Functional outcomes for children with severe sepsis: is a "good save" good enough?

Outcomes following admission to paediatric intensive care: A systematic review

AIM

To describe the long-term health outcomes of children admitted to a paediatric intensive care unit.

METHODS

A systematic review of the literature was performed. Studies of children under 18 years of age admitted to a paediatric intensive care unit were included. Studies focussed on neonatal admissions and investigating specific paediatric intensive care unit interventions or admission diagnoses were excluded. A table was created summarising the study characteristics and main findings. Risk of bias was assessed using the Newcastle Ottawa Quality Assessment Scale for observational studies. Primary outcome was short-, medium- and long-term mortality. Secondary outcomes included measures of neurodevelopment, cognition, physical, behavioural and psychosocial function as well as quality of life.

RESULTS

One hundred and eleven studies were included, most were conducted in high-income countries and focussed on short-term outcomes. Mortality during admission ranged from 1.3 to 50%. Mortality in high-income countries reduced over time but this trend was not evident for lower income countries. Higher income countries had lower standardised mortality rates than lower income countries. Children had an ongoing increased risk of death for up to 10 years following intensive care admission as well as increased physical and psychosocial morbidity compared to healthy controls, with associated poorer quality of life.

CONCLUSIONS

There is limited high-level evidence for the long-term health outcomes of children after intensive care admission, with the burden of related morbidity remaining greater in poorly resourced regions. Further research is recommended to identify risk factors and modifiable factors for poor outcomes, which could be targeted in practice improvement initiatives.

Functional assessment of a series of paediatric patients receiving neurointensive treatment: New Functional status scale

INTRODUCTION

Functional health, a reliable parameter of the impact of disease, should be used systematically to assess prognosis in paediatric intensive care units (PICU). Developing scales for the assessment of functional health is therefore essential. The Paediatric Overall and Cerebral Performance Category (POPC, PCPC) scales have traditionally been used in paediatric studies. The new Functional Status Scale (FSS) was designed to provide more objective results. This study aims to confirm the validity of the FSS compared to the classic POPC and PCPC scales, and to evaluate whether it may also be superior to the latter in assessing of neurological function.

PATIENTS AND METHOD

We conducted a retrospective descriptive study of 266 children with neurological diseases admitted to intensive care between 2012 and 2014. Functional health at discharge and at one year after discharge was evaluated using the PCPC and POPC scales and the new FSS.

RESULTS

Global FSS scores were found to be well correlated with all POPC scores (P<.001), except in category 5 (coma/vegetative state). Global FSS score dispersion increases with POPC category. The neurological versions of both scales show a similar correlation.

DISCUSSION

Comparison with classic POPC and PCPC categories suggests that the new FSS scale is a useful method for evaluating functional health in our setting. The dispersion of FSS values underlines the poor accuracy of POPC-PCPC compared to the new FSS scale, which is more disaggregated and objective.

Valuation of Quality of Life in Pediatric Disability in a Developing Country

This article assessed how Indian providers and mothers value quality of life in pediatric disabilities, hypothesizing lower values with increasing disability, lower values among providers than mothers, and lower values among mothers with versus mothers without a disabled child. We asked 175 participants: "If born tomorrow, how many years of a disabled life ( y) would you trade to avoid life-long disability" for 4 hypothetical disabilities, calculating "utility" scores as: (life span - y) / life span, where death = 0 and full life without disability = 1. Providers' utilities were 0.67 (mild), 0.18 (moderate), -0.70 (severe), and -0.60 (profound); 0.67, 0, -0.77, and -0.88 for mothers without and 0.38, -0.49, -0.86, and -0.87 for mothers with a disabled child. Mothers without reported lower utilities than providers (severe and profound disability [ P ≤ .03]), and higher utilities than mothers (for mild and moderate disability [ P < .001]). Major disability is valued as a fate worse than death in India.

Functional progression of patients with neurological diseases in a tertiary paediatric intensive care unit: Our experience

INTRODUCTION

Neurological diseases explain a considerable proportion of admissions to paediatric intensive care units (PICU), and are a significant cause of morbidity and mortality. This study aims to analyse the functional progression of children with critical neurological conditions.

MATERIAL AND METHODS

Retrospective descriptive study of children admitted to PICU with neurological diseases over a period of 3 years (2012-2014), assessing vital and functional prognosis at PICU discharge and at one year according to the Pediatric Cerebral and Overall Performance Category scales (PCPC-POPC) and the Functional Status Scale (FSS). The results are compared with our previous data (1990-1999), and those of the international multicentre PANGEA study.

RESULTS

A total of 266 children were studied. The mortality rate was 3%; the PRISM-III and PIM2 models did not show predictive ability. Clinically significant worsening was observed in functional health at discharge in 30% of the sample, according to POPC, 15% according to PCPC, and 5% according to FSS. After one year, functional performance improved according to PCPC-POPC, but not according to FSS. Children with no underlying neurological disease had a higher degree of functional impairment; this was prolonged over time. We observed a decrease in overall and neurocritical mortality compared with our previous data (5.60 vs. 2.1%, P=.0003, and 8.44 vs. 2.63%, P=.0014, respectively). Compared with the PANGEA study, both mortality and cerebral functional impairment in neurocritical children were lower in our study (1.05 vs. 13.32%, P<.0001, and 10.47% vs. 23.79%, P<.0001, respectively).

CONCLUSIONS

Nearly one-third of critically ill children have neurological diseases. A significant percentage, mainly children without underlying neurological diseases, had a clinically significant functional impact at PICU discharge and after a year. Neuromonitoring and neuroprotection measures and the evaluation of functional progression are necessary to improve critical child care.

Update on pediatric sepsis: a review

BACKGROUND

Sepsis is one of the leading causes of mortality among children worldwide. Unfortunately, however, reliable evidence was insufficient in pediatric sepsis and many aspects in clinical practice actually depend on expert consensus and some evidence in adult sepsis. More recent findings have given us deep insights into pediatric sepsis since the publication of the Surviving Sepsis Campaign guidelines 2012.

MAIN TEXT

New knowledge was added regarding the hemodynamic management and the timely use of antimicrobials. Quality improvement initiatives of pediatric "sepsis bundles" were reported to be successful in clinical outcomes by several centers. Moreover, a recently published global epidemiologic study (the SPROUT study) did not only reveal the demographics, therapeutic interventions, and prognostic outcomes but also elucidated the inappropriateness of the current definition of pediatric sepsis.

CONCLUSIONS

With these updated knowledge, the management of pediatric sepsis would be expected to make further progress. In addition, it is meaningful that the fundamental data on which future research should be based were established through the SPROUT study.

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.

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.