) of children who died in PICU over an 11-year period.

METHODS

We analysed demographic and clinical data of 165 473 admissions to PICUs in England and Wales, from January 2003 to December 2013. We assessed time trends in LOS for survivors and non-survivors and explored the effect of demographic and clinical characteristics on LOS for non-survivors.

RESULTS

LOS increased 0.310 days per year in non-survivors (95% CI 0.169 to 0.449) and 0.064 days per year in survivors (95% CI 0.046 to 0.083). The proportion of early deaths (<24 h of admission) fell 0.44% points per year (95% CI -0.971 to 0.094), but the proportion of late deaths (>28 days of PICU stay) increased by 0.44% points per year (95% CI 0.185 to 0.691). The paediatric index of mortality score in early deaths increased by 0.77% points per year (95% CI 0.31% to 1.23%).

DISCUSSION

Increased LOS in children who die in PICU is driven by a decreased proportion of early deaths and an increased proportion of late deaths. This trend, combined with an increase in the severity of illness in early deaths, is consistent with a reduction in early mortality for acutely ill children, but a prolongation of life for those children admitted to PICU with life-limiting illnesses.

Transforming PICU Culture to Facilitate Early Rehabilitation

Children who survive a critical illness are at risk of developing significant, long-lasting morbidities that may include neuromuscular weakness, cognitive impairments, and new mental health disorders. These morbidities, collectively known as post-intensive care syndrome (PICS), may lead to functional impairments, difficulty in school and social settings, and reduced quality of life. Interventions aimed at rehabilitation such as early mobilization, sedation minimization and prevention of ICU-acquired weakness, delirium, and posttraumatic stress disorder may lead to improved clinical outcomes and functional recovery in critically ill children. Acute rehabilitation is challenging to implement in a pediatric intensive care unit (PICU), and a culture change is needed to effect widespread transformation in this setting. Our objectives in this article are to review the evidence on PICS in children and strategies for affecting culture change to facilitate early rehabilitation in the PICU.

In-Bed Mobilization in Critically Ill Children: A Safety and Feasibility Trial

The objective of this study was to evaluate the feasibility and safety of implementing two methods of in-bed mobilization in critically ill children. This prospective cohort trial was conducted at McMaster Children's Hospital, Pediatric Critical Care Unit (PCCU). Hemodynamically stable patients aged 3 to 17 years with a longer than 24-hour PCCU stay were eligible to participate in the study. Children with cardiorespiratory instability, already mobilizing well or at their baseline mobility, anticipated death during this PCCU admission, and those with contraindications to mobilization were excluded. Two methods of mobilization were applied for a maximum of 2 days, respectively, depending on the level of consciousness and cognitive ability of the participant. In-bed cycling was used for passive mobilization and interactive video games (VG) were used for active mobilization. The primary outcomes were safety and feasibility. Secondary outcomes were physical activity during the study period, as reflected by accelerometer measurements. A total of 406 patients were screened over 1 year, 35 of who were eligible and 31 (89%) consented to participate. Median age of participants was 11 years (quartile 1 is 6 years and quartile 3 is 14 years), and 15 (48%) were male. Twenty-five (81%) participants received the study intervention, 22 (88%) of who received the intervention within 24 hours of consent. Twenty-one (84%) participants received in-bed cycling, five (20%) received VG, and only one received both. Fifteen (60%) completed the prescribed 2-day intervention, while in 11 (44%) the intervention was interrupted or not applied, most commonly because the patient was transferred out of the PCCU. Physical activity was greater during the intervention compared with nonintervention times with in-bed cycling, but not with VG. There were no adverse events attributable to the intervention. This pilot reveals that in-bed cycling can enhance physical activity, and appears to be safe and feasible in this group of critically ill children. VG was feasible only in a minority of patients who were cooperative and age appropriate. Further research is necessary to evaluate the efficacy and most appropriate methods of enhancing mobility and rehabilitation in this population.

Early mobilization in the pediatric intensive care unit: a systematic review

Children admitted to the pediatric intensive care unit (PICU) can experience significant morbidity as a consequence of mechanical ventilation and sedative medications. This morbidity could potentially be decreased with the implementation of activities to promote early mobilization during critical illness. The objective of this systematic review is to summarize the current evidence regarding rehabilitation therapies in the PICU and to highlight the knowledge gaps and avenues for future research on early mobilization in the PICU. Using a combination of controlled vocabulary and key word terms PubMed, CINAHL, and EMBASE databases were searched; no limiters were imposed on search strategies. Two reviewers abstracted data and assessed quality independently. From the 1928 articles identified in the search 168 abstracts were identified for full text review. Fifty-nine articles were chosen for data extraction and five were identified for inclusion in review. A sixth article was identified through expert clinician query. The studies were categorized into three groups based on the outcomes discussed: safety and feasibility, functional outcomes, and length of stay. A synthesis of the studies indicates that early rehabilitation in the PICU is safe and feasible with potential short and long-term benefits. Institutional, provider and patient-related barriers to initiation of early rehabilitation in the PICU are identified. Recommendations for future investigation include early rehabilitation protocols for children hospitalized in the PICU and identification of outcome measures.

Functional recovery following critical illness in children: the "wee-cover" pilot study

OBJECTIVE

To determine the feasibility of conducting a longitudinal prospective study to evaluate functional recovery and predictors of impaired functional recovery in critically ill children.

DESIGN

Prospective pilot study.

SETTING

Single-center PICU at McMaster Children's Hospital, Hamilton, Canada.

PATIENTS

Children aged 12 months to 17 years, with at least one organ dysfunction, limited mobility or bed rest during the first 48 hours of PICU admission, and a minimum 48-hour PICU length of stay, were eligible. Patients transferred from a neonatal ICU prior to ever being discharged home, already mobilizing well or at baseline functional status at time of screening, with an English language barrier, and prior enrollment into this study, were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was feasibility, as defined by the ability to screen, enroll eligible patients, and execute the study procedures and measurements on participants. Secondary outcomes included functional status at baseline, 3 and 6 months, PICU morbidity, and mortality. Functional status was measured using the Pediatric Evaluation of Disability Inventory and the Participation and Environment Measure for Children and Youth. Thirty-three patients were enrolled between October 2012 and April 2013. Consent rate was 85%, and follow-up rates were 93% at 3 months and 71% at 6 months. We were able to execute the study procedures and measurements, demonstrating feasibility of conducting a future longitudinal study. Functional status deteriorated following critical illness. Recovery appears to be influenced by baseline health or functional status and severity of illness.

CONCLUSION

Longitudinal research is needed to understand how children recover after a critical illness. Our results suggest factors that may influence the recovery trajectory and were used to inform the methodology, outcomes of interest, and appropriate sample size of a larger multicenter study evaluating functional recovery in this population.

What is the role of the physiotherapist in paediatric intensive care units? A systematic review of the evidence for respiratory and rehabilitation interventions for mechanically ventilated patients

BACKGROUND

Physiotherapy in intensive care units (ICU) has traditionally focussed on the respiratory management of mechanically ventilated patients. Gradually, focus has shifted to include rehabilitation in adult ICUs, though evidence of a similar shift in the paediatric ICU (PICU) is limited.

OBJECTIVES

Review the evidence to determine the role of physiotherapists in the management of mechanically ventilated patients in PICU.

DATA SOURCES

A search was conducted of: PEDro, CINAHL, Medline, PubMed and the Cochrane Library.

ELIGIBILITY CRITERIA

Studies involving PICU patients who received physiotherapy while invasively ventilated were included in this review. Those involving neonatal or adult ICU patients, or patients on non-invasive or long-term ventilation, were not included in the study.

STUDY APPRAISAL

All articles were critically appraised by two reviewers and results were analysed descriptively.

RESULTS

Six studies on chest physiotherapy (CPT) met the selection criteria. Results support the use of the expiratory flow increase technique and CPT, especially manual hyperinflation and vibrations, for secretion clearance. Evidence does not support the routine use of either CPT or suction alone. No studies investigating rehabilitation in PICU met selection criteria.

LIMITATIONS

A lack of high level evidence was available to inform this review.

CONCLUSION

Evidence indicates that CPT is still the focus of physiotherapy intervention in PICU for mechanically ventilated patients, and supports its use for secretion clearance in this setting. PROSPERO register for systematic reviews (registration no. CRD42014009582).

Acute rehabilitation practices in critically ill children: a multicenter study

OBJECTIVE

To evaluate acute rehabilitation practices in pediatric critical care units across Canada.

DESIGN

Retrospective cohort study.

SETTING

Six Canadian, tertiary care pediatric critical care units.

PATIENTS/SUBJECTS

Six hundred children aged under 17 years admitted to pediatric critical care unit during a winter and summer month of 2011 with a greater than 24-hour length of stay.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome of interest was the nature and timing of pediatric critical care unit rehabilitation practices.Rehabilitation was classified according to mobility and nonmobility interventions. Predictors of mobilization and the time to mobilization were evaluated through regression and time-dependent survival analyses, respectively. The most common form of rehabilitation provided in pediatric critical care unit was physical therapy (45.5% patients) followed by occupational therapy (4.5%) and speech and language therapy (1.5%). Interventions were primarily nonmobility in nature (69.7% of sessions), most frequently in the form of chest physiotherapy (42.7% of sessions). The median time to mobilization was 2 days (interquartile range, 1-6) as compared with 1 day for nonmobility interventions (interquartile range, 1-3). Only 57 patients (9.5%) received early mobilization. Regression analyses revealed that increasing age, admission during winter, neuromuscular blockade, and sedative infusions were associated with an increased likelihood of receiving mobility therapy. Increasing age was a predictor of early mobilization, while neuromuscular blockade was associated with delayed mobilization. No significant differences in adverse events were found between nonmobility and mobility interventions.

CONCLUSIONS

Only half of the children receive rehabilitation while in the pediatric critical care unit, and when it occurs, therapy is primarily focused on respiratory function. Mobilization appears to be reserved for at-risk children who were muscle relaxed and sedated; however, its implementation in these patients is delayed. Future pediatric-specific research is essential to identify patients at risk and to understand treatment priorities and rehabilitation strategies to improve functional recovery in critically ill children.

Early mobilization in critically ill children: a survey of Canadian practice

OBJECTIVES

While early mobilization is safe and enhances functional recovery in critically ill adults, rehabilitation practices in critically ill children are not well characterized. The objective of this study was to evaluate the knowledge, perceptions, and stated practices of early mobilization among physicians and physiotherapists practicing in Canadian pediatric critical care units.

DESIGN AND MEASUREMENTS

A self-administered survey was mailed to 102 physicians and 35 physiotherapists. Survey domains included barriers to early mobilization, the timing, nature and thresholds for rehabilitation, and staffing workload. We assessed for associations using chi-square tests.

MAIN RESULTS

The overall response rate was 64.2% (88 of 137), representing 59.8% (61 of 102) physicians and 77.1% (27 of 35) physiotherapists, respectively. Key institutional barriers to early mobilization included a lack of practice guidelines (75.4% physician, 48.1% physiotherapist respondents; p = 0.01) and the need for physician orders prior to initiating physiotherapy (26.2% physician vs 55.6% physiotherapist, p = 0.008). Only 3.4% of respondents reported having local guidelines for early mobilization. Conflicting perceptions regarding the clinical thresholds for early mobilization and the safety of early mobilization were the most commonly reported patient-level barriers. Increasing illness severity was associated with decreased clinician comfort with early mobilization. Respiratory physiotherapy and passive range of motion were the most frequently applied rehabilitation interventions (77.8%), while pregait physiotherapy and ambulation were only sometimes or infrequently (70.4%) used. The type and extent of physiotherapy varied depending on the time of day and week.

CONCLUSIONS

There are numerous perceived institutional, patient- and provider-level barriers to early mobilization in Canadian pediatric critical care units, and diverse opinions on the appropriateness of early mobilization. Limited awareness of existing literature and the lack of practice guidelines on early mobilization are not surprising in light of the paucity of pediatric-specific evidence. These results strongly support the need for further research, evaluating the feasibility, safety, and efficacy of early mobilization in critically ill children.

Chronic conditions among children admitted to U.S. pediatric intensive care units: their prevalence and impact on risk for mortality and prolonged length of stay*

OBJECTIVE

To estimate the prevalence of chronic conditions among children admitted to U.S. pediatric intensive care units and to assess whether patients with complex chronic conditions experience pediatric intensive care unit mortality and prolonged length of stay risk beyond that predicted by commonly used severity-of-illness risk-adjustment models.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort analysis of 52,791 pediatric admissions to 54 U.S. pediatric intensive care units that participated in the Virtual Pediatric Intensive Care Unit Systems database in 2008.

MEASUREMENTS

Hierarchical logistic regression models, clustered by pediatric intensive care unit site, for pediatric intensive care unit mortality and length of stay >15 days. Standardized mortality ratios adjusted for severity-of-illness score alone and with complex chronic conditions.

MAIN RESULTS

Fifty-three percent of pediatric intensive care unit admissions had complex chronic conditions, and 18.5% had noncomplex chronic conditions. The prevalence of these conditions and their organ system subcategories varied considerably across sites. The majority of complex chronic condition subcategories were associated with significantly greater odds of pediatric intensive care unit mortality (odds ratios 1.25-2.9, all p values < .02) compared to having a noncomplex chronic condition or no chronic condition, after controlling for age, gender, trauma, and severity-of-illness. Only respiratory, gastrointestinal, and rheumatologic/orthopedic/psychiatric complex chronic conditions were not associated with increased odds of pediatric intensive care unit mortality. All subcategories were significantly associated with prolonged length of stay. All noncomplex chronic condition subcategories were either not associated or were negatively associated with pediatric intensive care unit mortality, and most were not associated with prolonged length of stay, compared to having no chronic conditions. Among this group of pediatric intensive care units, adding complex chronic conditions to risk-adjustment models led to greater model accuracy but did not substantially change unit-level standardized mortality ratios.

CONCLUSIONS

Children with complex chronic conditions were at greater risk for pediatric intensive care unit mortality and prolonged length of stay than those with no chronic conditions, but the magnitude of risk varied across subcategories. Inclusion of complex chronic conditions into models of pediatric intensive care unit mortality improved model accuracy but had little impact on standardized mortality ratios.