Epidemiology of long-stay patients in the pediatric intensive care unit: prevalence, characteristics, resource consumption and complications

Erector spinae plane block versus intravenous opioid for analgesia in pediatric cardiac surgery: A systematic review and meta-analysis

INTRODUCTION

The erector spinae plane block (ESPB) has recently emerged as a regional anesthesia technique for perioperative pain management in pediatric cardiac surgery. However, evidence comparing its effectiveness with intravenous (IV) opioid-based analgesia is limited. We aimed to evaluate and compare the analgesic efficacy of ESPB versus IV opioids in this setting.

METHODS

We systematically reviewed and meta-analyzed studies comparing ESPB with IV opioid analgesia in pediatric cardiac surgeries with midline sternotomy. Primary outcomes were intraoperative fentanyl consumption and intensive care unit (ICU) length of stay (LOS). Secondary outcomes included postoperative opioid consumption, time to first rescue analgesia, pain scores, postoperative vomiting and other complications, extubation time, and hospital LOS. Statistical analyses were performed using RStudio version 4.2.3.

RESULTS

Five studies with 384 patients were included, with 178 receiving ESPB. ESPB significantly reduced intraoperative fentanyl use (MD -1.90 μg.kg-1; 95% CI -3.15 to -0.66 μg.kg-1; p = .003; I2 = 58%) and ICU LOS (MD -3.50 h; 95% CI -4.32 to -2.69 h; p < .0001; I2 = 0%). No significant differences were found in the remaining outcomes.

CONCLUSION

Our findings suggest the ESPB might be an important adjunct to enhancing analgesia for midline sternotomies in pediatric cardiac surgery, potentially reducing intraoperative opioid requirements and ICU LOS.

PROSPERO REGISTRATION

CRD 42024526961.

Impact and outcomes of hyperglycemia among post-operative children who underwent repair of congenital cardiac defects in a tertiary care setup of Pakistan

Objective

To determine frequency of postoperative hyperglycemia in children who underwent repair of Congenital Cardiac Defects (CCDs) in a tertiary care hospital of Pakistan. The other objective was to compare outcomes in children with versus without postoperative hyperglycemia who underwent repair of CCDs in a tertiary care hospital of Pakistan.

Methods

A descriptive study was conducted at the Cardiac Intensive Care Unit (CICU), Aga Khan University Hospital (AKUH), Karachi, Pakistan from October 3, 2020, to April 2, 2021. A total of 185 patients aged one month-18 years admitted to CICU underwent elective surgical repair of CCDs meeting the eligibility criteria were included. Glucose monitoring was collected at immediate, 4th and 8th postoperative hours on the first day and once daily on postoperative days Two and Three to assess hyperglycemia. Data including age, weight, gender, pre-operative diagnosis, type of surgery and variables such as CICU stay, duration of hospital stay and duration of mechanical ventilation were recorded.

Results

The mean age of the patients was 40.40±48.63 months. Out of 185 patients, 115 (62.2%) were male while 70 (37.8%) were female. Hyperglycemia was found to be in 182 (98.4%) patients. Out of 182 hyperglycemic patients, 53 (28.6%) had moderate hyperglycemia while 129 (69.7%) had severe hyperglycemia. Mean duration of hospital stays was 9.24±7.45, mean duration of pediatric CICU stays was 141.61±169.02 hours and mean duration of mechanical ventilation was 80.59±98.54 hours.

Conclusion

Hyperglycemia is a frequent finding in children who underwent repair of CCDs, and it is not significantly associated with duration of mechanical ventilation, length of hospital and CICU stay.

Burden of Respiratory Disease in Pediatric Intensive Care Unit: Experience from a PICU of a Tertiary Care Center in Pakistan

INTRODUCTION

We aimed to determine the burden of respiratory disease by examining clinical profiles and associated predictors of morbidity and mortality of patients admitted to a Pediatric Intensive Care Unit (PICU) in Pakistan, a resource limited country. We also stratified the respiratory diseases as defined by the Pediatric Advanced Life Support (PALS) Classification.

METHODS

A retrospective study was conducted on children aged 1 month to 18 years who were diagnosed with respiratory illness at the PICU in a tertiary hospital in Karachi, Pakistan. Demographics, essential clinical details including immunization status, and the outcome in terms of mortality or survival were recorded. Predictors of mortality and morbidity including prolonged intubation and mechanical ventilation in the PICU were analyzed using the chi-square test or Fischer's exact test as appropriate.

RESULTS

279 (63.8% male; median age 9 months, IQR 4-36 months) patients were evaluated of which 44.2% were malnourished and 23.3% were incompletely immunized. The median length of stay in the PICU was 3 days (IQR 2-5 days). Pneumonia was the principal diagnosis in 170 patients (62%) and accounted for most deaths. 76/279 (27.2%) were ventilated, and 67/279(24.0%) needed inotropic support. A high Pediatric Risk of Mortality (PRISM) III score, pneumothorax, and lower airway disease were significantly associated with ventilation support. The mortality rate of patients was 14.3%. Predictors of mortality were a high PRISM III score (OR 1.179; 95% CI 1.024-1.358, P=0.022) and a positive blood culture (OR 4.305; 95% CI 1.062-17.448, P=0.041).

CONCLUSION

Pneumonia is a significant contributor of respiratory diseases in the PICU in Pakistan and is the leading cause of morbidity and mortality. A high PRISM III score, pneumothorax, and lower airway disease were predictors for ventilation support. A high PRISM III score and a positive blood culture were predictors of patient mortality in our study.

A Snapshot of Chronic Critical Illness in Pediatric Intensive Care Units

Children with chronic critical illness (CCI) represent the sickest subgroup of children with medical complexity. In this article, we applied a proposed definition of pediatric CCI to assess point prevalence in medical, cardiovascular, and combined pediatric intensive care units (PICUs), screening all patients admitted to six academic medical centers in the United States on May 17, 2017, for pediatric CCI (PCCI) eligibility. We gathered descriptive data to understand medical complexity and resource needs of children with PCCI in PICUs including data regarding hospitalization characteristics, previous admissions, medical technology, and chronic multiorgan dysfunction. Descriptive statistics were used to characterize the study population and hospital data. The study cohort was divided between PICU-prolonged (stay > 14 days) and PICU-exposed (any time in PICU); comparative analyses were conducted. On the study day, 185 children met inclusion criteria, 66 (36%) PICU-prolonged and 119 (64%) PICU-exposed. Nearly all had home medical technology and most ( n  = 152; 82%) required mechanical ventilation in the PICU. The PICU-exposed cohort mirrored the PICU-prolonged with a few exceptions as follows: they were older, had fewer procedures and surgeries, and had more recurrent hospitalizations. Most ( n  = 44; 66%) of the PICU-prolonged cohort had never been discharged home. Children with PCCI were a sizable proportion of the unit census on the study day. We found that children with PCCI are a prevalent population in PICUs. Dividing the cohorts between PICU-prolonged and PICU-exposed helps to better understand the care needs of the PCCI population. Identifying and studying PCCI, including variables relevant to PICU-prolonged and PICU-exposed, could inform changes to PICU care models and training programs to better enable PICUs to meet their unique needs.

Comparison of clinical characteristics and healthcare resource use of pediatric chronic and non-chronic critically ill patients in intensive care units: a retrospective national registry study

Introduction

Chronic critically ill patients (CCI) in pediatric intensive care unit (PICU) are at risk of negative health outcomes, and account for a considerable amount of ICU resources. This study aimed to (a) describe the prevalence of CCI children, (b) compare their clinical characteristics and ICU resources use with non-CCI children, and (c) identify associated risk factors of CCI.

Methods

A retrospective national registry study including 2015-2017 data from the eight Swiss PICUs of five tertiary and three regional hospitals, admitting a broad case-mix of medical and surgical patients, including pre- and full-term infants. CCI patients were identified using an adapted definition: PICU length of stay (LOS) ≥8 days and dependence on ≥1 PICU technology.

Results

Out of the 12,375 PICU admissions, 982 (8%) were CCI children and compared to non-CCI children, they were younger (2.8 vs. 6.7 months), had more cardiac conditions (24% vs. 12%), and higher mortality rate (7% vs. 2%) (p < 0.001). Nursing workload was higher in the CCI compared to the non-CCI group (22 [17-27]; 21 [16-26] respectively p < 0.001). Factors associated with CCI were cardiac (aOR = 2.241) and neurological diagnosis (aOR = 2.062), surgery (aORs between 1.662 and 2.391), ventilation support (aOR = 2.278), high mortality risk (aOR = 1.074) and agitation (aOR = 1.867).

Conclusion

the results confirm the clinical vulnerability and the complexity of care of CCI children as they were defined in our study. Early identification and adequate staffing is required to provide appropriate and good quality care.

Defining Pediatric Chronic Critical Illness: A Scoping Review

OBJECTIVES

Children with chronic critical illness (CCI) are hypothesized to be a high-risk patient population with persistent multiple organ dysfunction and functional morbidities resulting in recurrent or prolonged critical care; however, it is unclear how CCI should be defined. The aim of this scoping review was to evaluate the existing literature for case definitions of pediatric CCI and case definitions of prolonged PICU admission and to explore the methodologies used to derive these definitions.

DATA SOURCES

Four electronic databases (Ovid Medline, Embase, CINAHL, and Web of Science) from inception to March 3, 2021.

STUDY SELECTION

We included studies that provided a specific case definition for CCI or prolonged PICU admission. Crowdsourcing was used to screen citations independently and in duplicate. A machine-learning algorithm was developed and validated using 6,284 citations assessed in duplicate by trained crowd reviewers. A hybrid of crowdsourcing and machine-learning methods was used to complete the remaining citation screening.

DATA EXTRACTION

We extracted details of case definitions, study demographics, participant characteristics, and outcomes assessed.

DATA SYNTHESIS

Sixty-seven studies were included. Twelve studies (18%) provided a definition for CCI that included concepts of PICU length of stay (n = 12), medical complexity or chronic conditions (n = 9), recurrent admissions (n = 9), technology dependence (n = 5), and uncertain prognosis (n = 1). Definitions were commonly referenced from another source (n = 6) or opinion-based (n = 5). The remaining 55 studies (82%) provided a definition for prolonged PICU admission, most frequently greater than or equal to 14 (n = 11) or greater than or equal to 28 days (n = 10). Most of these definitions were derived by investigator opinion (n = 24) or statistical method (n = 18).

CONCLUSIONS

Pediatric CCI has been variably defined with regard to the concepts of patient complexity and chronicity of critical illness. A consensus definition is needed to advance this emerging and important area of pediatric critical care research.

Group Concept Mapping Conceptualizes High-Quality Care for Long-Stay Pediatric Intensive Care Unit Patients and Families

OBJECTIVE

To describe and conceptualize high-quality care for long-stay pediatric intensive care unit (PICU) patients using group concept mapping (GCM).

STUDY DESIGN

We convened an expert panel to elucidate domains of high-quality care for this growing patient population for which transitory care models fail to meet their needs. Thirty-one healthcare professionals and 7 parents of patients with previous prolonged PICU hospitalizations comprised a diverse, interprofessional multidisciplinary panel. Participants completed the prompt "For PICU patients and families experiencing prolonged lengths of stay, high quality care from the medical team includes ______", with unlimited free text responses. Responses were synthesized into individual statements, then panelists sorted them by idea similarity and rated them by perceived importance. Statement analysis using GCM software through GroupWisdom generated nonoverlapping clusters representing domains of high-quality care.

RESULTS

Participants submitted 265 prompt responses representing 313 unique ideas, resulting in 78 final statements for sorting and rating. The resultant cluster map best representing the data contained 8 domains: (1) Family-Centered Care and Shared Decision Making, (2) Humanizing the Patient, (3) Clinician Supports and Resources, (4) Multidisciplinary Coordination of Care, (5) Family Well-Being, (6) Anticipatory Guidance and Care Planning, (7) Communication, and (8) Continuity of Care.

CONCLUSIONS

GCM empowered a panel of healthcare professionals and parents to explicitly describe and conceptualize high-quality care for patients and families experiencing prolonged PICU stays. This information will aid the effort to address shortcomings of transitory PICU care models.

Factors influencing the length of stay among patients admitted to a tertiary pediatric intensive care unit in Saudi Arabia

This study aimed to assess the variables contributing to the length of stay in the pediatric intensive care unit. This study utilized a retrospective design by analyzing data from the Virtual Pediatric Systems web-based database. The study was conducted in a tertiary hospital-King Fahad Medical City in Riyadh, Saudi Arabia-from January 1, 2014 to December 31, 2019. The patients were admitted to intensive care with complex medical and surgical diseases. The variables were divided into quantitative and qualitative parameters, including patient data, Pediatric Risk of Mortality III score, and complications. Data from 3,396 admissions were analyzed. In this cohort, the median and mean length of stay were 2.8 (interquartile range, 1.08-7.04) and 7.43 (standard deviation, 14.34) days, respectively. The majority of long-stay patients-defined as those staying longer than 30 days-were less than 12 months of age (44.79%), had lower growth parameters (p < 0.001), and had a history of admission to pediatric intensive care units. Moreover, the majority of long-stay patients primarily suffered from respiratory diseases (51.53%) and had comorbidities and complications during their stay (p < 0.001). Multivariate analysis of all variables revealed that central line-associated bloodstream infections (p < 0.001), external ventricular drain insertion (p < 0.005), tracheostomy (p < 0.001), and use of mechanical ventilation (p < 0.001) had the most significant associations with a longer stay in the pediatric intensive care unit. The factors associated with longer stays included the admission source, central nervous system disease comorbidity, and procedures performed during the stay. Factors such as respiratory support were also associated with prolonged intensive care unit stays.

Clinical Analysis and Management of Long-Stay Patients

Background

Worldwide, a certain proportion of patients stay for long periods. Reduction of length of stay is a critical intervention to optimize in-hospital resource utilization. Length of stay itself is a reliable quality index for healthcare systems. Interventions to reduce long hospital stays require understanding organizational and individual factors that affect the length of stay. The purposes of this study are to attempt to reduce long stays (defined as >30 days) by identifying the causes and preventing such situations.

Methods

This was a retrospective observational study of patients who stayed in the hospital for long periods (>30 days) between 1 January 2018 and 31 December 2018. We identified subgroups of patients with long stays, evaluated their associations with baseline variables, relevant discharge departments, and causes of long stays. We proposed improvement plans.

Results

There were 446 long-stay patients (mean age 66.7 years; 37.7% females), including 158 undergoing prolonged mechanical ventilation, 109 with diseases requiring hospitalization, 93 due to nosocomial infection, 31 with delayed discharge, 20 with iatrogenic complications, and 35 patients with long stays for various causes. There were 9331 hospital days associated with 158 patients with prolonged mechanical ventilation. The number of hospital days for those undergoing prolonged mechanical ventilation was significantly different from that of patients who did not undergo prolonged mechanical ventilation. Depending on the causes of long stay, we could reduce the length of stay in 188 (42.1%) of patients using an aggressive management strategy.

Conclusions

Setting a ventilator weaned unit for prolonged mechanical ventilation patients in a tertiary-level hospital is essential to reduce long stay of intensive care unit. Aggressive management strategies can reduce long stays.

Long-stay patients in pediatric intensive care units. Five-years, 2-points, cross-sectional study

Objectives:

To explore the changing patterns of long-stay patients (LSP) to improve the utilization of pediatric intensive care units (PICUs) resources.

Methods:

This is a 2-points cross-sectional study (5 years apart; 2014-2019) conducted among PICUs and SCICUs in Riyadh, Saudi Arabia. Children who have stayed in PICU for more than 21 days were included.

Results:

Out of the 11 units approached, 10 (90%) agreed to participate. The prevalence of LSP in all these hospitals decreased from 32% (48/150) in 2014 to 23.4% (35/149) in 2019. The length of stay ranged from 22 days to 13.5 years. The majority of LSP had a neuromuscular or cardiac disease and were admitted with respiratory compromise. Ventilator-associated pneumonia was the most prevalent complication (37.5%). The most commonly used resources were mechanical ventilation (93.8%), antibiotics (60.4%), and blood-products transfusions (35.4%). The most common reason for the extended stay was medical reasons (51.1%), followed by a lack of family resources (26.5%) or lack of referral to long-term care facilities (22.4%).

Conclusion:

A long-stay is associated with significant critical care bed occupancy, complications, and utilization of resources that could be otherwise utilized as surge capacity for critical care services. Decreasing occupancy in this multicenter study deserves further engagement of the healthcare leaders and families to maximize the utilization of resources.

A comparative two-cohort study of pediatric patients with long term stay in ICUs

During the last decades, the number of patients with long stay admissions (LSA) in PICU has increased. The purpose of this study was to identify factors associated with PICU LSA, assessing healthcare resources use and changes in the profile of these patients. A retrospective, observational, single-center study was carried out. Characteristics of LSA were compared between two periods (2006–2010 and 2011–2015). During the earlier period there were 2,118 admissions (3.9% of them LSA), whereas during the second period, there were 1,763 (5.4% of them LSA) (p = 0.025). LSA accounted for 33.7% PICU stay days during the first period and 46.7% during the second (p < 0.001). Higher use of non-invasive ventilation (80.2% vs. 37.8%, p = 0.001) and high-flow oxygen therapy (68.8% vs. 37.8%, p = 0.005) was observed in the 2011–2015 cohort, whereas the use of arterial catheter (77.1% vs. 92.6%, p = 0.005), continuous infusion of adrenaline (55.2% vs. 75.9%, p = 0.004), and hemoderivative transfusion (74% vs. 89.2%, p = 0.010) was less frequent. In the 2006–2010 cohort, hospital-acquired infections were more common (95.2% vs. 68.8%, p < 0.001) and mortality was higher (26.8% vs. 13.8%, p = 0.026). The number of long-stay PICU admissions have increased entailing an intensive use of healthcare resources. These patients have a high risk for complications and mortality.