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Hassinger AB, Mody K, Li S, Flagg LK, Faustino EVS, Kudchadkar SR, Breuer RK. Parental Perspectives From the Survey of Sleep Quality in the PICU Validation Study on Environmental Factors Causing Sleep Disruption in Critically Ill Children. Crit Care Med 2024; 52:e578-e588. [PMID: 39269232 DOI: 10.1097/ccm.0000000000006403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2024]
Abstract
OBJECTIVES Sleep promotion bundles being tested in PICUs use elements adapted from adult bundles. As children may react differently than adults in ICU environments, this study investigated what parents report disrupted the sleep of their child in a PICU. DESIGN Secondary analysis of a multicenter validation study of the Survey of Sleep quality in the PICU. SETTING Four Northeastern U.S. PICUs, one hospital-based pediatric sleep laboratory. PATIENTS Parents sleeping at the bedside of a child in the PICU or hospital-based sleep laboratory. INTERVENTIONS Anonymous one-time survey eliciting parts of hospital or ICU environments that have been described as disruptive to sleep in validated adult ICU and pediatric inpatient questionnaires. MEASUREMENTS AND MAIN RESULTS Level of sleep disruption was scored by Likert scale, with higher scores indicating more disruption. Age, demographics, baseline sleep, and PICU exposures were used to describe causes of sleep disruption in a PICU. Of 152 PICU parents, 71% of their children's sleep was disrupted significantly by at least one aspect of being in the PICU. The most prevalent were "being in pain or uncomfortable because they are sick" (38%), "not sleeping at home" (30%), "alarms on machines" (28%), and "not sleeping on their home schedule" (26%). Only 5% were disrupted by excessive nocturnal light exposure. Overall sleep disruption was not different across four PICUs or in those receiving sedation. The validation study control group, healthy children undergoing polysomnography, had less sleep disruption than those in a PICU despite sleeping in a hospital-based sleep laboratory. CONCLUSIONS There are multiple aspects of critical care environments that affect the sleep of children, which are different from that of adults, such as disruption to home schedules. Future interventional sleep promotion bundles should include sedated children and could be applicable in multicenter settings.
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Affiliation(s)
- Amanda B Hassinger
- Department of Pediatrics, Division of Pulmonology and Sleep Medicine, University at Buffalo School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, NY
| | - Kalgi Mody
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Robert Wood Johnson Medical School, Bristol-Myers Squibb Children's Hospital, New Brunswick, NJ
| | - Simon Li
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Robert Wood Johnson Medical School, Bristol Myers Squibb Children's Hospital, New Brunswick, NJ
| | - Lauren K Flagg
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Yale New Haven Children's Hospital, Yale School of Nursing, New Haven, CT
| | - E Vincent S Faustino
- Department of Pediatrics, Division of Pediatric Critical Care, Yale School of Medicine, Yale New Haven Children's Hospital, New Haven, CT
| | - Sapna R Kudchadkar
- Department of Pediatrics, Division of Critical Care Medicine, Pediatrics and Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Johns Hopkins Children's Center, Baltimore, MD
| | - Ryan K Breuer
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University at Buffalo School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, NY
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Curley MAQ, Dawkins-Henry OS, Kalvas LB, Perry-Eaddy MA, Georgostathi G, Yuan I, Wypij D, Asaro LA, Zuppa AF, Kudchadkar SR. The Nurse-Implemented Chronotherapeutic Bundle in Critically Ill Children, RESTORE Resilience (R2): Pilot Testing in a Two-Phase Cohort Study, 2017-2021. Pediatr Crit Care Med 2024:00130478-990000000-00373. [PMID: 39133067 DOI: 10.1097/pcc.0000000000003595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
OBJECTIVES Pilot test the nurse-led chronotherapeutic bundle in critically ill children, RESTORE Resilience (R2). DESIGN A two-phase cohort study was carried out from 2017 to 2021. SETTING Two similarly sized and organized PICUs in the United States. PATIENTS Children 6 months to 17 years old who were mechanically ventilated for acute respiratory failure. INTERVENTIONS R2 seven-item chronotherapeutic bundle, including: 1) replication of child's pre-hospital daily routine (i.e., sleep/wake, feeding, activity patterns); 2) cycled day-night light/sound modulation; 3) minimal effective sedation; 4) night fasting with bolus enteral daytime feedings; 5) early progressive mobility; 6) nursing care continuity; and 7) parent diaries. MEASUREMENTS AND MAIN RESULTS Children underwent environmental (light, sound) and patient (actigraphy, activity log, salivary melatonin, electroencephalogram) monitoring. Parents completed the Child's Daily Routine and Sleep Survey (CDRSS) and Family-Centered Care Scale. The primary outcome was post-extubation daytime activity consolidation (Daytime Activity Ratio Estimate [DARE]). Twenty baseline-phase (2017-2019) and 36 intervention-phase (2019-2021) participants were enrolled. During the intervention phase, nurses used the CDRSS to construct children's PICU schedules. Overall compliance with nurse-implemented R2 elements 1-5 increased from 18% (interquartile range, 13-30%) at baseline to 63% (53-68%) during the intervention phase (p < 0.001). Intervention participants were exposed to their pre-hospitalization daily routine (p = 0.002), cycled day-night light/sound modulation (p < 0.001), and early progressive mobility on more PICU days (p = 0.02). Sedation target identification, enteral feeding schedules, and nursing care continuity did not differ between phases. Parent diaries were seldom used. DARE improved during the intervention phase and was higher pre-extubation (median 62% vs. 53%; p = 0.04) but not post-extubation (62% vs. 57%; p = 0.56). CONCLUSIONS In the PICU, implementation of an individualized nurse-implemented chronotherapeutic bundle is feasible. Children who received the R2 bundle had increased pre-extubation daytime activity consolidation compared to children receiving usual care. Given variation in protocol adherence, further R2 testing should include interprofessional collaboration, pragmatic trial design, and implementation science strategies.
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Affiliation(s)
- Martha A Q Curley
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Laura Beth Kalvas
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Mallory A Perry-Eaddy
- University of Connecticut School of Nursing, Storrs, CT
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT
- Pediatric Intensive Care Unit, Connecticut Children's Medical Center, Hartford, CT
| | - Georgia Georgostathi
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ian Yuan
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Lisa A Asaro
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Athena F Zuppa
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sapna R Kudchadkar
- Pediatric Intensive Care Unit, Children's Center, Johns Hopkins Medicine, Baltimore, MD
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD
- Department of Pediatrics, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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Kalvas LB, Harrison TM. Screen time and sleep duration in pediatric critical care: Secondary analysis of a pilot observational study. J Pediatr Nurs 2024; 76:e101-e108. [PMID: 38307758 PMCID: PMC11081838 DOI: 10.1016/j.pedn.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 02/04/2024]
Abstract
PURPOSE Quantify and describe screen time (screen type, child engagement, adult co-viewing) in eight critically ill children and determine its association with sleep duration before (parent report) and during (actigraphy) a 24-h period in the PICU. DESIGN AND METHODS Exploratory secondary analysis of 24-h video and actigraphy recordings in eight children 1-4 years old in the PICU. Videos were coded for screen time using Noldus Observer XT® software. Screen time was compared to American Academy of Pediatrics recommendations (0 h/day <2 years, ≤1 h/day 2-5 years). Parents completed the Brief Infant Sleep Questionnaire-Revised-Short Form (BISQ-R-SF) to understand children's pre-hospital sleep. Actigraphy was used to measure PICU sleep duration. Associations between screen time and sleep were determined with bivariate analyses. RESULTS Average age was 23.1 months (SD = 9.7). Daily screen time was 10.7 h (SD = 7), ranging from 2.4 to 21.4 h. Children (15.1% of sampling intervals) and adults (16.3%) spent little time actively engaged with screen media. BISQ-R-SF scores ranged from 48.9 to 97.7. Children had an average of 7.9 (SD = 1.2) night shift (19:00-6:59) sleep hours. Screen time was associated with worse pre-hospital sleep quality and duration with large effect sizes (rs= -0.7 to -1) and fewer nighttime sleep hours with a medium effect size (rs= -0.5). CONCLUSIONS All children exceeded screen time recommendations. Screen time was associated with worse pre-hospital sleep quality and duration, and decreased PICU sleep duration. Large-scale studies are needed to explore PICU screen time and sleep disruption. PRACTICE IMPLICATIONS Clinicians should model developmentally appropriate screen media use in PICU.
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Affiliation(s)
- Laura Beth Kalvas
- The Ohio State University Center for Clinical & Translational Science, 236A Newton Hall, 333 W. 10(th) Ave., Columbus, OH 43210, USA.
| | - Tondi M Harrison
- The Ohio State University College of Nursing, 360 Newton Hall, 1585 Neil Avenue, Columbus, OH 43210, USA.
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4
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Kalvas LB, Harrison TM. Sources of Sound Exposure in Pediatric Critical Care. Am J Crit Care 2024; 33:202-209. [PMID: 38688851 PMCID: PMC11403585 DOI: 10.4037/ajcc2024688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Sound levels in the pediatric intensive care unit (PICU) are often above recommended levels, but few researchers have identified the sound sources contributing to high levels. OBJECTIVES To identify sources of PICU sound exposure. METHODS This was a secondary analysis of continuous bedside video and dosimeter data (n = 220.7 hours). A reliable coding scheme developed to identify sound sources in the adult ICU was modified for pediatrics. Proportions of sound sources were compared between times of high (≥45 dB) and low (<45 dB) sound, during day (7 AM to 6:59 PM) and night (7 PM to 6:59 AM) shifts, and during sound peaks (≥70 dB). RESULTS Overall, family vocalizations (38% of observation time, n = 83.9 hours), clinician vocalizations (32%, n = 70.6 hours), and child nonverbal vocalizations (29.4%, n = 64.9 hours) were the main human sound sources. Media sounds (57.7%, n = 127.3 hours), general activity (40.7%, n = 89.8 hours), and medical equipment (31.3%, n = 69.1 hours) were the main environmental sound sources. Media sounds occurred in more than half of video hours. Child nonverbal (71.6%, n = 10.2 hours) and family vocalizations (63.2%, n = 9 hours) were highly prevalent during sound peaks. General activity (32.1%, n = 33.2 hours), clinician vocalizations (22.5%, n = 23.3 hours), and medical equipment sounds (20.6, n = 21.3 hours) were prevalent during night shifts. CONCLUSIONS Clinicians should partner with families to limit nighttime PICU noise pollution. Large-scale studies using this reliable coding scheme are needed to understand the PICU sound environment.
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Affiliation(s)
- Laura Beth Kalvas
- Laura Beth Kalvas is a postdoctoral fellow, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Tondi M Harrison
- Tondi M. Harrison is an associate professor, The Ohio State University College of Nursing, Columbus, Ohio
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Hassinger AB, Afzal S, Rauth M, Breuer RK. Pediatric Intensive Care Unit related Sleep and Circadian Dysregulation: a focused review. Semin Pediatr Neurol 2023; 48:101077. [PMID: 38065630 DOI: 10.1016/j.spen.2023.101077] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/16/2023] [Accepted: 08/16/2023] [Indexed: 12/18/2023]
Abstract
The pediatric intensive care unit (PICU) is bright, loud, and disruptive to children. Strategies to improve the sleep of adults in the ICU have improved delirium and mortality rates. Children need more sleep than adults for active growth, healing, and development when well; this is likely true when they are critically ill. This review was performed to describe what we know in this area to date with the intent to identify future directions for research in this field. Since the 1990s, 16 articles on 14 observational trials have been published investigating the sleep on a total of 312 critically ill children and the melatonin levels of an additional 144. Sleep measurements occurred in 9 studies through bedside observation (n = 2), actigraphy (n = 2), electroencephalogram (n = 1) and polysomnography (n = 4), of which polysomnography is the most reliable. Children in the PICU sleep more during the day, have fragmented sleep and disturbed sleep architecture. Melatonin levels may be elevated and peak later in critically ill children. Early data suggest there are at-risk subgroups for sleep and circadian disruption in the PICU including those with sepsis, burns, traumatic brain injury and after cardiothoracic surgery. The available literature describing the sleep of critically ill children is limited to small single-center observational studies with varying measurements of sleep and inconsistent findings. Future studies should use validated measurements and standardized definitions to begin to harmonize this area of medicine to build toward pragmatic interventional trials that may shift the paradigm of care in the pediatric intensive care unit.
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Affiliation(s)
- Amanda B Hassinger
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences; Division of Pulmonary and Sleep Medicine, John R. Oishei Children's Hospital of Buffalo, Buffalo, NY.
| | - Syeda Afzal
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences; Division of Pediatric Critical Care, John R. Oishei Children's Hospital of Buffalo, Buffalo, NY
| | - Maya Rauth
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences; John R. Oishei Children's Hospital of Buffalo, Buffalo, NY
| | - Ryan K Breuer
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences; Division of Pediatric Critical Care, John R. Oishei Children's Hospital of Buffalo, Buffalo, NY
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Kalvas LB, Harrison TM, Curley MAQ, Ordway MR, Redeker NS, Happ MB. An observational pilot study of sleep disruption and delirium in critically ill children. Heart Lung 2023; 62:215-224. [PMID: 37591147 PMCID: PMC10592139 DOI: 10.1016/j.hrtlng.2023.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/10/2023] [Accepted: 08/06/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Sleep disruption is frequently observed in children with delirium in the pediatric intensive care unit (PICU). OBJECTIVES This observational pilot study explores relationships among modifiable characteristics of the PICU environment (i.e., light, sound, clinician caregiving patterns), sleep disruption, and delirium. METHODS Ten children, 1 to 4 years old, were recruited within 48 h of PICU admission and followed until discharge. A light meter, dosimeter, and video camera were placed at bedside to measure PICU environmental exposures. Sleep was measured via actigraphy. Twice daily delirium screening was conducted. Descriptive statistics were used to describe the PICU environment, sleep, and delirium experienced by children. Bivariate analyses were performed to determine relationships among variables. RESULTS Average participant age was 21 (SD = 9.6) months. Eight (80%) were admitted for respiratory failure. Median PICU length of stay was 36.7 (IQR[29.6, 51.5]) hours, which limited data collection duration. Delirium prevalence was 60% (n = 6). Children experienced low daytime light levels (x¯ = 112.8 lux, SD = 145.5) and frequent peaks (x¯ = 1.9/hr, SD = 0.5) of excessive sound (i.e., ≥ 45 A-weighted decibels). Clinician caregiving episodes were frequent (x¯ = 4.5/hr, SD = 2.6). Children experienced 7.3 (SD = 2.1) awakenings per hour of sleep and a median sleep episode duration of 1.4 (IQR[0.6, 2.3]) hours. On average, children with delirium experienced 1.1 more awakenings per sleep hour and 42 fewer minutes of sleep per sleep episode during the night shift. Increased clinician care frequency and duration were associated with worse sleep quality and delirium. CONCLUSIONS Study results will inform future, large-scale research and nurse-driven sleep promotion interventions.
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Affiliation(s)
- Laura Beth Kalvas
- The Ohio State University Center for Clinical and Translational Science, 236A Newton Hall, 333 W. 10th Ave., Columbus, OH, 43210, USA.
| | - Tondi M Harrison
- The Ohio State University College of Nursing, 360 Newton Hall, 1585 Neil Avenue, Columbus OH 43210, USA
| | - Martha A Q Curley
- Ruth M. Colket Endowed Chair in Pediatric Nursing, Children's Hospital of Philadelphia, PA 19104, USA; University of Pennsylvania School of Nursing, 425 Claire M. Fagin Hall, 418 Curie Boulevard, Philadelphia, PA 19104-4217, USA
| | - Monica R Ordway
- Yale School of Nursing, Office 21403, 400 West Campus Drive, Orange, CT 06477, USA
| | - Nancy S Redeker
- University of Connecticut School of Nursing, 313 Augustus Storrs Hall, 231 Glenbrook Road, Unit 4026, Storrs, CT 06269-4026, USA
| | - Mary Beth Happ
- The Ohio State University College of Nursing, 360 Newton Hall, 1585 Neil Avenue, Columbus OH 43210, USA
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Van der Linden IA, Hazelhoff EM, De Groot ER, Vijlbrief DC, Schlangen LJM, De Kort YAW, Vermeulen MJ, Van Gilst D, Dudink J, Kervezee L. Characterizing light-dark cycles in the Neonatal Intensive Care Unit: a retrospective observational study. Front Physiol 2023; 14:1217660. [PMID: 37664437 PMCID: PMC10469299 DOI: 10.3389/fphys.2023.1217660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/02/2023] [Indexed: 09/05/2023] Open
Abstract
Objectives: To characterize bedside 24-h patterns in light exposure in the Neonatal Intensive Care Unit (NICU) and to explore the environmental and individual patient characteristics that influence these patterns in this clinical setting. Methods: We conducted a retrospective cohort study that included 79 very preterm infants who stayed in an incubator with a built-in light sensor. Bedside light exposure was measured continuously (one value per minute). Based on these data, various metrics (including relative amplitude, intradaily variability, and interdaily stability) were calculated to characterize the 24-h patterns of light exposure. Next, we determined the association between these metrics and various environmental and individual patient characteristics. Results: A 24-h light-dark cycle was apparent in the NICU with significant differences in light exposure between the three nurse shifts (p < 0.001), with the highest values in the morning and the lowest values at night. Light exposure was generally low, with illuminances rarely surpassing 75 lux, and highly variable between patients and across days within a single patient. Furthermore, the season of birth and phototherapy had a significant effect on 24-h light-dark cycles, whereas no effect of bed location and illness severity were observed. Conclusion: Even without an official lighting regime set, a 24-h light-dark cycle was observed in the NICU. Various rhythmicity metrics can be used to characterize 24-h light-dark cycles in a clinical setting and to study the relationship between light patterns and health outcomes.
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Affiliation(s)
- Isabelle A. Van der Linden
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Esther M. Hazelhoff
- Laboratory for Neurophysiology, Department of Cellular and Chemical Biology, Leiden University Medical Center, Leiden, Netherlands
| | - Eline R. De Groot
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Daniel C. Vijlbrief
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Luc J. M. Schlangen
- Department of Industrial Engineering and Innovation Sciences, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Yvonne A. W. De Kort
- Department of Industrial Engineering and Innovation Sciences, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Marijn J. Vermeulen
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC—Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Demy Van Gilst
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC—Sophia Children’s Hospital, Rotterdam, Netherlands
| | - Jeroen Dudink
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Laura Kervezee
- Laboratory for Neurophysiology, Department of Cellular and Chemical Biology, Leiden University Medical Center, Leiden, Netherlands
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Kalvas LB, Harrison TM, Solove S, Happ MB. Sleep disruption and delirium in critically ill children: Study protocol feasibility. Res Nurs Health 2022; 45:604-615. [PMID: 35986659 PMCID: PMC9529999 DOI: 10.1002/nur.22259] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/12/2022] [Accepted: 07/31/2022] [Indexed: 08/19/2023]
Abstract
Delirium is a serious complication of pediatric critical illness. Sleep disruption is frequently observed in children with delirium, and circadian rhythm dysregulation is one proposed cause of delirium. Children admitted to the pediatric intensive care unit (PICU) experience multiple environmental exposures with the potential to disrupt sleep. Although researchers have measured PICU light and sound exposure, sleep, and delirium, these variables have not yet been fully explored in a single study. Furthermore, caregiving patterns have not often been included as a component of the PICU environment. Measuring the light and sound exposure, caregiving patterns, and sleep of critically ill children requires continuous PICU bedside data collection. This presents multiple methodological challenges. In this paper, we describe the protocol for an observational pilot study of the PICU environment, sleep, and delirium experienced by a sample of 10 critically ill children 1-4 years of age. We also evaluate and discuss the feasibility (i.e., acceptability, implementation, practicality) of the study protocol. Light and sound exposure were measured with bedside sensors. Caregiving was quantified through video recording. Sleep was measured via actigraphy and confirmed by video recording. Delirium screening with the Cornell Assessment of Pediatric Delirium was conducted twice daily, either in person or via video review. This study provides a refined measurement framework to inform future, large-scale studies and the development of nurse-driven sleep promotion interventions.
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Affiliation(s)
- Laura Beth Kalvas
- Post-Docotral Fellow
- The Ohio State University College of Nursing, Columbus, OH
| | - Tondi M. Harrison
- The Ohio State University College of Nursing, Columbus, OH
- Associate Professor
| | - Sandra Solove
- The Ohio State University College of Nursing, Columbus, OH
- Research Regulatory Coordinator
| | - Mary Beth Happ
- The Ohio State University College of Nursing, Columbus, OH
- Senior Associate Dean for Research and Innovation
- Distinguished Professor of Critical Care Research
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Turner AD, Sullivan T, Drury K, Hall TA, Williams CN, Guilliams KP, Murphy S, Iqbal O’Meara AM. Cognitive Dysfunction After Analgesia and Sedation: Out of the Operating Room and Into the Pediatric Intensive Care Unit. Front Behav Neurosci 2021; 15:713668. [PMID: 34483858 PMCID: PMC8415404 DOI: 10.3389/fnbeh.2021.713668] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/26/2021] [Indexed: 11/13/2022] Open
Abstract
In the midst of concerns for potential neurodevelopmental effects after surgical anesthesia, there is a growing awareness that children who require sedation during critical illness are susceptible to neurologic dysfunctions collectively termed pediatric post-intensive care syndrome, or PICS-p. In contrast to healthy children undergoing elective surgery, critically ill children are subject to inordinate neurologic stress or injury and need to be considered separately. Despite recognition of PICS-p, inconsistency in techniques and timing of post-discharge assessments continues to be a significant barrier to understanding the specific role of sedation in later cognitive dysfunction. Nonetheless, available pediatric studies that account for analgesia and sedation consistently identify sedative and opioid analgesic exposures as risk factors for both in-hospital delirium and post-discharge neurologic sequelae. Clinical observations are supported by animal models showing neuroinflammation, increased neuronal death, dysmyelination, and altered synaptic plasticity and neurotransmission. Additionally, intensive care sedation also contributes to sleep disruption, an important and overlooked variable during acute illness and post-discharge recovery. Because analgesia and sedation are potentially modifiable, understanding the underlying mechanisms could transform sedation strategies to improve outcomes. To move the needle on this, prospective clinical studies would benefit from cohesion with regard to datasets and core outcome assessments, including sleep quality. Analyses should also account for the wide range of diagnoses, heterogeneity of this population, and the dynamic nature of neurodevelopment in age cohorts. Much of the related preclinical evidence has been studied in comparatively brief anesthetic exposures in healthy animals during infancy and is not generalizable to critically ill children. Thus, complementary animal models that more accurately "reverse translate" critical illness paradigms and the effect of analgesia and sedation on neuropathology and functional outcomes are needed. This review explores the interactive role of sedatives and the neurologic vulnerability of critically ill children as it pertains to survivorship and functional outcomes, which is the next frontier in pediatric intensive care.
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Affiliation(s)
- Ashley D. Turner
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, United States
| | - Travis Sullivan
- Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States
| | - Kurt Drury
- Department of Pediatrics, Division of Pediatric Critical Care, Doernbecher Children’s Hospital, Oregon Health & Science University, Portland, OR, United States
| | - Trevor A. Hall
- Department of Pediatrics, Division of Pediatric Psychology, Pediatric Critical Care and Neurotrauma Recovery Program, Doernbecher Children’s Hospital, Oregon Health & Science University, Portland, OR, United States
| | - Cydni N. Williams
- Department of Pediatrics, Division of Pediatric Critical Care, Doernbecher Children’s Hospital, Oregon Health & Science University, Portland, OR, United States
| | - Kristin P. Guilliams
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, United States
- Division of Pediatric Neurology, Department of Neurology, Washington University in St. Louis, St. Louis, MO, United States
- Division of Neuroradiology, Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, United States
| | - Sarah Murphy
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - A. M. Iqbal O’Meara
- Department of Pediatrics, Child Health Research Institute, Children’s Hospital of Richmond at Virginia Commonwealth University School of Medicine, Richmond, VA, United States
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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