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LaRosa JM, Kudchadkar SR. Personalizing ICU liberation for critically Ill children: shaping the future of the ABCDEF bundle. Curr Opin Pediatr 2025; 37:216-222. [PMID: 40172269 DOI: 10.1097/mop.0000000000001465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2025]
Abstract
PURPOSE OF REVIEW Intensive care unit (ICU) liberation bundles aim to reduce acquired morbidities in the growing population of pediatric ICU survivors. This review will explore emerging precision medicine strategies to personalize the implementation of the ICU liberation bundle. RECENT FINDINGS The ICU liberation bundle, also known as the ABCDEF bundle, consists of six interrelated components: A: assess, prevent, and manage pain; B: spontaneous breathing trials; C: choice of analgesia and sedation; D: delirium assessment, prevention, and management; E: early mobility and exercise; F: family engagement and empowerment. Emerging research and technology are advancing personalized approaches to each component, enabling researchers and clinicians to optimize implementation based on patient-specific factors. Key innovations include automated screening and risk stratification using computational models, wearable technologies that detect bundle elements, and genetic assessments to evaluate disease risk and medication responses. SUMMARY This review provides an overview of the ICU liberation bundle for critically ill children and highlights opportunities to personalize each bundle element to enhance survivorship. By integrating advancements in precision medicine, clinicians and researchers can improve the quality of care for the growing population of PICU survivors, ultimately leading to better long-term outcomes.
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Affiliation(s)
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine
- Department of Physical Medicine & Rehabilitation
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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García-Fernández J, Romero-García M, Benito-Aracil L, Pilar Delgado-Hito M. Humanisation in paediatric intensive care units: A narrative review. Intensive Crit Care Nurs 2024; 85:103725. [PMID: 38824005 DOI: 10.1016/j.iccn.2024.103725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 05/02/2024] [Accepted: 05/17/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVE To identify findings in the scientific literature relevant to the strategic lines proposed by the Humanising Intensive Care Project in the context of paediatric intensive care units. DESIGN Narrative review. METHODS A literature search was conducted in the databases PubMed, Scopus, CINHAL, and Cochrane Library. Specific indexing terms and search strategies adapted to each database were designed. The inclusion of publications was based on two criteria: 1) related to the paediatric intensive care unit and 2) addresses at least one of the topics related to the strategic lines of the Humanising Intensive Care Project. Study selection was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the quality of the included studies was assessed using the Mixed Method Appraisal tool. RESULTS A total of 100 articles from 19 different countries were included, covering the period between 2019 and 2021. Nineteen different design types were identified. Thirty-two studies were cross-sectional observational studies, while 15 had an experimental approach. The articles were distributed among the seven strategic lines of the Humanising Intensive Care Project. CONCLUSIONS Synthesising the knowledge related to humanisation in paediatric intensive care units will allow progress to be made in improving quality in these units. However, there is disparity in the amount of experimental research overall. IMPLICATIONS FOR CLINICAL PRACTICE There is a disparity in the available research related to the different strategic lines, and it is necessary to carry out more exhaustive research on topics such as the presence and participation of the family in care or the management of post-paediatric intensive care syndrome.
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Affiliation(s)
- Javier García-Fernández
- Multidisciplinary Nursing Research Group of the Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Marta Romero-García
- Fundamental and Clinical Nursing Department, Faculty of Nursing, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain; GRIN-IDIBELL, Institute of Biomedical Research, L'Hospitalet de Llobregat, Barcelona, Spain; International Research Project for the Humanisation of Health Care, HU-CI Project: Humanising Intensive Care (HU-CI) Project, Collado Villalba, Madrid, Spain.
| | - Llúcia Benito-Aracil
- Fundamental and Clinical Nursing Department, Faculty of Nursing, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain; GRIN-IDIBELL, Institute of Biomedical Research, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Mª Pilar Delgado-Hito
- Fundamental and Clinical Nursing Department, Faculty of Nursing, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain; GRIN-IDIBELL, Institute of Biomedical Research, L'Hospitalet de Llobregat, Barcelona, Spain; International Research Project for the Humanisation of Health Care, HU-CI Project: Humanising Intensive Care (HU-CI) Project, Collado Villalba, Madrid, Spain
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Gershengorn HB, Patel S, Mallow CM, Falise J, Sosa MA, Parekh DJ, Ferreira T. Association of language concordance and restraint use in adults receiving mechanical ventilation. Intensive Care Med 2023; 49:1489-1498. [PMID: 37843570 DOI: 10.1007/s00134-023-07243-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/25/2023] [Indexed: 10/17/2023]
Abstract
PURPOSE Clinician-patient language concordance improves patient outcomes in non-intensive care unit (ICU) settings. We sought to assess the association of ICU nurse-patient language concordance with delirium-related outcomes. METHODS We conducted a retrospective cohort study of adult English- or Spanish-speaking mechanically ventilated ICU patients admitted to ICUs at the University of Miami Hospital and Clinics (January 2021-September 2022). Our primary exposure was nurse-patient language concordance on each shift. We used mixed-effects multivariable regression to evaluate the association of language concordance with the primary outcome of restraint use, and secondary outcomes of agitation and identification of delirium, during each shift (with patient as a random effect). RESULTS Our cohort included 4326 shifts (3380 [78.1%] with language concordance) from 548 patients and 157 nurses. Spanish language was preferred by 269 (49.1%) of patients. English-speaking patients tended to be younger (65 [53, 75] vs 73 [61, 83], p < 0.001) and of non-Hispanic ethnicity (55.5% vs 7.1%, p < 0.001). English-speakers had restraints ordered on fewer of their included shifts (0 [0, 3] vs 1 [0, 3], p = 0.005). After adjustment, the odds of restraint use on shifts with language concordance was significantly lower (odds ratio [OR, 95% confidence interval [CI]]: 0.50 [0.39-0.63], p < 0.001). Agitation (18.6% vs 25.2%; OR [95% CI]: 0.71 [0.55-0.92], p = 0.009) and delirium identification (34.5% vs 41.3%; OR [95% CI]: 0.54 [0.34-0.88], p = 0.014) were also less common. CONCLUSIONS We identified a twofold reduction in the odds of restraint use among mechanically ventilated patients for language concordant nurse-patient dyads. Ensuring nurse-patient language concordance may improve ICU delirium, agitation, and restraint use.
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Affiliation(s)
- Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, 1951 NW 7th Avenue, Miami, FL, 33136, USA.
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Samira Patel
- Care Transformation, University of Miami Hospital and Clinics, Miami, FL, USA
| | - Christopher M Mallow
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, 1951 NW 7th Avenue, Miami, FL, 33136, USA
| | - Joseph Falise
- Nursing, University of Miami Hospital and Clinics, Miami, FL, USA
| | - Marie Anne Sosa
- Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Dipen J Parekh
- Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tanira Ferreira
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, 1951 NW 7th Avenue, Miami, FL, 33136, USA
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Miller AG, Scott BL. 2021 Year in Review: Pediatric Mechanical Ventilation. Respir Care 2022; 67:1476-1488. [PMID: 36100276 PMCID: PMC9993959 DOI: 10.4187/respcare.10311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Mechanical ventilation is commonly used in the pediatric intensive care unit. This paper reviews studies of pediatric mechanical ventilation published in 2021. Topics include physiology, ventilator modes, alarms, disease states, airway suctioning, ventilator liberation, prolonged ventilation, and others.
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Affiliation(s)
- Andrew G Miller
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina; and Respiratory Care Services, Duke University Medical Center, Durham, North Carolina.
| | - Briana L Scott
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
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Crisamore KR, Empey PE, Pelletier JH, Clark RSB, Horvat CM. Patient-Specific Factors Associated with Dexmedetomidine Dose Requirements in Critically Ill Children. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1753537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
AbstractThe objective of this study was to evaluate patient-specific factors associated with dexmedetomidine dose requirements during continuous infusion. A retrospective cross-sectional analysis of electronic health record-derived data spanning 10 years for patients admitted with a primary respiratory diagnosis at a quaternary children's hospital and who received a dexmedetomidine continuous infusion (n = 346 patients) was conducted. Penalized regression was used to select demographic, clinical, and medication characteristics associated with a median daily dexmedetomidine dose. Identified characteristics were included in multivariable linear regression models and sensitivity analyses. Critically ill children had a median hourly dexmedetomidine dose of 0.5 mcg/kg/h (range: 0.1–1.8), median daily dose of 6.7 mcg/kg/d (range: 0.9–38.4), and median infusion duration of 1.6 days (range: 0.25–5.0). Of 26 variables tested, 15 were selected in the final model with days of dexmedetomidine infusion (β: 1.9; 95% confidence interval [CI]: 1.6, 2.3), median daily morphine milligram equivalents dosing (mg/kg/d) (β: 0.3; 95% CI: 0.1, 0.5), median daily ketamine dosing (mg/kg/d) (β: 0.2; 95% CI: 0.1, 0.3), male sex (β: −1.1; 95% CI: −2.0, −0.2), and non-Black reported race (β: −1.2; 95% CI: −2.3, −0.08) significantly associated with median daily dexmedetomidine dose. Approximately 56% of dose variability was explained by the model. Readily obtainable information such as demographics, concomitant medications, and duration of infusion accounts for over half the variability in dexmedetomidine dosing. Identified factors, as well as additional environmental and genetic factors, warrant investigation in future studies to inform precision dosing strategies.
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Affiliation(s)
- Karryn R. Crisamore
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
| | - Philip E. Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Jonathan H. Pelletier
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
| | - Robert S. B. Clark
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
| | - Christopher M. Horvat
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
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Gallaway KA, Skaar TC, Biju A, Slaven J, Tillman EM. A pilot study of ADRA2A genotype association with doses of dexmedetomidine for sedation in pediatric patients. Pharmacotherapy 2022; 42:453-459. [PMID: 35429176 PMCID: PMC9325491 DOI: 10.1002/phar.2684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 01/09/2023]
Abstract
STUDY OBJECTIVE Dexmedetomidine is titrated to achieve sedation in the pediatric and cardiovascular intensive care units (PICU and CVICU). In adults, dexmedetomidine response has been associated with an ADRA2A polymorphism (rs1800544); CC genotype is associated with an increased sedative response compared with GC and GG. To date, this has not been studied in children. DESIGN We conducted a pilot study to determine whether ADRA2A genotype is associated with dexmedetomidine dose in children. MEASUREMENTS AND MAIN RESULTS Forty intubated PICU or CVICU patients who received dexmedetomidine as a continuous infusion for at least 2 days were genotyped for ADRA2A with a custom-designed TaqMan® Assay. Ten (25%) subjects were wildtype (GG), 15 (37.5%) were heterozygous (GC), and 15 (37.5%) were homozygous (CC) variant. The maximum dexmedetomidine doses (mCg/kg/h) were not different between genotype groups CC (1, 0.3-1.2), GC (1, 0.3-1.3), and GG (0.8, 0.3-1.2), (p = 0.37); neither were mean dexmedetomidine doses for these respective genotype groups 0.68 (0.24-1.07), 0.72 (0.22-0.98), 0.58 (0.3-0.94), (p = 0.67). CONCLUSIONS These findings did not confirm the results from adult studies where ADRA2A polymorphisms correlate with dexmedetomidine response, therefore highlighting the need for pediatric studies to validate PGx findings in adults prior to implementation in pediatrics.
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Affiliation(s)
- Katherine A. Gallaway
- Division of Clinical PharmacologyIndiana University School of MedicineIndianapolisIndianaUSA
| | - Todd C. Skaar
- Division of Clinical PharmacologyIndiana University School of MedicineIndianapolisIndianaUSA
| | - Ashwin Biju
- Division of Clinical PharmacologyIndiana University School of MedicineIndianapolisIndianaUSA
| | - James Slaven
- Department of Biostatistics and Health Data ScienceIndiana University School of MedicineIndianapolisIndianaUSA
| | - Emma M. Tillman
- Division of Clinical PharmacologyIndiana University School of MedicineIndianapolisIndianaUSA
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