Intensive care unit acquired weakness in children: Critical illness polyneuropathy and myopathy

The Physical Abilities and Mobility Scale as a New Measure of Functional Progress in the PICU

Assessing functional motor changes and their relationship to discharge needs in the pediatric intensive care unit (PICU) population is difficult given challenges quantifying small functional gains with current tools. Therefore, we compared the Physical Abilities and Mobility Scale (PAMS) to the Functional Status Scale (FSS) in PICU patients to assess correlation and differences and association with discharge needs. This study was a retrospective chart review of all patients (2-18 years old) admitted to the PICU and cardiac PICU for over 9 months who received early mobility services, including PAMS and FSS scoring. Correlation between scales, relationship of scores to disposition, and logistic regression model of changes in PAMS in relation to disposition were determined. Data were obtained for 122 patients. PAMS and FSS scores strongly negatively correlated (Spearman's ρ  =  - 0.85), but with a nonlinear relationship, as the PAMS more readily differentiated among patients with higher functional status. The median FSS at discharge was 12.5 for those recommended an inpatient rehabilitation facility (IRF) ( n  = 24), versus 9 for those recommended discharge home ( n  = 83, Δ 3.5, 95% confidence interval [CI]: 1-6, around one-tenth of FSS scale). The corresponding median PAMS were 42 and 66 (Δ 24, 95% CI: 10-30, one-fourth of PAMS scale). Although not statistically significant, a logistic regression model was consistent with patients who showed modest change in PAMS across hospitalization but persistent deficits (PAMS < 60) were more likely to be recommended an IRF. The PAMS correlates to the FSS, but appears more sensitive to small functional changes, especially in higher functioning patients. It may be useful in prognosticating discharge needs.

A realist review of the effective implementation of the ICU Liberation Bundle in the paediatric intensive care unit setting

OBJECTIVE

The objective of this study was to produce an evidence base of what works, for whom, and in what context when implementing the ICU Liberation Bundle into the paediatric intensive care unit (PICU).

REVIEW METHOD USED

This is a realist review (a review that considers what works, for whom, and in what context) of contemporary international literature.

DATA SOURCES

Data were collected via electronic searches of CINAHL, PubMed, EMBASE and MEDLINE, Google Scholar, and Web of Science for articles published before October 2020.

REVIEW METHOD

An initial scoping search identified the underpinning theory of the implementation of the ICU Liberation Bundle (a multifactor intervention aimed at improving patient outcomes) which was mapped onto the Consolidated Framework for Implementation Research (CFIR). We identified 547 unique citations; 12 full-text papers were included that reported eight studies. Data were extracted and mapped to the CFIR domains.

RESULTS

Data mapped to all CFIR domains. Characteristics of individuals included involvement of key stakeholders, champions, and parents and understanding of staff attitudes and perceptions of the intervention, and all bedside staff members were involved and given training. Within the inner setting, understanding of unit culture, ensuring effective support systems in place, knowledge of the baseline, and leadership support, and buy-in were important. Culture of family-centred care and alignment of the intervention to national guidelines related to the outer setting. Intervention characteristics included the number and timings of interventions, de-escalation rounding checklists, the use of age-appropriate and validated assessment tools, and local policies for the bundle. The process included set training program, senior unit/hospital team consultation on all processes, continual audit adherence to the bundle and feedback, and celebration of successes.

CONCLUSIONS

This novel realist review of the literature identified that successful implementation of the ICU Liberation Bundle into PICU settings involves the following: (i) a thorough understanding of the PICU context, including baseline metrics, resources, and staff attitudes; (ii) using contextual information to adapt the intervention elements to ensure fit; and (iii) both clinical effectiveness and implementation outcomes must be measured. Registration of review: PROSPERO 2020 CRD42020211944.

Knowledge, attitudes and practices regarding children with ICU-acquired weakness in pediatric intensive care unit among chinese medical staff: a cross-sectional survey

BACKGROUND

ICU-AW (Intensive Care Unit Acquired Weakness) is characterized by significant muscle weakness and can be caused by a variety of factors, including immobility, medication use, and underlying medical conditions.ICU-AW can affect critically ill children who have been hospitalized in the PICU for an extended period of time.The knowledge, attitude and practice level of ICU-AW of PICU medical staff directly affect the treatment of critically ill children with ICU-AW.The aim to this study was to explore the knowledge, attitudes, and practices of Chinese medical staff regarding critically ill children with intensive care unit-acquired weakness (ICU-AW) and related factors.

METHODS

A Knowledge, Attitudes, and Practices (KAP) Questionnaire regarding critically ill children with ICU-AW was distributed to a stratified sample of 530 pediatric intensive care unit (PICU) healthcare workers. The questionnaire consisted of 31 items-with scores of 45, 40, and 40 for each dimension and a total score of 125.

RESULTS

The mean total score of Chinese PICU healthcare workers for the KAP questionnaire regarding children with ICU-AW was 87.36 ± 14.241 (53-121), with mean total knowledge, attitudes, and practices scores of 30.35 ± 6.317, 30.46 ± 5.632, and 26.54 ± 6.454, respectively. The population distribution indicated that 50.56%, 46.04%, and 3.4% of healthcare workers had poor, average, and good scores, respectively. Multiple linear regression showed that gender, education, and hospital level classification influenced the KAP level of PICU healthcare workers regarding critically ill children with ICU-AW.

CONCLUSIONS

Overall, PICU healthcare workers in China have an average KAP level about ICU-AW, and the gender and education level of PICU healthcare workers, as well as the classification of hospitals where they work, predict the KAP status of healthcare workers regarding children with ICU-AW. Therefore, healthcare leaders should plan and develop specific training programs to improve the KAP level of PICU healthcare workers.

2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility

RATIONALE

A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available.

OBJECTIVE

To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility.

DESIGN

The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to.

METHODS

Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence.

RESULTS

The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements.

CONCLUSIONS

The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.

Intensive Care Unit-Acquired Weakness in Children: A Prospective Observational Study Using Simplified Serial Electrophysiological Testing (PEDCIMP Study)

Background

To study the incidence and time of onset of intensive care unit—acquired weakness in a prospective cohort of children (2–12 years) by serial simplified electrophysiological assessment (Pediatric Critical Illness Myopathy Polyneuropathy study, PEDCIMP).

Methods

A single-center, prospective cohort study (Trial Registry Number: NCT02763709; PEDCIMP2016) was conducted at the pediatric intensive care unit of a tertiary care hospital in North India. A complete electrophysiological evaluation (4 motor nerves and 2 sensory nerves) was performed at baseline in children (2–12 years) admitted to the ICU with a pediatric risk of mortality (PRISM) of > 20 with more than 24-h stay. Following the entry evaluation, a minimal alternate day simplified electrophysiological testing of the unilateral common peroneal nerve and the sural nerve was assessed. A 25% reduction in compound muscle action potential (CMAP) and sensory nerve action potential from baseline was considered significant for ICUAW and was confirmed by complete electrophysiological re-evaluation.

Results

Of the total 481 children assessed for eligibility, 97 were enrolled. The median age of the cohort was 7 years. Sepsis (81%); need for vasoactive support (43%); multiorgan dysfunction (26%) were the common reasons for admission. Of the 433 eligible patient ICU days, 380 electrophysiological observations were done. A significant decrease of > 25% in CMAP of common peroneal nerve was not detected in any of the 380 observations. However, two children unfit for inclusion were diagnosed with ICUAW during the study period.

Conclusions

Children admitted with PRISM > 20 have a very low incidence of intensive care unit—acquired weakness by serial clinical and abbreviated electrophysiological evaluation.

Electronic supplementary material

The online version of this article (10.1007/s12028-020-01123-x) contains supplementary material, which is available to authorized users.

Early mobilization for children in intensive therapy: A protocol for systematic review and meta-analysis

INTRODUCTION

Intensive care units focus primarily on life support and treatment of critically ill patients, but there are many survivors with complications, such as generalized muscle disorders, functional disability and reduced quality of life after hospital discharge, resulting from prolonged stays in these units. The current evidence suggests that early mobilization-based rehabilitation (exercise initiated immediately after the patient's significant physiological changes have stabilized) in critically ill adults can alleviate these complications from immobility and critical illness. However, there are a lack of practice guidelines, conflicting perceptions about safety, and knowledge gaps about benefits in the critically ill paediatric population. Therefore, we aim to assess the effects of early mobilization for children in intensive therapy.

METHODS AND ANALYSIS

Systematic searches will be carried out in Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cochrane Central Register of Controlled Trials, Latin American and Caribbean Centre on Health Sciences Information, Cumulative Index to Nursing & Allied Health Literature and physiotherapy evidence database databases at a minimum without date or language restrictions for relevant individual parallel, cross-over and cluster randomized controlled trials. In addition, a search will also be carried out in the World Health Organization International Clinical Trials Registry Platform, and in the clinical trial registries of ClinicalTrials.gov, looking for any on-going randomised controlled trials that compare early mobilization with any other type of intervention. Two review authors will independently perform data extraction and quality assessments of data from included studies, and any disagreements will be resolved by discussion or by arbitration. The primary outcomes will be mortality and adverse events. Secondary outcomes will include duration of critical care (days), duration of mechanical ventilation support, muscle strength, pain and neuropsychomotor development. The Cochrane handbook will be used for guidance. If the results are not appropriate for a meta-analysis in RevMan 5 software (e.g., if the data have considerable heterogeneity and are drawn from different comparisons), a descriptive analysis will be performed.

ETHICS AND DISSEMINATION

This protocol was prospectively registered at Open Science Framework and approved by the Ethics and Research Committee of the Federal University of Sao Paulo (8543210519). We intend to update the public registry used in this review, report any important protocol amendments and publish the results in a widely accessible journal. REGISTRATION:: osf.io/ebju9.

Beta-thalassemia major complicated by intracranial hemorrhage and critical illness polyneuropathy

Intracranial hemorrhage (ICH) is rarely seen in patients with thalassemia. A seven-year-old male, known case of beta-thalassemia major, on irregular packed cell transfusions (elsewhere) and non-compliant with chelation therapy, presented with congestive cardiac failure (Hb-3 gm/dl). He received three packed red cell transfusions over 7 days (cumulative volume 40 cc/kg). On the 9^th day, he developed projectile vomiting and two episodes of generalized tonic-clonic convulsions with altered sensorium. He had exaggerated deep tendon reflexes and extensor plantars. CT-scan of brain revealed bilateral acute frontal hematoma with diffuse subarachnoid hemorrhage (frontal and parietal). Coagulation profile was normal. CT-angiography of brain showed diffuse focal areas of reduced caliber of anterior cerebral, middle cerebral, and basilar and internal carotid arteries (likely to be a spasmodic reaction to subarachnoid hemorrhage). He required mechanical ventilation for 4 days and conservative management for the hemorrhage. However, on the 18^th day, he developed one episode of generalized tonic-clonic convulsion and his sensorium deteriorated further (without any new ICH) and required repeat mechanical ventilation for 12 days. On the 28^th day, he was noticed to have quadriplegia (while on a ventilator). Nerve conduction study (42^nd day) revealed severe motor axonal neuropathy (suggesting critical illness polyneuropathy). He improved with physiotherapy and could sit upright and speak sentences at discharge (59^th day). The child recovered completely after 3 months. It is wise not to transfuse more than 20 cc/kg of packed red cell volume during each admission and not more than once in a week (exception being congestive cardiac failure) for thalassemia patients.

The ICU Liberation Bundle and Strategies for Implementation in Pediatrics

PURPOSE OF REVIEW

We briefly review post-intensive care syndrome (PICS) and the morbidities associated with critical illness that led to the intensive care unit (ICU) liberation movement. We review each element of the ICU liberation bundle, including pediatric support data, as well as tips and strategies for implementation in a pediatric ICU (PICU) setting.

RECENT FINDINGS

Numerous studies have found children have cognitive, physical, and psychiatric deficits after a PICU stay. The effects of the full ICU liberation bundle in children have not been published, but in adults, bundle implementation (even partial) resulted in significant improvement in survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.

SUMMARY

Although initially described in adults, children also suffer from PICS. The ICU liberation bundle is feasible in children and may ameliorate the effects of a PICU stay. Further studies are needed to characterize the benefits of the ICU liberation bundle in children.

Neurophysiological study of critical illness polyneuropathy and myopathy in mechanically ventilated children; additional aspects in paediatric critical illness comorbidities

BACKGROUND AND PURPOSE

Critical illness polyneuropathy and myopathy (CIP/CIM) is being increasingly recognized as a significant clinical problem in critically ill children especially if they have spent long periods in the intensive care unit. So the aim was to determine the frequency of CIP/CIM amongst mechanically ventilated children and to analyse the associated risk factors and drawbacks frequently encountered in this cohort.

METHODS

The study included 105 patients admitted to the paediatric intensive care unit who underwent mechanical ventilation for ≥7 days. These patients were screened daily for awakening. Patients with severe muscle weakness on day 7 post-awakening underwent nerve conduction studies and electromyography. Accordingly, the patients were classified as CIP/CIM patients if they had abnormal neurophysiology studies or control patients if normal neurophysiology studies were obtained. Their clinical and laboratory profiles had been recorded as well.

RESULTS

Overall, of 105 patients who achieved satisfactory awakening, 34 patients (32.4%) developed CIP/CIM mostly of the axonal polyneuropathy pattern (27.6%) whilst 71 control patients (67.6%) showed normal electrophysiological studies. The mean duration of mechanical ventilation was significantly longer in patients with CIP/CIM compared to control patients (P = 0.001). The study also revealed that 62.1% of our CIP/CIM patients failed weaning trials and finally died. CIP/CIM was significantly associated with decreased platelets, elevated liver enzymes and prolonged prothrombin time. Acidosis, low serum calcium and albumin levels and higher blood glucose were also found to be more significant in CIP/CIM patients compared to control patients.

CONCLUSION

Critically ill children frequently develop CIP/CIM, mostly of axonal polyneuropathy pattern, which compromises rehabilitation and recovery and is associated with a number of comorbidities.

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.

Acute muscular weakness in children

Acute muscle weakness in children is a pediatric emergency. During the diagnostic approach, it is crucial to obtain a detailed case history, including: onset of weakness, history of associated febrile states, ingestion of toxic substances/toxins, immunizations, and family history. Neurological examination must be meticulous as well. In this review, we describe the most common diseases related to acute muscle weakness, grouped into the site of origin (from the upper motor neuron to the motor unit). Early detection of hyperCKemia may lead to a myositis diagnosis, and hypokalemia points to the diagnosis of periodic paralysis. Ophthalmoparesis, ptosis and bulbar signs are suggestive of myasthenia gravis or botulism. Distal weakness and hyporeflexia are clinical features of Guillain-Barré syndrome, the most frequent cause of acute muscle weakness. If all studies are normal, a psychogenic cause should be considered. Finding the etiology of acute muscle weakness is essential to execute treatment in a timely manner, improving the prognosis of affected children.

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.

An Analysis of Reliability and Accuracy of Muscle Thickness Ultrasonography in Critically Ill Children and Adults

BACKGROUND

Muscle wasting starts already within the first week in critically patients and is strongly related to poor outcome. Nevertheless, the early detection of muscle wasting is difficult. Therefore, we investigated the reliability and accuracy of ultrasonography to evaluate skeletal muscle wasting in critically ill children and adults.

METHODS

This prospective observational study enrolled 30 sedated critically ill children and 14 critically ill adults. Two independent investigators made 210 ultrasonographical assessments of muscle thigh thickness. Inter- and intraobserver reliability and cutoff levels were calculated as a function of muscle thickness and the expected reduction in muscle size (predefined at 20% and 30%).

RESULTS

Mean ± SD muscle thickness was 1.67 ± 0.55 cm in the pediatric and 2.10 ± 0.85 cm in the adult population. The median absolute interobserver variability was 0.07 cm (interquartile range [IQR], 0.04-0.20 cm) in the pediatric population and 0.05 cm (IQR, 0.03-0.09 cm) in the adult population. However, the absolute intraobserver accuracy had a 95% confidence interval of 0.43 cm in children and 0.22 cm in adults. Only a 30% decrease (0.50 cm) in muscle thickness can be detected in critically ill children.

CONCLUSION

Although the interobserver variability is acceptable in the pediatric population, the intraobserver variability is too large with respect to the expected reduction in muscle thickness. In adults, ultrasonography may be a reliable tool for early detection of muscle mass wasting.

Intensive care unit acquired weakness in children: Critical illness polyneuropathy and myopathy

BACKGROUND AND AIMS

Intensive care unit acquired weakness (ICUAW) is a common occurrence in patients who are critically ill. It is most often due to critical illness polyneuropathy (CIP) or to critical illness myopathy (CIM). ICUAW is increasingly being recognized partly as a consequence of improved survival in patients with severe sepsis and multi-organ failure, partly related to commonly used agents such as steroids and muscle relaxants. There have been occasional reports of CIP and CIM in children, but little is known about their prevalence or clinical impact in the pediatric population. This review summarizes the current understanding of pathophysiology, clinical presentation, diagnosis and treatment of CIP and CIM in general with special reference to published literature in the pediatric age group.

SUBJECTS AND METHODS

Studies were identified through MedLine and Embase using relevant MeSH and Key words. Both adult and pediatric studies were included.

RESULTS

ICUAW in children is a poorly described entity with unknown incidence, etiology and unclear long-term prognosis.

CONCLUSIONS

Critical illness polyneuropathy and myopathy is relatively rare, but clinically significant sequelae of multifactorial origin affecting morbidity, length of intensive care unit (ICU) stay and possibly mortality in critically ill children admitted to pediatric ICU.