A Core Outcome Measurement Set for Pediatric Critical Care

Neurodevelopmental outcome and quality of life in children admitted to the paediatric intensive care unit: A single-centre Australian cohort study

BACKGROUND

The development of new morbidities has become increasingly identified in paediatric critical care medicine. To date, there has been limited research of long-term outcomes following paediatric critical illness in Australia.

OBJECTIVES

The objective of this study was to quantify neurodevelopmental impairments in children following paediatric intensive care unit (PICU) discharge and their association with health-related quality of life (HRQoL).

METHODS

A single-centre ambidirectional cohort study at an Australian hospital. Parents of children admitted to the PICU between 2015 and 2017 were invited to participate. Neurodevelopmental outcome and HRQoL was prospectively evaluated, using the Ages and Stages Questionnaire (<5 years), Strengths and Difficulties Questionnaire (≥5 years), and Pediatric Quality of Life Inventory™, respectively.

RESULTS

A total of 230 parents of critically ill children participated. Children were 1.9 years old (median, interquartile range [IQR]: 0.2, 7.5), male (59.6%), and ventilated (49.1%) at PICU admission. The median time to follow-up was 24.4 months (IQR: 16.3, 36.7). Parent respondents were more likely to be female (85.5%), White (88.3%), and partnered (81.1%). The incidence of overall neurodevelopmental impairment was 30% (33% in children aged <5 years; 24% in children aged ≥5 years). The incidence of poor HRQoL was 37.9%. History of developmental delay was independently associated with overall neurodevelopmental impairment (adjusted odds ratio [aOR]: 4.21, 95% confidence interval: 2.05, 8.63) and poor HRQoL (aOR: 7.29, 95% confidence interval: 3.26, 16.27). Two or more PICU admissions (aOR: 4.10, IQR: 1.82, 9.26) was also associated with poor HRQoL.

CONCLUSIONS

This is the first contemporary view of PICU long-term outcomes conducted in Australia and significantly informs ongoing research in this area. Approximately one-third of PICU survivors demonstrate neurodevelopmental impairment and reduced quality of life. Multiple domains of post-intensive care syndrome-paediatrics must be considered to have a comprehensive understanding of child outcomes. Assessment of baseline/premorbid functioning is also essential in order to understand the true impact of illness and PICU admission.

ECMO Survivors' Reflections on Their ICU Experience and Recovery

OBJECTIVE

As pediatric mortality improves, approaches to pediatric critical care now focus on understanding long-term implications of survivorship on patients and families. We aimed to characterize how patients recall time spent sedated and recovering to identify areas for improvement in patient outcomes.

METHODS

We undertook qualitative analysis using semistructured interviews of pediatric patients requiring extra-corporeal support in our intensive care units from 2018 to 2023. All patients were English-speaking, >12 years old at time of hospitalization, and able to communicate at an age-appropriate level. Priority sampling was given to those with more recent hospitalizations to improve recall. Interviews were recorded and transcribed before thematic, inductive analysis.

RESULTS

Forty-one patients met inclusion criteria; 14 patients were enrolled before achieving thematic saturation. Several themes emerged, centering on cognitive, physical, and socioemotional experiences during and after hospitalization. Notable findings include profound awareness under sedation, impaired sleep, challenges with communication, physical discomfort, frustration with activities of daily living limitations, and gratitude for provider and family presence. Postdischarge, patients highlighted persistent memory, concentration, sleep, and physical impairments, as well as emotional processing of their illness and mortality.

CONCLUSIONS

Our findings describe how pediatric critical illness impacts short and long term cognitive, physical, and socioemotional outcomes for children in the ICU. Future research is necessary to study if there are specific, modifiable factors in patients' care that impacts their experience of critical illness, such as specific medication choices, diagnoses, communication styles, or physical and speech therapy interventions.

Pediatric Acute Respiratory Distress Syndrome Severity and Health-Related Quality of Life Outcomes: Single-Center Retrospective Cohort, 2011-2017

OBJECTIVES

To determine factors associated with health-related quality of life (HRQL) decline among pediatric acute respiratory distress syndrome (PARDS) survivors.

DESIGN

Retrospective cohort study.

SETTING

Academic children's hospital.

PATIENTS

Three hundred fifteen children 1 month to 18 years old with an unplanned PICU admission from December 2011 to February 2017 enrolled in the hospital's Outcomes Assessment Program.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Pre-admission baseline and median 6-week post-discharge HRQL were assessed using the Pediatric Quality of Life Inventory or the Functional Status II-R. Patients meeting retrospectively applied Second Pediatric Acute Lung Injury Consensus Conference criteria for PARDS were identified, and PARDS severity was classified using binary (mild/moderate, severe) and trichotomous (mild, moderate, severe) categorization for noninvasive ventilation and invasive mechanical ventilation (IMV). PARDS occurred in 41 of 315 children (13.0%). Clinically important HRQL decline (≥ 4.5 points) occurred in 17 of 41 patients (41.5%) with PARDS and 64 of 274 without PARDS (23.4%). On multivariable generalized linear regression adjusted for age, baseline Pediatric Overall Performance Category, maximum nonrespiratory Pediatric Logistic Organ Dysfunction score, diagnosis, length of stay, and time to follow-up, PARDS was associated with HRQL decline (adjusted relative risk [aRR], 1.70; 95% CI, 1.03-2.77). Four-hour and maximum PARDS severity were the only factors associated with HRQL decline. HRQL decline occurred in five of 18 patients with mild PARDS at 4 hours, five of 13 with moderate PARDS (aRR 2.35 vs. no PARDS [95% CI, 1.01-5.50]), and seven of ten with severe PARDS (aRR 2.56 vs. no PARDS [95% CI, 1.45-4.53]). The area under the receiver operating characteristic curve for discrimination of HRQL decline for IMV patients was 0.79 (95% CI, 0.66-0.91) for binary and 0.80 (95% CI, 0.69-0.93) for trichotomous severity categorization.

CONCLUSIONS

HRQL decline is common among children surviving PARDS, and risk of decline is associated with PARDS severity. HRQL decline from baseline may be an efficient and clinically meaningful endpoint to incorporate into PARDS clinical trials.

The burden and contemporary epidemiology of sepsis in children

Sepsis is a dysregulated host response to infection that leads to life-threatening organ dysfunction. Half of the 50 million people affected by sepsis globally every year are neonates and children younger than 19 years. This burden on the paediatric population translates into a disproportionate impact on global child health in terms of years of life lost, morbidity, and lost opportunities for children to reach their developmental potential. This Series on paediatric sepsis presents the current state of diagnosis and treatment of sepsis in children, and maps the challenges in alleviating the burden on children, their families, and society. Drawing on diverse experience and multidisciplinary expertise, we offer a roadmap to improving outcomes for children with sepsis. This first paper of the Series is a narrative review of the burden of paediatric sepsis from low-income to high-income settings. Advances towards improved operationalisation of paediatric sepsis across all age groups have facilitated more standardised assessment of the Global Burden of Disease estimates of the impact of sepsis on child health, and these estimates are expected to gain further precision with the roll out of the new Phoenix criteria for sepsis. Sepsis remains one of the leading causes of childhood morbidity and mortality, with immense direct and indirect societal costs. Although substantial regional differences persist in relation to incidence, microbiological epidemiology, and outcomes, these cannot be explained by differences in income level alone. Recent insights into post-discharge sequelae after paediatric sepsis, ranging from late mortality and persistent neurodevelopmental impairment to reduced health-related quality of life, show how common post-sepsis syndrome is in children. Targeting sepsis as a key contributor to poor health outcomes in children is therefore an essential component of efforts to meet the Sustainable Development Goals.

Supporting families during pediatric critical illness: Opportunities identified in a multicenter, qualitative study

Critical illness resulting in a pediatric intensive care unit (PICU) admission is a profoundly stressful experience for a child and their family. Increasing evidence for emotional and behavioral sequelae post-PICU emphasizes a need to provide better support for families throughout this period of care and recovery. The aim of this qualitative investigation was to identify salient and modifiable aspects of a critical care experience that can be addressed to better support families of critically ill children. Individual semi-structured interviews were conducted with 26 caregivers of children who survived a PICU admission. Interviews were audio-recorded and transcribed verbatim; themes were identified via thematic analysis. Caregivers were enrolled using convenience sampling from seven tertiary care PICUs in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Themes from caregiver interviews were identified within two overarching categories containing three themes each. Advice for future PICU families: (1) Be intentional about caring for your own well-being, (2) speak up, ask questions, and challenge decisions you're not comfortable with, and (3) continue to engage with your child. Characteristics of a satisfactory PICU experience: (1) A caregiver-provider relationship of mutual trust established through clear communication and respectful collaboration, (2) hospital environments that provide physical and social supports to maintain humanity in healthcare, and (3) preparing families for care transitions. Targeted, interdisciplinary approaches to partner with families during critical care may improve their PICU experience and contribute to improved long-term outcomes for PICU survivors.

Long-term follow-up in pediatric intensive care-a narrative review

Pediatric intensive care is a rapidly developing medical specialty and with evolving understanding of pediatric pathophysiology and advances in technology, most children in the developed world are now surviving to intensive care and hospital discharge. As mortality rates for children with critical illness continue to improve, increasing PICU survivorship is resulting in significant long-term consequences of intensive care in these vulnerable patients. Although impairments in physical, psychosocial and cognitive function are well documented in the literature and the importance of establishing follow-up programs is acknowledged, no standardized or evidence-based approach to long-term follow-up in the PICU exists. This narrative review explores pediatric post-intensive care syndrome and summarizes the multifactorial deficits and morbidity that can occur in these patients following recovery from critical illness and subsequent discharge from hospital. Current practices around long-term follow-up are explored with discussion focusing on gaps in research and understanding with suggested ways forward and future directions.

Effectiveness of Injectable Platelet-Rich Fibrin Therapy in Alopecia and Facial Rejuvenation: A Systematic Review

Platelet-rich fibrin (PRF) has gained attention in regenerative medicine for its potential to enhance tissue repair and regeneration. Its application in dermatology, particularly for treating alopecia and facilitating facial rejuvenation, is of significant interest but requires systematic evaluation. This review aims to systematically assess the effectiveness of injectable PRF therapy in treating alopecia and facial rejuvenation procedures. We searched PubMed, Scopus, and Web of Science for studies published up to 2023 that involved injectable PRF for alopecia and facial rejuvenation. Eligible studies included prospective cohorts, original studies, case series, and retrospective studies that reported clinical outcomes. Key outcomes were improved hair growth for alopecia and skin texture, elasticity, and appearance for facial rejuvenation. Seven studies met the inclusion criteria, encompassing 130 patients. For alopecia, three studies reported a noticeable improvement in hair density and growth. For facial rejuvenation, four studies demonstrated moderate to significant improvements in skin texture and elasticity and a reduction in facial wrinkles and lines, confirmed by both subjective assessments and objective measurements such as VISIA® skin analysis. Injectable PRF therapy shows promise in treating androgenetic alopecia and enhancing facial esthetics, indicating its potential as an effective treatment option in regenerative dermatology. However, further research involving larger sample sizes, control groups, and longer follow-ups is required to validate these findings and establish standardized treatment protocols.

Association of Pediatric Postcardiac Arrest Ventilation and Oxygenation with Survival Outcomes

Rationale: Adult and pediatric studies provide conflicting data regarding whether post-cardiac arrest hypoxemia, hyperoxemia, hypercapnia, and/or hypocapnia are associated with worse outcomes. Objectives: We sought to determine whether postarrest hypoxemia or postarrest hyperoxemia is associated with lower rates of survival to hospital discharge, compared with postarrest normoxemia, and whether postarrest hypocapnia or hypercapnia is associated with lower rates of survival, compared with postarrest normocapnia. Methods: An embedded prospective observational study during a multicenter interventional cardiopulmonary resuscitation trial was conducted from 2016 to 2021. Patients ⩽18 years old and with a corrected gestational age of ≥37 weeks who received chest compressions for cardiac arrest in one of the 18 intensive care units were included. Exposures during the first 24 hours postarrest were hypoxemia, hyperoxemia, or normoxemia-defined as lowest arterial oxygen tension/pressure (PaO2) <60 mm Hg, highest PaO2 ⩾200 mm Hg, or every PaO2 60-199 mm Hg, respectively-and hypocapnia, hypercapnia, or normocapnia, defined as lowest arterial carbon dioxide tension/pressure (PaCO2) <30 mm Hg, highest PaCO2 ⩾50 mm Hg, or every PaCO2 30-49 mm Hg, respectively. Associations of oxygenation and carbon dioxide group with survival to hospital discharge were assessed using Poisson regression with robust error estimates. Results: The hypoxemia group was less likely to survive to hospital discharge, compared with the normoxemia group (adjusted relative risk [aRR] = 0.71; 95% confidence interval [CI] =  0.58-0.87), whereas survival in the hyperoxemia group did not differ from that in the normoxemia group (aRR = 1.0; 95% CI = 0.87-1.15). The hypercapnia group was less likely to survive to hospital discharge, compared with the normocapnia group (aRR = 0.74; 95% CI = 0.64-0.84), whereas survival in the hypocapnia group did not differ from that in the normocapnia group (aRR = 0.91; 95% CI = 0.74-1.12). Conclusions: Postarrest hypoxemia and hypercapnia were each associated with lower rates of survival to hospital discharge.

Neurorehabilitation across the Continuum: From the Neurocritical care unit to home

Children admitted to neurocritical care units often experience new neurodevelopmental disabilities due to both their acquired neurologic injuries and deconditioning from prolonged hospitalizations. Rehabilitation for critically ill children is multifactorial and begins in the intensive care unit itself. The goals of rehabilitation include prevention of complications associated with immobilization and evolving tone, comprehensive evaluation and treatment of functional deficits, and implementation of adaptive strategies with the goal of maximizing recovery. As a child progresses along the medical continuum from the neurocritical care unit to acute care to post-hospitalization settings, their rehabilitative needs and interventions should also evolve. A child in the neurocritical care unit is likely to have sustained an acquired brain injury. Whether resulting from traumatic or non-traumatic causes, all etiologies of pediatric acquired brain injury can result in significant challenges for the child and their family. Post-intensive care syndrome-pediatrics is a clinical construct that that systematically organizes the range of physical, cognitive, psychological, and social symptoms that emerge in both a child and their family members following a critical illness. Ideally, outpatient care for this population evaluates and supports all areas of post-intensive care syndrome-pediatrics through an interdisciplinary clinical care model. Proactive and comprehensive rehabilitation across the continuum provides the opportunity to support the child and their family in all areas affected, thereby minimizing distress, maximizing function, and optimizing outcomes.

Sedation Research in Critically Ill Pediatric Patients: Proposals for Future Study Design From the Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research IV Workshop

OBJECTIVES

Sedation and analgesia for infants and children requiring mechanical ventilation in the PICU is uniquely challenging due to the wide spectrum of ages, developmental stages, and pathophysiological processes encountered. Studies evaluating the safety and efficacy of sedative and analgesic management in pediatric patients have used heterogeneous methodologies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) IV hosted a series of multidisciplinary meetings to establish consensus statements for future clinical study design and implementation as a guide for investigators studying PICU sedation and analgesia.

DESIGN

Twenty-five key elements framed as consensus statements were developed in five domains: study design, enrollment, protocol, outcomes and measurement instruments, and future directions.

SETTING

A virtual meeting was held on March 2-3, 2022, followed by an in-person meeting in Washington, DC, on June 15-16, 2022. Subsequent iterative online meetings were held to achieve consensus.

SUBJECTS

Fifty-one multidisciplinary, international participants from academia, industry, the U.S. Food and Drug Administration, and family members of PICU patients attended the virtual and in-person meetings. Participants were invited based on their background and experience.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Common themes throughout the SCEPTER IV consensus statements included using coordinated multidisciplinary and interprofessional teams to ensure culturally appropriate study design and diverse patient enrollment, obtaining input from PICU survivors and their families, engaging community members, and using developmentally appropriate and validated instruments for assessments of sedation, pain, iatrogenic withdrawal, and ICU delirium.

CONCLUSIONS

These SCEPTER IV consensus statements are comprehensive and may assist investigators in the design, enrollment, implementation, and dissemination of studies involving sedation and analgesia of PICU patients requiring mechanical ventilation. Implementation may strengthen the rigor and reproducibility of research studies on PICU sedation and analgesia and facilitate the synthesis of evidence across studies to improve the safety and quality of care for PICU patients.

Impression of Primary Care Follow-Up After a PICU Admission: A Pilot Survey of Primary Care Pediatricians

OBJECTIVES

The majority of PICU general follow-up occurs with primary care providers. Our objective was to investigate primary care pediatricians': 1) comfort with and barriers to caring for children after a PICU admission, 2) knowledge of and screening for post-intensive care syndrome in pediatrics (PICS-P), and 3) resource needs.

DESIGN

Pilot cross-sectional survey study.

SETTING

Metropolitan Detroit, Michigan from September 2022 to March 2023.

SUBJECTS

Primary care pediatricians.

MEASUREMENT AND MAIN RESULTS

The survey included 15 questions on provider demographics, comfort with and barriers to caring for children after a PICU admission, knowledge of and screening practices for PICS-P, and resource needs. The median values for continuous data and frequencies for categorical data were calculated. The survey response rate was 17% (26/152). The median age was 38.5 years (interquartile range 34-52 yr) and 19 of 26 (73%) were female. In case studies, 26 of 26 (100%) were "very comfortable" resuming care for a patient with a straightforward bronchiolitis PICU admission while 8 of 26 participants (31%) were "somewhat uncomfortable" and 1 of 26 (4%) was "not at all comfortable" with caring for a patient after a complex acute respiratory distress syndrome PICU admission. Seven of 26 participants (27%) were familiar with the term "post-intensive care syndrome in pediatrics." Over 50% screened for four of five PICS-P domains. Key barriers were care coordination with specialists, discomfort or difficulties with managing new home equipment, and inadequate or missing documentation.

CONCLUSIONS

In this pilot study, approximately one-third of primary care pediatricians had knowledge of PICS-P. Participants experienced numerous care barriers. Our findings suggest future research could engage improved study methods and designs, and focus on interventions to support primary care-provided PICU follow-up.

Design and rationale of the Post-Intensive Care Syndrome - paediatrics (PICS-p) Longitudinal Cohort Study

INTRODUCTION

As paediatric intensive care unit (PICU) mortality declines, there is growing recognition of the morbidity experienced by children surviving critical illness and their families. A comprehensive understanding of the adverse physical, cognitive, emotional and social sequelae common to PICU survivors is limited, however, and the trajectory of recovery and risk factors for morbidity remain unknown.

METHODS AND ANALYSIS

The Post-Intensive Care Syndrome - paediatrics Longitudinal Cohort Study will evaluate child and family outcomes over 2 years following PICU discharge and identify child and clinical factors associated with impaired outcomes. We will enrol 750 children from 30 US PICUs during their first PICU hospitalisation, including 500 case participants experiencing ≥3 days of intensive care that include critical care therapies (eg, mechanical ventilation, vasoactive infusions) and 250 age-matched, sex-matched and medical complexity-matched control participants experiencing a single night in the PICU with no intensive care therapies. Children, parents and siblings will complete surveys about health-related quality of life, physical function, cognitive status, emotional health and peer and family relationships at multiple time points from baseline recall through 2 years post-PICU discharge. We will compare outcomes and recovery trajectories of case participants to control participants, identify risk factors associated with poor outcomes and determine the emotional and social health consequences of paediatric critical illness on parents and siblings.

ETHICS AND DISSEMINATION

This study has received ethical approval from the University of Pennsylvania Institutional Review Board (protocol #843844). Our overall objective is to characterise the ongoing impact of paediatric critical illness to guide development of interventions that optimise outcomes among children surviving critical illness and their families. Findings will be presented at key disciplinary meetings and in peer-reviewed publications at fixed data points. Published manuscripts will be added to our public study website to ensure findings are available to families, clinicians and researchers.

TRIALS REGISTRATION NUMBER

NCT04967365.

Mental Health Provision in PICU: An Analysis of Referrals to an Embedded Psychologist Over 20 Years at a Single Center

OBJECTIVES

The main aim of this study was to illustrate the type of mental health provision possible on PICU by describing the nature of referrals of child patients and their parents to an embedded psychologist over a 20-year period, adding to the literature on intervention and service development.

DESIGN

Retrospective evaluation of anonymized departmental database.

SETTING

Twelve-bed PICU at a teaching hospital in a major urban center.

PATIENTS

Five hundred forty-five consecutive referrals for support for parent and/or child by PICU staff between 1998 and 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Referrals increased from seven of 288 (2.4%) in 1998 to 85 of 643 (13.2%) in 2017. The majority were for parent support initially (456/545, 84%). Mean ( sd ) number of contacts was 4.5 (10.2), range 1 to 143, and mode was 1. Patient gender and age typical of the total PICU population, but referrals were more common where children had an oncology or trauma diagnosis ( p < 0.001). Comparisons with other inpatient referrals at the same hospital revealed a higher proportion of requests were made for parent support on PICU (456/545 [84%] vs 789/1,997 [40%]; p < 0.001) and that nurses were more likely to initiate referrals on PICU than on the other wards (437/543 [80%] vs 1,190/1,993 [60%]; p < 0.001). In other respects, the two groups were similar in terms of number of sessions, waiting times, and attendance rates.

CONCLUSIONS

Growing appreciation of the psychological impact of a child's admission to PICU has been associated with increasing referral to an embedded psychologist over a 20-year period, at this center. Clinical and service implications are outlined in the context of the latest research on the mitigation of post-intensive care syndrome in this population.

Post-PICU Cognitive and Psychological Outcomes in Children Receiving Treatments for Acute Lymphoblastic Leukemia

OBJECTIVES

To examine neurocognitive and psychological outcomes associated with post-PICU admissions in children treated for childhood acute lymphoblastic leukemia (ALL).

DESIGN

Observational study from October 2007 to March 2017.

SETTING

Pediatric onco-critical care unit.

PATIENTS

All patients in this study (n = 296; ages 3-21) were treated for ALL on the St. Jude Total Therapy 16 clinical trial (NCT00549848) from 2007 to 2017. Of these, 104 patients were admitted to the PICU during protocol-directed therapy. All patients completed protocol-directed neurocognitive monitoring prospectively, at the end of cancer-directed therapy. Data on PICU stays were abstracted retrospectively from the medical record.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic and critical illness variables were abstracted from institutional databases and medical records. Neurocognitive and psychosocial outcomes were prospectively obtained at the end of treatment. Children who had a PICU admission experienced significantly lower functioning compared to normative samples in several areas of cognitive functioning (working memory, processing speed, executive functions, inattention, math achievement, fine motor dexterity, and speed), daily living skills, and internalizing problems (all ps < 0.05). Compared with those without PICU admissions, patients with PICU admissions had worse performance on a measure of sustained attention (p = 0.017). The frequency of patients at risk for problems with learning and memory was significantly higher in the PICU group compared with the non-PICU group (25% vs 12%, p = 0.006). Critical illness symptom severity was not associated with neurocognitive or psychological outcomes.

CONCLUSIONS

Children with ALL, with or without a PICU admission, experienced lower cognitive and psychological outcomes following treatment. Future research is needed to continue identifying risk factors for post-intensive care syndrome (PICS-p) and post-PICU cognitive and psychological impairments in pediatric patients.

Parental Perception and Measured Functional Status Following Pediatric Critical Illness: A Secondary Analysis of the Survivor Outcomes Study

OBJECTIVES

We evaluated the concordance between parent/guardian perception of child long-term function and objectively scored long-term functional status using the Functional Status Scale (FSS) among PICU survivors.

DESIGN

Secondary analysis of prospective cohort study.

SETTING

Urban, tertiary, academic PICU.

PATIENTS

PICU patients less than 18 years old were admitted between June and August 2012.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We conducted telephone interviews of parents/guardians of PICU survivors ( n = 77) 6 months post-PICU discharge. We asked parents/guardians to characterize their child's functional status, and we determined FSS scores using scripted interview questions. Concordance between parent/guardian perceptions and FSS scores was assessed, revealing that parent/guardian perceptions of their child's functional status aligned poorly with FSS scores at 6 months (kappa coefficient 0.16).

CONCLUSIONS

These findings shed light on a critical disconnect between parent/guardian perspective and our current tools to measure a child's functional status following critical illness. In an era of decreased PICU mortality and increased long-term morbidity, the discordance between parent/guardian perception and available scoring tools in the assessment of long-term functional status highlights a key opportunity to improve communication and anchor expectations for long-term outcomes among PICU survivors.

Long-term Pain Symptomatology in PICU Survivors Aged 8-18 Years

BACKGROUND AND OBJECTIVES

Children discharged from the PICU often experience long-term physical, psychological, social and cognitive challenges, described as postintensive care syndrome. This study fills a critical gap by describing the long-term pain symptoms many children experience using child self-report.

METHODS

Participants in this cross-sectional study were children aged 8 to 18 years (and 1 parent, n = 64 dyads) who were 8 to 24 months post-PICU discharge. Participants completed measures assessing pain, psychosocial function, and treatment utilization. Health information relevant to the PICU admission was obtained from the electronic medical record.

RESULTS

Children were an average age of 14.3 years and 50% female. Average pain intensity in the past month was 3.65 (0-10 numeric rating scale), with 36% of children reporting pain ≥2 to 3 days a week. Youth with higher intensity (≥4) and more frequent pain (≥2-3 days a week) had greater pain catastrophizing, pain-related fear, anxiety, and sleep disturbance than those with less frequent and intense pain. Higher pain frequency was also associated with greater pain-related disability and depressive symptoms. Pain was not associated with any PICU-related variables abstracted from the electronic medical record. Parents reported children frequently accessed pain treatment services postdischarge; however, 37.5% reported the coronavirus disease 2019 pandemic impacted access to recommended services.

CONCLUSIONS

A significant portion of children experience pain post-PICU discharge. For many of these children, pain is frequent and is associated with impairments in psychosocial function. Future prospective research studies can be used to identify risk factors of poor pain outcomes so children can receive targeted interventions.

Promoting Functional Recovery in Critically Ill Children

Over two-thirds of pediatric critical illness survivors will experience functional impairments that persist after discharge, that is, post-intensive care syndrome in pediatrics (PICS-p). Risk factors include child and family characteristics, invasive procedures, and social determinants of health. Approaches to remediate PICS-p include early rehabilitation, minimizing sedation, psychosocial resources for caregivers, delivery of family-centered care, and longitudinal screening for PICS-p. Challenges include feasible and validated approaches to screening, and resources and coordination for multidisciplinary care. Next steps should include resources to identify and address adverse social determinants of health and examination of treatment efficacy and implementation equity.

Structured Multidisciplinary Follow-Up After Pediatric Intensive Care: A Model for Continuous Data-Driven Health Care Innovation

OBJECTIVES

Morbidity after PICU admission for critical illness is a growing concern. Sequelae may occur in various domains of functioning and can only appropriately be determined through structured follow-up. Here, we describe the process of designing and implementing a structured multidisciplinary follow-up program for patients and their parents after PICU admission and show the first results illustrating the significance of our program.

DESIGN

Prospective observational cohort study.

SETTING

Outpatient PICU follow-up clinic.

PATIENTS

Patients 0-18 years old admitted to our PICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In our structured multidisciplinary follow-up program, follow-up care is provided by a pediatric intensivist and psychologist and in addition, depending on patient's critical illness and received PICU treatment(s), by a pediatric pulmonologist, cardiologist, neurologist, and/or neuropsychologist. All consultations are scheduled consecutively. Collected data are stored in a hospital-wide data warehouse and used for yearly health care evaluation sessions as well as scientific research. Challenges in organizing this follow-up program include technological challenges, providing time-efficient care, participation rate, and completeness of questionnaires. In our experience, a dedicated team is essential to tackle these challenges. Our first results, obtained in 307 of 388 referred patients (79.1%), showed the diversity of problems arising after PICU discharge, including physical, neurocognitive, and psychosocial sequelae. In addition, our data also reflected the risk of psychosocial problems among parents. Within the limited operation time of our follow-up program, the program has evolved based on our experiences and the data collected.

CONCLUSIONS

We successfully developed and implemented a structured multidisciplinary follow-up program for patients and their parents after PICU admission. This program may help to timely initiate appropriate interventions, improve the standard of care during and after PICU admission, and facilitate scientific research on outcome and prognosis after PICU admission.

Pediatric Critical Care Outcomes: State of the Science

Children who survive the pediatric intensive care unit (PICU) are at risk of developing post-intensive care syndrome in pediatrics (PICS-p). PICS-p, defined as new physical, cognitive, emotional, and/or social health dysfunction following critical illness, can affect the child and family. Historically, synthesizing PICU outcomes research has been challenging due to inconsistency in study design and in outcomes measurement. PICS-p risk may be mitigated by implementing intensive care unit best practices that limit iatrogenic injury and by supporting the resiliency of critically ill children and their families.

Outcomes of Children Surviving Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

To summarize the evidence for the Second Pediatric Acute Lung Injury Consensus Conference-2 (PALICC-2) recommendations for assessment of outcomes among patients surviving pediatric acute respiratory distress syndrome (PARDS).

DATA SOURCES

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

STUDY SELECTION

We conducted a scoping review to identify studies evaluating outcomes following PARDS. We included studies of survivors of PARDS, acute respiratory failure with a high proportion of PARDS patients, or other critical illnesses if PARDS-specific outcomes could be extracted.

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. Of 8,037 abstracts screened, we identified 20 articles for inclusion. Morbidity following PARDS was common and affected multiple domains of pulmonary and nonpulmonary function. There was insufficient evidence to generate any evidence-based recommendations. We generated eight good practice statements and five research statements. A panel of 52 experts discussed each proposed good practice statement and research statement, and the agreement rate was measured with an online voting process. Good practice statements describe the approach to clinical outcome assessment, assessment of pulmonary outcomes of children surviving PARDS, and assessment of nonpulmonary outcomes of children surviving PARDS including health-related quality of life and physical, neurocognitive, emotional, family, and social functioning. The five research statements relate to assessment of patient preillness status, use of postdischarge endpoints for clinical trials, the association between short-term and longer term outcomes, the trajectory of recovery following PARDS, and practices to optimize follow-up.

CONCLUSIONS

There is increasing evidence that children are at risk for impairments across a range of pulmonary and nonpulmonary health domains following hospitalization for PARDS. The results of this extensive scoping review and consensus conference involving experts in PARDS research, clinical care, and outcomes assessment provide guidance to clinicians and researchers on postdischarge follow-up to optimize the long-term health of patients surviving PARDS.

Pediatric Acute Lung Injury and Sepsis Investigators (PALISI): Evolution of an Investigator-Initiated Research Network

The Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network originated over 20 years ago to foster research to optimize the care of critically ill infants and children. Over this period, PALISI has seen two major evolutions: formalization of our network infrastructure and a broadening of our clinical research focus. First, the network is unique in that its activities and meetings are funded by subscriptions from members who now comprise a multidisciplinary group of investigators from over 90 PICUs all over the United States (US) and Canada, with collaborations across the globe. In 2020, the network converted into a standalone, nonprofit organizational structure (501c3), making the PALISI Network formally independent of academic and clinical institutions or professional societies. Such an approach allows us to invest in infrastructure and future initiatives with broader opportunities for fund raising. Second, our research investigations have expanded beyond the original focus on sepsis and acute lung injury, to incorporate the whole field of pediatric critical care, for example, efficient liberation from mechanical ventilator support, prudent use of blood products, improved safety of intubation practices, optimal sedation practices and glucose control, and pandemic research on influenza and COVID-19. Our network approach in each field follows, where necessary, the full spectrum of clinical and translational research, including: immunobiology studies for understanding basic pathologic mechanisms; surveys to explore contemporary clinical practice; consensus conferences to establish agreement about literature evidence; observational prevalence and incidence studies to measure scale of a clinical issue or question; case control studies as preliminary best evidence for design of definitive prospective studies; and, randomized controlled trials for informing clinical care. As a research network, PALISI and its related subgroups have published over 350 peer-reviewed publications from 2002 through September 2022.

Parent post-traumatic growth after a child's critical illness

OBJECTIVE

Post-traumatic growth is the experience of a positive change after a traumatic event. Our objective is to characterize the factors associated with post-traumatic growth in parents after a child's pediatric intensive care unit (PICU) admission.

STUDY DESIGN

A cross-sectional survey study examining post-traumatic growth and select independent variables in parents 1 year after a child's ≥72 h PICU admission for an acute illness or injury. The study was completed in parents of children discharge alive from a tertiary care PICU from January 1, 2017 to December 31, 2017. A mixed-effects linear regression model was built to evaluate the association of post-traumatic stress, anxiety, depression, resiliency, family function, and child function with post-traumatic growth.

RESULTS

Eighty-two parents of 52 children discharged alive in 2017 completed the survey. Fifty-two percent were ≥35 years and 64.3% were mothers. Median age of their children was 2.8 years (IQR 0.5-11.3) with a median hospital stay of 12 Days (IQR 6-20). Moderate-to-high levels of post-traumatic growth occurred in 67.1% of parents. Increased hospital length of stay (β Coeff 0.85; p = 0.004, 95% CI 0.27, 1.43) and parent post-traumatic stress symptoms (β Coeff 1.04; p = 0.006, 95% CI 0.29, 1.78) were associated with increased post-traumatic growth, and increased parent depression symptoms (β Coeff -1.96; p = 0.015; 95% CI -3.54, -0.38) with decreased post-traumatic growth.

CONCLUSION

Longer child hospital stays and increased parent post-traumatic stress symptoms were associated with increased post-traumatic growth, while increased depression was associated with less post-traumatic growth. The impact of future PICU parent psychosocial interventions on parents may be best assessed using a dual outcome focused on both reducing negative mental health symptoms while concurrently promoting skills to facilitate parent adaptation and post-traumatic growth.