Quality of life in children three and nine months after discharge from a paediatric intensive care unit: a prospective cohort study

Early Mobilization in Pediatric Critical Care: Exploring the Gap Between Theory and Practice in Saudi Arabia

BACKGROUND Because of advancements in critical care, Pediatric Intensive Care Units (PICUs) have experienced improved survival rates. However, PICU-acquired frailty and cognitive deficits continue to be issues. In PICUs, early mobilization is emerging as a useful technique. The present study assesses early mobilization awareness, opinions, and practices among pediatric critical care providers in Saudi Arabia. MATERIAL AND METHODS From July 2020 to February 2021, a survey was undertaken in Saudi Arabia, targeting 110 physicians, 200 nurses, 30 respiratory therapists, and 20 physiotherapists. It concentrated on emergency medicine practices, operational issues, initiation time, rehabilitation modalities, and PICU staff strain. RESULTS The results showed that 64.7% of the 266 respondents were nurses, usually working in 5- to 15-bed ICUs providing medical and surgical treatment. Early mobilization was evaluated as highly significant by 40.6% of the respondents. Equipment constraints (63.5%), patient medical instability (67.3%), endotracheal intubation complications (65.4%), and personnel limits (56.4%) were major challenges. Non-physicians cited space constraints 38.9% of the time, whereas physicians cited safety concerns 47.4% of the time. Respiratory physiotherapy and passive range-of-motion exercises were the most used rehabilitation techniques (77.8%). Only 38.7% of patients with ICU-acquired weakness were referred for outpatient therapy. CONCLUSIONS The study emphasizes the importance of early mobilization in Saudi Arabian pediatric critical care while also recognizing considerable limitations. Addressing these difficulties necessitates a multidisciplinary, strategic approach. Future research should strive to standardize practices to enhance patient outcomes and develop standards in pediatric critical care.

Parental Perception and Measured Functional Status Following Pediatric Critical Illness: A Secondary Analysis of the Survivor Outcomes Study

OBJECTIVES

We evaluated the concordance between parent/guardian perception of child long-term function and objectively scored long-term functional status using the Functional Status Scale (FSS) among PICU survivors.

DESIGN

Secondary analysis of prospective cohort study.

SETTING

Urban, tertiary, academic PICU.

PATIENTS

PICU patients less than 18 years old were admitted between June and August 2012.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We conducted telephone interviews of parents/guardians of PICU survivors ( n = 77) 6 months post-PICU discharge. We asked parents/guardians to characterize their child's functional status, and we determined FSS scores using scripted interview questions. Concordance between parent/guardian perceptions and FSS scores was assessed, revealing that parent/guardian perceptions of their child's functional status aligned poorly with FSS scores at 6 months (kappa coefficient 0.16).

CONCLUSIONS

These findings shed light on a critical disconnect between parent/guardian perspective and our current tools to measure a child's functional status following critical illness. In an era of decreased PICU mortality and increased long-term morbidity, the discordance between parent/guardian perception and available scoring tools in the assessment of long-term functional status highlights a key opportunity to improve communication and anchor expectations for long-term outcomes among PICU survivors.

The risks of the new morbidities acquired during pediatric onco-critical care and their life-shortening effects

OBJECTIVE

The authors investigated the functional status at ICU admission and at hospital discharge, and the impact of dysfunctions on survivors' lifespan.

METHOD

Single-center retrospective cohort. The FSS (Functional Status Scale) was calculated at ICU admission and at hospital discharge. A new morbidity was defined as an increase in FSS ≥ 3.

RESULTS

Among 1002 patients, there were 855 survivors. Of these, 194 (22.6%) had died by the end of the study; 45 (5.3%) had a new morbidity. Means in the motor domain at admission and discharge were 1.37 (SD: 0.82) and 1.53 (SD 0.95, p = 0.002). In the feeding domain, the means were 1.19 (SD 0.63) and 1.30 (SD 0.76), p = 0.002; global means were 6.93 (SD 2.45) and 7.2 (SD 2.94), p = 0.007.  Acute respiratory failure requiring mechanical ventilation, the score PRISM IV, age < 5 years, and central nervous system tumors were independent predictors of new morbidity. New morbidity correlated with lower odds of survival after hospital discharge, considering all causes of death (p = 0.014), and was independently predictive of death (Cox hazard ratio = 1.98). In Weibull models, shortening in the life span of 14.2% (p = 0.014) was estimated as a new morbidity.

CONCLUSIONS

New morbidities are related to age, disease severity at admission, and SNC tumors. New morbidities, in turn, correlate with lower probabilities of survival and shortening of the remaining life span. Physical rehabilitation interventions in this population of children may have the potential to provide an increase in lifespan.

Interoperable and explainable machine learning models to predict morbidity and mortality in acute neurological injury in the pediatric intensive care unit: secondary analysis of the TOPICC study

Background

Acute neurological injury is a leading cause of permanent disability and death in the pediatric intensive care unit (PICU). No predictive model has been validated for critically ill children with acute neurological injury.

Objectives

We hypothesized that PICU patients with concern for acute neurological injury are at higher risk for morbidity and mortality, and advanced analytics would derive robust, explainable subgroup models.

Methods

We performed a secondary subgroup analysis of the Trichotomous Outcomes in Pediatric Critical Care (TOPICC) study (2011-2013), predicting mortality and morbidity from admission physiology (lab values and vital signs in 6 h surrounding admission). We analyzed patients with suspected acute neurological injury using standard machine learning algorithms. Feature importance was analyzed using SHapley Additive exPlanations (SHAP). We created a Fast Healthcare Interoperability Resources (FHIR) application to demonstrate potential for interoperability using pragmatic data.

Results

1,860 patients had suspected acute neurological injury at PICU admission, with higher morbidity (8.2 vs. 3.4%) and mortality (6.2 vs. 1.9%) than those without similar concern. The ensemble regressor (containing Random Forest, Gradient Boosting, and Support Vector Machine learners) produced the best model, with Area Under the Receiver Operating Characteristic Curve (AUROC) of 0.91 [95% CI (0.88, 0.94)] and Average Precision (AP) of 0.59 [0.51, 0.69] for mortality, and decreased performance predicting simultaneous mortality and morbidity (0.83 [0.80, 0.86] and 0.59 [0.51, 0.64]); at a set specificity of 0.995, positive predictive value (PPV) was 0.79 for mortality, and 0.88 for mortality and morbidity. By comparison, for mortality, the TOPICC logistic regression had AUROC of 0.90 [0.84, 0.93], but substantially inferior AP of 0.49 [0.35, 0.56] and PPV of 0.60 at specificity 0.995. Feature importance analysis showed that pupillary non-reactivity, Glasgow Coma Scale, and temperature were the most contributory vital signs, and acidosis and coagulopathy the most important laboratory values. The FHIR application provided a simulated demonstration of real-time health record query and model deployment.

Conclusions

PICU patients with suspected acute neurological injury have higher mortality and morbidity. Our machine learning approach independently identified previously-known causes of secondary brain injury. Advanced modeling achieves improved positive predictive value in this important population compared to published models, providing a stepping stone in the path to deploying explainable models as interoperable bedside decision-support tools.

Individualized Goal Setting for Pediatric Intensive Care Unit-Based Rehabilitation Using the Canadian Occupational Performance Measure

The Canadian Occupational Performance Measure (COPM) is a client-centered outcome measure that facilitates the prioritization of individualized interventions. Given the rising emphasis on individualized intervention in pediatric intensive care units (PICUs), this cross-sectional study aimed to explore caregivers' perspectives on their children's functional goals within PICUs. From 1 September 2020 to 26 June 2022, caregivers of 41 children aged 1-18 years completed the COPM within 48 h of PICU admission. The study also explored the clinical variables predicting a high number of occupational performance goals (≥4/5). Out of 190 goals proposed by caregivers, 87 (45.8%) pertained to occupational performance, while 103 (54.2%) were related to personal factors. Among the occupational performance goals, the majority were associated with functional mobility (55; 28.9%), followed by personal care (29; 15.2%) and quiet recreation (3; 1.6%). Among personal goals, physiological factors (68; 35.8%) were most common, followed by physical factors (35; 18.4%). We found caregiver anxiety, measured by the State-Trait Anxiety Inventory-State, to be a significant predictor of the number of occupational performance goals. These findings underscore the importance of caregiver psychological assessment in the PICU to facilitate personalized goal setting and improve rehabilitation outcomes.

Translation and cross-cultural adaptation of the pediatric cerebral performance category (PCPC) and pediatric overall performance category (POPC) to Brazilian Portuguese

OBJECTIVE

To translate and culturally adapt the scales Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC) to the Brazilian population.

METHODS

Two English language proficient professionals independently translated the original version of the scales into Brazilian Portuguese. After consensus, it was generated a translated version of each scale. These were back translated into English by two native English translators. A new consensus process resulted in an English version of each scale, which were compared with the originals and approved by the author. A committee of experts with clinical and academic experience in intensive care checked the validity of the content and produced the pre-final versions of the scales, which were tested by 25 professionals from a Pediatric Intensive Care Unit. An audit was conducted to verify the consistency of the methodological process.

RESULTS

The pre-final versions were approved by 96% of the Brazilian professionals. No significant changes were made to the content of the instrument; however, it was identified the need of a guide with instructions on how to use the scales.

CONCLUSIONS

The process of translation and cross-cultural adaptation of the scales was completed and resulted in PCPC-BR and POPC-BR scales.

Health-related quality of life 6 months after pediatric intensive care unit admission for bronchiolitis: a prospective single-center cohort study

Health-Related Quality of Life (HRQoL) after Pediatric Intensive Care Unit (PICU) admission is considered a valuable outcome measure. Yet, data on HRQoL after PICU admission are scarce and often collected in heterogeneous patient groups. The current study aimed to evaluate HRQoL in children with bronchiolitis 6 months after PICU admission, which represents a homogenous patient group. This study was conducted at the Radboud University Medical Centre in the Netherlands. Children admitted to the PICU between November 2019 and April 2020 were eligible. HRQoL was assessed with the "TNO-AZL Preschool children Quality of Life" (TAPQOL) questionnaire and compared to Dutch normative data. Lower scores represent worse HRQoL. HRQoL was assessed in 34 children (response rate 81%), mean age at assessment was 7.6 months (SD 2.5 months), and median length of stay was 5 days (range 1-17). Parents reported significant lower scores on stomach problems (p < 0.001; d = 0.8) and lung problems (p < 0.001; d = 1.2) and significant higher scores on appetite (p < 0.001; d = 0.6) and problem behavior (p < 0.001; d = 0.5) compared to normative data. Effect sizes were moderate to large.

CONCLUSION

Significant differences in several HRQoL domains were found after PICU admission for bronchiolitis compared to normative data. Whereas the domains lung and stomach problems showed significantly impaired scores, most domains revealed HRQoL levels comparable with healthy peers. This study may contribute to the optimization of HRQoL PICU outcomes by highlighting specific HRQoL domains to focus on at admission and during follow-up.

WHAT IS KNOWN

• With the decline in PICU mortality, HRQoL became an important outcome measure. Yet, the currently limited number of studies on HRQoL outcomes often involve heterogeneous patient groups. • Bronchiolitis is one of the most frequent reasons for PICU admission, and although a significant part of children admitted for bronchiolitis has a medical history, compared with other reasons for PICU admission, this patient group is relatively homogeneous in terms of age, disease course, and treatment.

WHAT IS NEW

• In the present study, six months after PICU admission for bronchiolitis, children scored differently on multiple HRQoL domains compared to healthy peers. • Significantly impaired HRQoL scores were reported on lung and stomach problems in comparison to normative data.

Impact of paediatric intensive care unit admission on neurocognitive function in children

Background

Advances in paediatric critical care have resulted in a reduction in mortality. This has shifted the focus to paediatric intensive care unit (PICU)-related morbidities and how to reduce or prevent them. In this study, we aimed to study the impact of paediatric intensive care unit (PICU) admission on neurocognitive performance.

Methods

Intelligence quotient (IQ) was tested in 50 children (27 boys, 23 girls; mean age 6.98 years) 3 months after PICU discharge and in 75 controls using the Stanford-Binet IQ test.

Results

There was no statistically significant difference between patients and controls with regard to IQ scores, and no difference between medical and surgical patients (p > 0.05). IQ was unaffected by sedation, blood transfusion, or blood product transfusion. Patients who underwent a major surgical procedure, needed inotropic support, and needed mechanical ventilation had non-significantly lower IQ scores than those who did not. A non-significant negative correlation was observed between the length of PICU stay, mechanical ventilation duration, sedative use, and inotropic support.

Conclusions

PICU admission does not appear to significantly affect cognitive outcomes in paediatric survivors.

The impact of the family-centered empowerment model on the children's quality of life with chemical burns and their parent’s perceived stress

BACKGROUND AND AIM

Chemical burns are challenging for children and their families due to the unpleasant health consequences. Therefore, it is necessary to provide organized programs to support and educate families suffering child burns. This study aimed at determining the impact of the Family-Centered Empowerment Model (FCEM) on the quality of life of children with chemical burns and their parents' stress.

METHODS

This two-group pre-test-post-test experimental study was conducted on 50 children 1-12 years old with chemical burns along with their parents (n = 50) in three hospitals in Birjand, Iran. Eligible participants were selected by convenience randomized sampling method and then assigned to intervention and control groups. The questionnaires included: PedsQL for measuring the quality of life of children aged 6-12 years, TAPQOL for evaluating the quality of life of children aged 1-6 years, and PSS for exploring the perceived parental stress. The intervention group received the FCEM-based program consisting of four steps (perceived threat, self-efficacy, self-esteem, and evaluation) and the control group received the standard care. Perceived parental stress and children's quality of life were assessed before and after the intervention in both groups. The data were analyzed using SPSS statistical software V. 23.

RESULTS

The results showed that the mean scores of parental stress and children's quality of life (total and subscales) were not significantly different before the intervention. The independent t-test results exhibited a significant difference after the intervention between the mean scores of the variables of the two groups (P < 0.001), indicating an increase in the quality-of-life score and its subscales and a decrease in the parents' stress score. The paired t-test results revealed a significant difference between the means of scores before and after the intervention in the intervention group (P < 0.001).

CONCLUSION

FCEM is an effective approach to reducing parental stress and improving the children's quality of life aged 1-12 years old suffered chemical burns. Therefore, it is suggested to consider the model care plan for this population.

Components of Health-Related Quality of Life Most Affected Following Pediatric Critical Illness

OBJECTIVES

To evaluate which individual elements of health-related quality of life contribute most to decline in overall health-related quality of life status following pediatric critical care.

DESIGN

Retrospective cohort study.

SETTING

Seattle Children's Hospital.

PATIENTS

ICU patients age 1 month to 18 years admitted between December 2011 and February 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We assessed health-relatedquality of life decline from baseline to postdischarge (median, 6 wk) and determined the individual items of the Pediatric Quality of Life Inventory Infant Scales (< 2 yr) and Generic Core Scales (2-18 yr) with the highest prevalence of decline. We used multivariable regression to estimate the risk of decline in each of seven thematic categories by patient age, baseline health status, diagnosis, Pediatric Risk of Mortality score, and ICU length of stay. Decline from baseline health-related quality of life occurred in 22.5% of 539 patients. Items most commonly affected for infants less than 2 years were primarily emotional (cranky/crying, sleep, and self-soothing). Children 2-18 years most commonly experienced declines in physical functioning (play/exercise, lifting, and pain). Across the entire cohort, declines in categories of energy (31.5%), activity (31.0%), sleep (28.0%), and fear (24.7%) were most commonly endorsed. Risk of decline in each category varied with patient age, medical complexity, and diagnosis.

CONCLUSIONS

Deconditioning, sleep, fear, and pain are important targets for intervention to improve health-related quality of life outcomes for critically ill children.

The Association Between Functional Status and Health-Related Quality of Life Following Discharge from the Pediatric Intensive Care Unit

BACKGROUND

Despite one third of children with acquired brain injury (ABI) experiencing new functional impairments following critical care admission, there is limited research investigating the impact of new functional impairments on overall health-related quality of life (HRQOL) or among important HRQOL domains. We aimed to investigate the association between new functional impairments, measured by the Functional Status Scale (FSS), and HRQOL in pediatric patients with ABI after critical care.

METHODS

We conducted a secondary analysis of a prospective observational study of 275 children aged 2 months to 18 years with ABI. The primary exposure evaluated was change in FSS from baseline at hospital discharge, categorized per prior work (no change, 1-2 point increase, and ≥ 3 point increase). The primary outcome was overall HRQOL 6 months after hospital discharge, measured by the Pediatric Quality of Life Inventory (PedsQL) total score. Secondary outcomes were PedsQL domain scores. PedsQL total and domain scores were transformed into age-standardized z scores for analyses. Multiple linear regression models evaluated the association between FSS change category and HRQOL (overall and domain z scores) when controlling for demographic and clinical characteristics and were reported as β-coefficients with 95% confidence intervals.

RESULTS

Complete data were analyzed for 195 (71%) children, including 127 with traumatic brain injury. New functional impairment was common with 32 (16%) patients experiencing FSS increases ≥ 3, 50 (26%) patients with FSS increases of 1-2 points, and 113 (58%) patients with no change from prehospital baseline. The majority of children (63%) demonstrated HRQOL ratings ≥ 1 standard deviation below healthy age-based standards (z scores ≤ - 1). Regression models demonstrated older age, female sex, presence of comorbidities, and preadmission cardiopulmonary resuscitation were all significantly associated with poorer overall HRQOL (all p < 0.05). FSS increase ≥ 3 at discharge was significantly associated with worse overall HRQOL at follow-up (β = - 1.07; 95% confidence interval = - 1.63 to - 0.52) when controlling for the aforementioned significant factors, and significantly improved model fit (p value for change = 0.001). Similar findings in secondary analyses were found for physical domain scores, with FSS increase showing a significant association with worse physical HRQOL scores and improvements in model fit. Change in FSS was not significantly associated with other HRQOL domain scores (emotional, social, school, psychosocial).

CONCLUSIONS

Many children with ABI after critical care experience new functional impairments (FSS increases) and worse HRQOL than healthy peers. FSS increase at discharge is a significant risk factor for worse HRQOL in the months after hospital discharge and improves HRQOL models beyond illness and demographic variables alone.

Building a culture of early mobilization in the pediatric intensive care unit-a nuts and bolts approach

The culture of sedation and immobilization in the pediatric intensive care unit (PICU) is associated with PICU-acquired weakness, delirium, and poor functional, neurocognitive and psychosocial outcomes. A structured approach to introducing physical activity, as early as possible after PICU admission, may prevent these complications and optimize the holistic outcomes of critically ill children. Changing culture and introducing new clinical practice in PICU is complex, but can be approached systematically, using a "nuts and bolts" approach targeting the basic, practical considerations and essential required elements or components. Extending the construction analogy, this article reviews the relevant literature to describe the essential elements required to build and sustain a successful and safe early mobility program in the PICU. Effective early mobilization requires individual patient assessment and goal setting, using a collaborative inter-disciplinary, patient- and family-centered approach, to ensure mobility goals and physical activities are appropriate for the patient's age, condition/s, premorbid function, strength, endurance and developmental level. Early mobility activities for the pediatric age spectrum include active or active-assisted range of motion exercises, neurodevelopmental play, use of mobility devices, in-bed exercises, transfers, sitting or standing tolerance, crawling, pre-gait activities, ambulation and activities of daily living, with a focus on play as function. Although there are few complete contraindications to early mobilization, appropriate precautions and preparation should be taken to mitigate potential safety concerns. Although there are many perceived barriers to early mobilization in the PICU, at the level of patient, provider, institution and knowledge translation; these are not objectively associated with increased risk during mobilization and can be overcome through an engaged process of practice change by all members of the interprofessional clinical team. Early mobility programs could be initiated in PICU as systematic quality improvement initiatives, with established processes to optimize structural, process and system elements and to provide continual feedback, measurement, benchmarking and collaboration; to ultimately impact on measurable patient outcomes. Early, graded, and individually prescribed mobilization should be considered as part of the standard PICU "package of care" for all critically ill and injured children, in order to improve their functional status and quality of life after PICU discharge.

Outcomes following admission to paediatric intensive care: A systematic review

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Trajectories and Risk Factors for Altered Physical and Psychosocial Health-Related Quality of Life After Pediatric Community-Acquired Septic Shock

OBJECTIVES

To evaluate the physical and psychosocial domains of health-related quality of life among children during the first year following community-acquired septic shock, and explore factors associated with poor physical and psychosocial health-related quality of life outcomes.

DESIGN

Secondary analysis of the Life After Pediatric Sepsis Evaluation.

SETTING

Twelve academic PICUs in the United States.

PATIENTS

Children greater than or equal to 1 month and less than 18 years old who were perceived to be without severe developmental disability by their family caregiver at baseline and who survived hospitalization for community-acquired septic shock.

INTERVENTIONS

Family caregivers completed the Pediatric Quality of Life Inventory for children 2-18 years old or the Pediatric Quality of Life Inventory Infant Scales for children less than 2 years old at baseline (reflecting preadmission status), day 7, and months 1, 3, 6, and 12 following PICU admission. Higher Pediatric Quality of Life Inventory Physical and Psychosocial Health Summary Scores indicate better health-related quality of life.

MEASUREMENTS AND MAIN RESULTS

Of 204 children, 58 (28.2%) had a complex chronic comorbid condition. Children with complex chronic comorbid conditions had lower baseline physical health-related quality of life (62.7 ± 22.6 vs 84.1 ± 19.7; p < 0.001) and psychosocial health-related quality of life (68.4 ± 14.1 vs 81.2 ± 15.3; p < 0.001) than reference norms, whereas children without such conditions had baseline scores similar to reference norms. Children with complex chronic comorbid conditions recovered to their baseline health-related quality of life, whereas children without such conditions did not (physical health-related quality of life 75.3 ± 23.7 vs 83.2 ± 20.1; p = 0.008 and psychosocial health-related quality of life 74.5 ± 18.7 vs 80.5 ± 17.9; p = 0.006). Age less than 2 years was independently associated with higher month 12 physical health-related quality of life, and abnormal neurologic examination and neurologic injury suspected by a healthcare provider during the PICU course were independently associated with lower month 12 physical health-related quality of life. Treatment of increased intracranial pressure and medical device use at month 1 were independently associated with lower month 12 psychosocial health-related quality of life.

CONCLUSIONS

Physical and psychosocial health-related quality of life were reduced among children during the first year following community-acquired septic shock compared with reference norms, although many recovered to baseline. Risk factors for poor health-related quality of life included neurologic complications during the hospitalization and dependence on a medical device 1 month postadmission.

Post-Intensive-Care Syndrome for the Pediatric Neurologist

The number of children who survive critical illness has steadily increased. However, lower mortality rates have resulted in a proportional increase in post-intensive-care morbidity. Critical illness in childhood affects a child's development, cognition, and family functioning. The constellation of physical, emotional, cognitive, and psychosocial symptoms that begin in the intensive care unit and continue after discharge has recently been termed post-intensive-care syndrome. A conceptual model of the post-intensive-care syndrome experienced by children who survive critical illness, their siblings, and parents has been coined post-intensive-care syndrome in pediatrics. Owing to their prolonged hospitalizations, the use of sedative medications, and the nature of their illness, children with primary neurological injury are among those at the highest risk for post-intensive-care syndrome in pediatrics. The pediatric neurologist participates in the care of children with acute brain injury throughout their hospitalization and remains involved after the patient leaves the hospital. Hence it is important for pediatric neurologists to become versed in the early recognition and management of post-intensive-care syndrome in pediatrics. In this review, we discuss the current knowledge regarding post-intensive-care syndrome in pediatrics and its risk factors. We also discuss our experience establishing Pediatric Neurocritical Care Recovery Programs at two large academic centers. Last, we provide a battery of validated tests to identify and manage the different aspects of post-intensive-care syndrome in pediatrics, which have been successfully implemented at our institutions. Dissemination of this "road map" may assist others interested in establishing recovery programs, therefore mitigating the burden of post-intensive-care morbidity in children.

Study protocol for a multicentre longitudinal mixed methods study to explore the Outcomes of ChildrEn and fAmilies in the first year after paediatric Intensive Care: the OCEANIC study

INTRODUCTION

Annually in the UK, 20 000 children become very ill or injured and need specialist care within a paediatric intensive care unit (PICU). Most children survive. However, some children and their families may experience problems after they have left the PICU including physical, functional and/or emotional problems. It is unknown which children and families experience such problems, when these occur or what causes them. The aim of this mixed-method longitudinal cohort study is to understand the physical, functional, emotional and social impact of children surviving PICU (aged: 1 month-17 years), their parents and siblings, during the first year after a PICU admission.

METHODS AND ANALYSIS

A quantitative study involving 300 child survivors of PICU; 300 parents; and 150-300 siblings will collect data (using self-completion questionnaires) at baseline, PICU discharge, 1, 3, 6 and 12 months post-PICU discharge. Questionnaires will comprise validated and reliable instruments. Demographic data, PICU admission and treatment data, health-related quality of life, functional status, strengths and difficulties behaviour and post-traumatic stress symptoms will be collected from the child. Parent and sibling data will be collected on the impact of paediatric health conditions on the family's functioning capabilities, levels of anxiety and social impact of the child's PICU admission. Data will be analysed using descriptive and inferential statistics. Concurrently, an embedded qualitative study involving semistructured interviews with 24 enrolled families at 3 months and 9 months post-PICU discharge will be undertaken. Framework analysis will be used to analyse the qualitative data.

ETHICS AND DISSEMINATION

The study has received ethical approval from the National Health Services Research Ethics Committee (Ref: 19/WM/0290) and full governance clearance. This will be the first UK study to comprehensively investigate physical, functional, emotional and social consequences of PICU survival in the first-year postdischarge.Clinical Trials Registration Number: ISRCTN28072812 [Pre-results].

Potential Neurodevelopmental Effects of Pediatric Intensive Care Sedation and Analgesia: Repetitive Benzodiazepine and Opioid Exposure Alters Expression of Glial and Synaptic Proteins in Juvenile Rats

Sedatives are suspected contributors to neurologic dysfunction in PICU patients, to whom they are administered during sensitive neurodevelopment. Relevant preclinical modeling has largely used comparatively brief anesthesia in infant age-approximate animals, with insufficient study of repetitive combined drug administration during childhood. We hypothesized that childhood neurodevelopment is selectively vulnerable to repeated treatment with benzodiazepine and opioid. We report a preclinical model of combined midazolam and morphine in early childhood age-approximate rats.

Health-related quality of life of children and their parents 6 months after children's critical illness

Purpose

This study aimed to examine health-related quality of life (HRQoL) of children and their parents, 6 months after the child’s admission to the Pediatric Intensive Care Unit (PICU). Associations between parents’ reports regarding HRQoL of their child and of themselves were investigated, as well as associations between children’s baseline variables and their parent-reported HRQoL outcomes.

Methods

This is a secondary analysis of cross-sectional data collected in a group of children who participated in the PEPaNIC trial. Six months after discharge from the PICU, parents of critically ill children completed the Infant–Toddler Quality of Life Questionnaire (ITQOL, for age 0–3 years) or the Child Health Questionnaire-Parent Form 50 (CHQ-PF50, for age 4–18 years), which are parallel questionnaires. Parents completed the Short Form Health Survey (SF-12) regarding their own HRQoL. Results were compared with normative data.

Results

At 6 months’ follow-up, 86 children of the 1343 (6%) had died which resulted in 1257 eligible children. Parents of 576 surviving children (46%) completed the questionnaires. Children of responding parents had less often an acute reason for admission and differed in diagnosis compared with children of non-responders. PICU children scored lower on most ITQOL (n = 390) scales and CHQ-PF50 (n = 186) scales compared with normative data. Parents reported (n = 570) higher scores on the physical (p < 0.001) and lower scores on the mental SF-12 scale (p < 0.001) compared with normative data. Parents̕ mental HRQoL correlated with HRQoL they reported for their child (Pearson Correlations range 0.25–0.57, p < 0.001–0.002). Shorter length of stay, lower risk of mortality, younger age, and cardiac diagnosis were associated with higher parent-reported HRQoL outcomes for the child.

Conclusions

Six months after PICU discharge, critically ill children have lower HRQoL compared with normative data. The mental component of HRQoL is impaired in parents and is associated with lower overall parent-reported HRQoL of their child.

Electronic supplementary material

The online version of this article (10.1007/s11136-019-02347-x) contains supplementary material, which is available to authorized users.

PICU Follow-Up: The Impact of Missed School in a Cohort of Children Following PICU Admission

For children and their families, PICU admission can be one of the most stressful and traumatic experiences in their lives. Children admitted to the PICU and their parents experience sequelae following admission including psychologic symptoms and lower health-related quality of life. The impact of a PICU admission on school attendance and performance may influence these sequelae. The purpose of our study was to examine how community supports from pediatricians and schools influence school success after critical illness.

DESIGN

Parents were recruited during their child's admission to the PICU. Three months after discharge, parents completed follow-up questionnaires via telephone.

SETTING

PICU in an urban academic children's hospital.

SUBJECTS

Thirty-three parents were enrolled in the study, and 21 (64%) completed phone follow-up.

MEASUREMENTS AND MAIN RESULTS

Forty-three percent of children missed 7 or more days of school while admitted to the PICU. Sixty-seven percent of parents reported that their pediatrician did not ask about missed school, and 29% felt their child's grades worsened since admission. Twenty percent of respondents felt that their child's school did not provide adequate services to help their child catch up.

CONCLUSIONS

There are missed opportunities for care coordination and educational support after critical illness. The transition back to school is challenging for some children, as reported by parents who described inadequate support from the school after PICU hospitalization and a subsequent decline in their child's school performance. Additional studies are needed to develop proactive community supports to improve the transition back to school for a child after critical illness.

PICU-Based Rehabilitation and Outcomes Assessment: A Survey of Pediatric Critical Care Physicians

OBJECTIVES

Characterize current practices for PICU-based rehabilitation, and physician perceptions and attitudes, barriers, resources, and outcome assessment in contemporary PICU settings.

DESIGN

International, self-administered, quantitative, cross-sectional survey.

SETTING

Online survey distributed from March 2017 to April 2017.

PATIENTS OR SUBJECTS

Pediatric critical care physicians who subscribed to email distribution lists of the Pediatric Acute Lung Injury and Sepsis Investigators, the Pediatric Neurocritical Care Research Group, or the Prevalence of Acute Critical Neurological Disease in Children: A Global Epidemiological Assessment study group, and visitors to the World Federation of Pediatric Intensive and Critical Care Societies website.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 170 subjects who began the survey, 148 completed it. Of those who completed the optional respondent information, most reported working in an academic medical setting and were located in the United States. The main findings were 1) a large majority of PICU physicians reported working in institutions with no guidelines for PICU-based rehabilitation, but expressed interest in developing and implementing such guidelines; 2) despite this lack of guidelines, an overwhelming majority of respondents reported that their current practices would involve consultation of multiple rehabilitation services for each case example provided; 3) PICU physicians believed that additional research evidence is needed to determine efficacy and optimal implementation of PICU-based rehabilitation; 4) PICU physicians reported significant barriers to implementation of PICU-based rehabilitation across centers; and 5) low routine assessment of long-term functional outcomes of PICU patients, although some centers have developed multidisciplinary follow-up programs.

CONCLUSIONS

Physicians lack PICU-based rehabilitation guidelines despite great interest and current practices involving a high degree of PICU-based rehabilitation consultation. Data are needed to identify best practices and necessary resources in the delivery of ICU-based multidisciplinary rehabilitation and long-term functional outcomes assessment to optimize recovery of children and families affected by critical illness.

Feasibility and Acceptability of Methods to Collect Follow-Up Information From Parents 12 Months After Their Child's Emergency Admission to Pediatric Intensive Care

OBJECTIVES

To evaluate the feasibility and acceptability of different methods of collecting follow-up data from parents 12 months after their child's emergency admission to a PICU.

DESIGN

Mixed-methods explanatory sequential design.

SETTING

One regional PICU transport service and three PICUs in England.

PATIENTS

Children undergoing emergency transport to PICU recruited to an ongoing biomarker study whose parents consented to be contacted for follow-up 12 months after PICU admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Parents or guardians who consented were asked to complete three questionnaires about their child's functional status, quality of life, and behavior 12 months after PICU admission. Parents were given a choice about method of questionnaire completion: postal, online, or telephone interview and also asked for telephone feedback about the process and the reasons for their choice. Of 486 parents who consented to be contacted at 12 months, 232 were successfully contacted. Consent to receive questionnaires was obtained in 218 of 232 (94%). Of the 218 parents, 102 (47%) chose to complete questionnaires online (with 77% completion rate), 91 (42%) chose to complete postal questionnaires (48% completion rate), and 25 (11%) chose to complete questionnaires by telephone interview (44% completion rate).

CONCLUSIONS

Parents expressed different preferences for follow-up questionnaire completion. Response rates varied by completion method. Understanding and catering for parental preferences is an important factor in maximizing response rates for follow-up studies in intensive care.

Brazilian version of the Pediatric Functional Status Scale: translation and cross-cultural adaptation

Objective

To translate and cross-culturally adapt the Functional Status Scale for hospitalized children into Brazilian Portuguese.

Methods

A methodological study of the translation and cross-cultural adaptation of the Functional Status Scale was conducted, according to the stages of translation, synthesis of translations, back-translation, synthesis of back-translations, expert committee analysis and pre-test with a sample of the target population. During the evaluation by the committee of experts, semantic, content and item analyses were performed.

Results

The semantic, idiomatic, cultural and conceptual equivalences between the translated version and the original version were obtained, resulting in the Brazilian version of the Functional Status Scale. After the analysis by the expert committee, there were no problems regarding the cultural or conceptual equivalences because the items were pertinent to the Brazilian culture and few terms were modified. In the pre-test stage, the scale was applied by two evaluators to a sample of 25 children. Clarity and ease in answering the scale items were observed. Good inter-observer reliability was obtained, with an intraclass correlation coefficient of 0.85 (0.59 - 0.95).

Conclusions

The Functional Status Scale for pediatric use was translated and culturally adapted into Portuguese spoken in Brazil. The translated items were pertinent to the Brazilian culture and evaluated the dimensions proposed by the original instrument. Validation studies of this instrument are suggested to make it feasible for use in different regions of Brazil.

"Keeping pace according to the child" during procedures in the paediatric intensive care unit: A grounded theory study

OBJECTIVE

The goal was to explore how nurses interact with children in the paediatric intensive care unit during potentially painful procedures.

RESEARCH METHODOLOGY/DESIGN

This was a qualitative research study that used grounded theory approach. Data were collected through participant observation and interviews. Nurse-child interactions were observed and recorded during potentially painful procedures performed by nurses. Following observation of a procedure, nurses were interviewed about their intentions, feelings and emotions during the procedure.

SETTING

The study took place in a seven-bed paediatric intensive care unit in an academic teaching hospital in Japan.

FINDINGS

Children's acceptance of a procedure was induced by nurses' pacing, particularly in a pattern of "keeping pace according to the child." Such pacing involved soothing the child, explaining what was being done to the child at each step and acknowledging the child's emotions. All of these child-centred procedures provoked cooperation from the children even during painful procedures.

CONCLUSIONS

Our study suggests that a collaborative practice approach, in which nurses use a series of calming tactics, might improve children's perceptions of painful procedures.

Long-Term Outcomes after Protocolized Sedation versus Usual Care in Ventilated Pediatric Patients

RATIONALE

Whether a nurse-implemented goal-directed sedation protocol resulting in more awake yet calm intubated children affects postdischarge functional status, health-related quality of life, or risk for post-traumatic stress disorder is unknown.

OBJECTIVES

To compare postdischarge outcomes in children with acute respiratory failure cluster-randomized to a sedation protocol or usual care.

METHODS

A stratified random sample of 1,360 patients from 31 centers in the RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) trial was assessed by mail, electronically, and/or telephone 6 months after ICU discharge. In treatment group comparisons, we controlled for age, baseline functional status, and severity of illness.

MEASUREMENTS AND MAIN RESULTS

We used the Pediatric Overall Performance Category and the Pediatric Cerebral Performance Category to characterize functional status, the Infant and Toddler Quality of Life Questionnaire (97-item full-length version) (<2 yr old) or Pediatric Quality of Life Inventory (≥2 yr old), and the Child Post-traumatic Stress Disorder Symptom Scale (≥8 yr old and developmentally able). Functional status worsened from baseline to follow-up in 20%. Decline in functional status did not differ by treatment arm and was more common among those with baseline impairment than those with baseline normal function (27 vs. 18%; P < 0.001). There were no significant differences in health-related quality of life total scores by treatment arm. Scores indicating risk of post-traumatic stress disorder occurred in 30%, with no difference between treatment arms.

CONCLUSIONS

A sedation strategy that allows patients to be more awake and exposes them to fewer sedative and analgesic medications produces no long-term harm. However, postdischarge morbidity after acute respiratory failure is common. Clinical trial registered with www.clinicaltrials.gov (NCT00814099).

Development and Validation of an Empiric Tool to Predict Favorable Neurologic Outcomes Among PICU Patients

OBJECTIVES

To create a novel tool to predict favorable neurologic outcomes during ICU stay among children with critical illness.

DESIGN

Logistic regression models using adaptive lasso methodology were used to identify independent factors associated with favorable neurologic outcomes. A mixed effects logistic regression model was used to create the final prediction model including all predictors selected from the lasso model. Model validation was performed using a 10-fold internal cross-validation approach.

SETTING

Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database.

PATIENTS

Patients less than 18 years old admitted to one of the participating ICUs in the Virtual Pediatric Systems database were included (2009-2015).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 160,570 patients from 90 hospitals qualified for inclusion. Of these, 1,675 patients (1.04%) were associated with a decline in Pediatric Cerebral Performance Category scale by at least 2 between ICU admission and ICU discharge (unfavorable neurologic outcome). The independent factors associated with unfavorable neurologic outcome included higher weight at ICU admission, higher Pediatric Index of Morality-2 score at ICU admission, cardiac arrest, stroke, seizures, head/nonhead trauma, use of conventional mechanical ventilation and high-frequency oscillatory ventilation, prolonged hospital length of ICU stay, and prolonged use of mechanical ventilation. The presence of chromosomal anomaly, cardiac surgery, and utilization of nitric oxide were associated with favorable neurologic outcome. The final online prediction tool can be accessed at https://soipredictiontool.shinyapps.io/GNOScore/. Our model predicted 139,688 patients with favorable neurologic outcomes in an internal validation sample when the observed number of patients with favorable neurologic outcomes was among 139,591 patients. The area under the receiver operating curve for the validation model was 0.90.

CONCLUSIONS

This proposed prediction tool encompasses 20 risk factors into one probability to predict favorable neurologic outcome during ICU stay among children with critical illness. Future studies should seek external validation and improved discrimination of this prediction tool.

Review of supplemental oxygen and respiratory support for paediatric emergency care in sub-Saharan Africa

INTRODUCTION

In African countries, respiratory infections and severe sepsis are common causes of respiratory failure and mortality in children under five years of age. Mortality and morbidity in these children could be reduced with adequate respiratory support in the emergency care setting. The purpose of this review is to describe management priorities in the emergency care of critically ill children presenting with respiratory problems. Basic and advanced respiratory support measures are described for implementation according to available resources, work load and skill-levels.

METHODS

We did a focused search of respiratory support for critically ill children in resource-limited settings over the past ten years, using the search tools PubMed and Google Scholar, the latest WHO guidelines, international 'Advanced Paediatric Life Support' guidelines and paediatric critical care textbooks.

RESULTS

The implementation of triage and rapid recognition of respiratory distress and hypoxia with pulse oximetry is important to correctly identify critically ill children with increased risk of mortality in all health facilities in resource constrained settings. Basic, effective airway management and respiratory support are essential elements of emergency care. Correct provision of supplemental oxygen is safe and its application alone can significantly improve the outcome of critically ill children. Non-invasive ventilatory support is cost-effective and feasible, with the potential to improve emergency care packages for children with respiratory failure and other organ dysfunctions. Non-invasive ventilation is particularly important in severely under-resourced regions unable to provide intubation and invasive mechanical ventilation support. Malnutrition and HIV-infection are important co-morbid conditions, associated with increased mortality in children with respiratory dysfunction.

DISCUSSION

A multi-disciplinary approach is required to optimise emergency care for critically ill children in low-resource settings. In this context, it is important to consider aspects of training of staff, technical support and pragmatic research.

Delirium in the Critically Ill Child: Assessment and Sequelae

Delirium is a common and serious neuropsychiatric complication in critically ill patients of all ages. In the context of critical illness, delirium may emerge as a result of a cascade of underlying pathophysiologic mechanisms and signals organ failure of the brain. Awareness of the clinical importance of delirium in adults is growing as emerging research demonstrates that delirium represents a serious medical problem with significant sequelae. However, our understanding of delirium in children lags significantly behind the adult literature. In particular, our knowledge of how to assess delirium is complicated by challenges in recognizing symptoms of delirium in pediatric patients especially in critical and intensive care settings, and our understanding of its impact on acute and long-term functioning remains in its infancy. This paper focuses on (a) the challenges associated with assessing delirium in critically ill children, (b) the current literature on the outcomes of delirium including morbidity following discharge from PICU, and care-giver well-being, and (c) the importance of assessment in determining impact of delirium on outcome. Current evidence suggests that delirium is a diagnostic challenge for clinicians and may play a detrimental role in a child's recovery after discharge from the pediatric intensive care unit (PICU). Recommendations are proposed for how our knowledge and assessment of delirium in children could be improved.

Characteristics of postintensive care syndrome in survivors of pediatric critical illness: A systematic review

AIM

To synthesize the available evidence focusing on morbidities in pediatric survivors of critical illness that fall within the defined construct of postintensive care syndrome (PICS) in adults, including physical, neurocognitive and psychological morbidities.

METHODS

A comprehensive search was conducted in MEDLINE, EMBASE, the Cochrane Library, PsycINFO, and CINAHL using controlled vocabulary and key word terms to identify studies reporting characteristics of PICS in pediatric intensive care unit (PICU) patients. Two reviewers independently screened all titles and abstracts and performed data extraction. From the 3176 articles identified in the search, 252 abstracts were identified for full text review and nineteen were identified for inclusion in the review. All studies reporting characteristics of PICS in PICU patients were included in the final synthesis.

RESULTS

Nineteen studies meeting inclusion criteria published between 1995 and 2016 were identified and categorized into studies reporting morbidities in each of three categories-physical, neurocognitive and psychological. The majority of included articles reported prospective cohort studies, and there was significant variability in the outcome measures utilized. A synthesis of the studies indicate that morbidities encompassing PICS are well-described in children who have survived critical illness, often resolving over time. Risk factors for development of these morbidities include younger age, lower socioeconomic status, increased number of invasive procedures or interventions, type of illness, and increased benzodiazepine and narcotic administration.

CONCLUSION

PICS-related morbidities impact a significant proportion of children discharged from PICUs. In order to further define PICS in children, more research is needed using standardized tools to better understand the scope and natural history of morbidities after hospital discharge. Improving our understanding of physical, neurocognitive, and psychological morbidities after critical illness in the pediatric population is imperative for designing interventions to improve long-term outcomes in PICU patients.

International Survey of Critically Ill Children With Acute Neurologic Insults: The Prevalence of Acute Critical Neurological Disease in Children: A Global Epidemiological Assessment Study

OBJECTIVE

The international scope of critical neurologic insults in children is unknown. Our objective was to assess the prevalence and outcomes of children admitted to PICUs with acute neurologic insults.

DESIGN

Prospective study.

SETTING

Multicenter (n = 107 PICUs) and multinational (23 countries, 79% in North America and Europe).

PATIENTS

Children 7 days to 17 years old admitted to the ICU with new traumatic brain injury, stroke, cardiac arrest, CNS infection or inflammation, status epilepticus, spinal cord injury, hydrocephalus, or brain mass.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We evaluated the prevalence and outcomes of children with predetermined acute neurologic insults. Child and center characteristics were recorded. Unfavorable outcome was defined as change in pre-post insult Pediatric Cerebral Performance Category score greater than or equal to 2 or death at hospital discharge or 3 months, whichever came first. Screening data yielded overall prevalence of 16.2%. Of 924 children with acute neurologic insults, cardiac arrest (23%) and traumatic brain injury (19%) were the most common. All-cause mortality at hospital discharge was 12%. Cardiac arrest subjects had highest mortality (24%), and traumatic brain injury subjects had the most unfavorable outcomes (49%). The most common neurologic insult was infection/inflammation in South America, Asia, and the single African site but cardiac arrest in the remaining regions.

CONCLUSIONS

Neurologic insults are a significant pediatric international health issue. They are frequent and contribute substantial morbidity and mortality. These data suggest a need for an increased focus on acute critical neurologic diseases in infants and children including additional research, enhanced availability of clinical resources, and the development of new therapies.

Long-Term Function After Pediatric Critical Illness: Results From the Survivor Outcomes Study

OBJECTIVE

Knowledge of the long-term outcomes of survivors of pediatric critical illness is sparse but important. The aim of this study was to evaluate morbidity and mortality 6 months and 3 years after hospital discharge.

DESIGN

Prospective cohort study.

SETTING

Urban, inner city, academic PICU.

PATIENTS

Consecutive patients admitted to the PICU from June 2012 to August 2012.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We collected descriptive and demographic information and functional status assessments at baseline, admission, hospital discharge, 6 months and 3 years following discharge. Functional status was measured with the Functional Status Scale. New morbidity was defined as a change in Functional Status Scale score of greater than or equal to 3. Postdischarge assessments utilized scripted telephone surveys. Of 303 consecutive PICU patients, 253 were eligible and 129 parents consented. Follow-up outcomes were obtained for 77 patients (59.7%) at 6 months and 70 of these patients (54.2%) at 3 years. Both mortality and morbidity increased after discharge. Cumulative mortality increased from 3.9% (n = 3) at discharge to 7.8% (n = 6) at 6 months (p = 0.08) and 10.4% (n = 8) at 3 years (p = 0.03). New morbidity increased cumulatively from 5.2% (n = 4) at discharge to 6.5% (n = 5) at 6 months (p = 0.65) and 10.4% (n = 8) at 3 years (p = 0.16). Almost as many children demonstrated worsening of their functional status or died (38%) as children who survived without a change in functional status (44%). Less than 10% of children exhibited functional gains over time. Long-term functional outcome was associated with PICU variables including the need for invasive therapies and indicators of severity of illness such as use of mechanical ventilation, ventilator days, use of vasoactive medications, and PICU length of stay. The combined poor outcomes of new morbidity and mortality increased cumulatively from 9.1% (n = 7) at discharge to 14.3% (n = 11) at 6 months (p = 0.16) and 20.8% (n = 16) by 3 years (p = 0.01).

CONCLUSIONS

Mortality and new morbidity appear to substantially increase after discharge. Critical illness is associated with a sustained impact on survival and functional status.

Primary Outcome Measures in Pediatric Septic Shock Trials: A Systematic Review

OBJECTIVE

To evaluate all published pediatric randomized controlled trials of patients with septic shock from any cause to examine the outcome measures used, the strengths and limitations of these measurements and whether the trial outcomes met feasibility criteria.

DATA SOURCES

We used a previously published database of pediatric critical care randomized controlled trials (PICUtrials.net) derived from searches of MEDLINE, EMBASE, LILACS, and CENTRAL.

STUDY SELECTION

We included randomized controlled trials of interventions to children admitted to a PICU with septic or dengue hemorrhagic shock which were published in English.

DATA EXTRACTION

Study characteristics and outcomes were retrieved by two independent reviewers with disagreement being resolved by a third reviewer. We defined feasibility as 1) recruitment of at least 90% of the targeted sample size and agreement of the observed outcome rate in the control group with the rate used for the sample size calculation to within 10% or 2) finding of a statistically significant difference in an interim or final analysis.

DATA SYNTHESIS

Nineteen of 321 identified articles were selected for review. Fourteen of 19 studies (74%) provided an a priori definition of their primary outcome measure in their "Methods section." Mortality rate was the most commonly reported primary outcome (8/14; 57%), followed by duration of shock (4/14; 29%) followed by organ failure (1/14; 7%). Only three of 19 included trials met feasibility criteria.

CONCLUSIONS

Our review found that use of mortality alone as a primary outcome in pediatric septic shock trials was associated with significant limitations and that long-term patient-centered outcomes were not used in this setting. Composite outcomes incorporating mortality and long-term outcomes should be explored for use in future pediatric septic shock trials.

Epidemiology and Outcomes of Pediatric Multiple Organ Dysfunction Syndrome

OBJECTIVE

To summarize the epidemiology and outcomes of children with multiple organ dysfunction syndrome as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development multiple organ dysfunction syndrome workshop (March 26-27, 2015).

DATA SOURCES

Literature review, research data, and expert opinion.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Moderated by an experienced expert from the field, issues relevant to the epidemiology and outcomes of children with multiple organ dysfunction syndrome were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities.

DATA SYNTHESIS

Summary of presentations and discussion supported and supplemented by the relevant literature.

CONCLUSIONS

A full understanding the epidemiology and outcome of multiple organ dysfunction syndrome in children is limited by inconsistent definitions and populations studied. Nonetheless, pediatric multiple organ dysfunction syndrome is common among PICU patients, occurring in up to 57% depending on the population studied; sepsis remains its leading cause. Pediatric multiple organ dysfunction syndrome leads to considerable short-term morbidity and mortality. Long-term outcomes of multiple organ dysfunction syndrome in children have not been well studied; however, studies of adults and children with other critical illnesses suggest that the risk of long-term adverse sequelae is high. Characterization of the long-term outcomes of pediatric multiple organ dysfunction syndrome is crucial to identify opportunities for improved treatment and recovery strategies that will improve the quality of life of critically ill children and their families. The workshop identified important knowledge gaps and research priorities intended to promote the development of standard definitions and the identification of modifiable factors related to its occurrence and outcome.

Long-Term Pulmonary Function and Quality of Life in Children After Acute Respiratory Distress Syndrome: A Feasibility Investigation

OBJECTIVES

To determine the feasibility of pulmonary function and quality of life evaluations in children after acute respiratory distress syndrome.

DESIGN

A prospective follow-up feasibility study.

SETTING

A tertiary PICU.

PATIENTS

Children less than 18 years old with acute respiratory distress syndrome admitted between 2000 and 2005.

INTERVENTION

Pulmonary function testing and patient and parental quality of life surveys approximately 12-month after acute respiratory distress syndrome.

MEASUREMENTS AND MAIN RESULTS

One hundred eighty patients met acute respiratory distress syndrome criteria; 37 (20%) died, 90 (51%) declined participation, 28 (16%) consented but did not return, and 24 (13%) returned for follow-up visit. Twenty-three patients completed quality of life testing and 17 completed pulmonary functions. Clinical characteristics of those who returned were no different from those who did not except for age (median age, 4.9 vs 1.8 yr). One-third had mild to moderate pulmonary function deficits. Quality of life scores were marginal with general health perception, physical functioning, and behavior being areas of concern. These scores were lower than scores in children with chronic asthma. Parental quality of life assessments report lower scores in single-parent homes but no differences were noted by race or parental employment status.

CONCLUSIONS

Valuable information may be discerned from acute respiratory distress syndrome patients who return for follow-up evaluation. In this pilot study, up to one-third of children with acute respiratory distress syndrome exhibit pulmonary function deficits and 12-month postillness quality of life scores are lower than in children with chronic asthma. Parental perceptions of postillness quality of life may be negatively impacted by socioeconomic constraints. Long-term follow of children with acute respiratory distress syndrome is feasible and bears further investigation.

Short-Term Health-Related Quality of Life of Critically Ill Children Following Daily Sedation Interruption

OBJECTIVE

Our earlier pediatric daily sedation interruption trial showed that daily sedation interruption in addition to protocolized sedation in critically ill children does not reduce duration of mechanical ventilation, length of stay, or amounts of sedative drugs administered when compared with protocolized sedation only, but undersedation was more frequent in the daily sedation interruption + protocolized sedation group. We now report the preplanned analysis comparing short-term health-related quality of life and posttraumatic stress symptoms between the two groups.

DESIGN

Preplanned prospective part of a randomized controlled trial.

SETTING

Two tertiary medical-surgical PICUs in the Netherlands.

PATIENTS

Critically ill children requiring mechanical ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Eight weeks after a child's discharge from the PICU, health-related quality of life was assessed with the validated Child Health Questionnaire and, only for children above 4 years old, posttraumatic stress was assessed with the Dutch Children's Responses to Trauma Inventory. Additionally, health-related quality of life of all study patients was compared with Dutch normative data. Of the 113 patients from two participating centers in the original study, 96 patients were eligible for follow-up and 64 patients were included (response rate, 67%). No difference was found with respect to health-related quality of life between the two study groups. None of the eight children more than 4 years old showed posttraumatic stress symptoms.

CONCLUSIONS

Daily sedation interruption in addition to protocolized sedation for critically ill children did not seem to have an effect on short-term health-related quality of life. Also in view of the earlier found absence of effect on clinical outcome, we cannot recommend the use of daily sedation interruption + protocolized sedation.

Functional Outcomes and Physical Impairments in Pediatric Critical Care Survivors: A Scoping Review

OBJECTIVE

Although more children are surviving critical illness, little is known about long-term physical impairment. This scoping review aims to critically appraise existing literature on functional outcome measurement tools, prevalence, and risk factors for physical impairments in pediatric critical care survivors.

DATA SOURCES

PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature, using a combination of MeSH terms and keywords (critical illness, intensive care, and functional outcomes/status).

STUDY SELECTION

All human studies reporting functional outcomes in children 0-18 years old admitted to the PICU. Non-English language, adult and preterm infant studies were excluded.

DATA SYNTHESIS

Three global assessment tools and eight multidimensional measures were used to measure functional outcome in pediatric survivors of critical illness. Rates of acquired functional impairment in a general pediatric intensive care cohort ranged from 10% to 36% at discharge and 10% to 13% after more than 2 years. Risk factors for acquired functional impairment include illness severity, the presence of organ dysfunction, length of ICU stay, and younger age. There is some evidence that physical impairment may be more severe and persistent than psychosocial components.

CONCLUSIONS

Functional impairment may be persistent in pediatric survivors of critical care. Unfortunately, studies varied largely in measurement timing and tools used. The lack of differentiation between impairment in different functional domains limited the generalizability of data. Further studies using a combination of standardized measures at various time points of the disease process can help establish more comprehensive rates of physical impairment.

Assessment of quality of life outcomes using the pediatric quality of life inventory survey in prenatally diagnosed congenital diaphragmatic hernia patients

INTRODUCTION

Congenital diaphragmatic hernia patients can have significant postnatal morbidity. To date, there has been no quality of life (QOL) study in a prenatally diagnosed CDH patient population, assessing prenatal disease severity and QOL. The purpose of this pilot study was to assess the QOL in a single institution fetal center CDH experience.

METHODS

The study was a retrospective cohort study of CDH patients diagnosed by fetal ultrasound and MRI at a fetal center between March 2002-March 2014. Parents of children ≥2years were contacted by telephone to participate in the validated Pediatric Quality of Life Inventory (PedsQL™, Version 4.0).

RESULTS

Of 95 CDH survivors, 68 met inclusion criteria, of which 28 (42%) completed the survey (mean age, range: 5.5, 2.3-11.7years). Based on prenatal markers of disease severity, there were no differences in performance between those with mild or severe forms of CDH. Overall, patients had minimal QOL limitations, but those with limitations had a higher risk for oxygen dependence at 30days of life (71%v. 29%, OR 0.16, CI, 0.031-0.82, p=0.02). ECMO was not associated with significantly worse QOL in physical or psychosocial functioning. Cronbach's alpha reliability coefficient yielded a correlation of 0.951 for the overall survey, 0.911 for physical functioning, and 0.901 for psychosocial functioning questions.

CONCLUSIONS

Patients that are prenatally diagnosed with severe forms of CDH have similar QOL outcomes across all categories of physical and psychosocial functioning. This pilot study is encouraging and may allow improved counseling for expectant parents of CDH patients.

The outcomes of children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference

OBJECTIVE

To provide additional details and evidence behind the recommendations for outcomes assessment of patients with pediatric acute respiratory distress syndrome from the Pediatric Acute Lung Injury Consensus Conference.

DESIGN

Consensus conference of experts in pediatric acute lung injury.

METHODS

A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The outcomes subgroup comprised four experts. When published data were lacking, a modified Delphi approach emphasizing strong professional agreement was used.

RESULTS

The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, seven of which related to outcomes after pediatric acute respiratory distress syndrome. All seven recommendations had strong agreement. Children with acute respiratory distress syndrome continue to have a high mortality, specifically, in relation to certain comorbidities and etiologies related to pediatric acute respiratory distress syndrome. Comorbid conditions, such as an immunocompromised state, increase the risk of mortality even further. Likewise, certain etiologies, such as non-pulmonary sepsis, also place children at a higher risk of mortality. Significant long-term effects were reported in adult survivors of acute respiratory distress syndrome: diminished lung function and exercise tolerance, reduced quality of life, and diminished neurocognitive function. Little knowledge of long-term outcomes exists in children who survive pediatric acute respiratory distress syndrome. Characterization of the longer term consequences of pediatric acute respiratory distress syndrome in children is vital to help identify opportunities for improved therapeutic and rehabilitative strategies that will lessen the long-term burden of pediatric acute respiratory distress syndrome and improve the quality of life in children.

CONCLUSIONS

The Consensus Conference developed pediatric-specific recommendations for pediatric acute respiratory distress syndrome regarding outcome measures and future research priorities. These recommendations are intended to promote optimization and consistency of care for children with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.

Health-related quality of life following pediatric critical illness

PURPOSE

The aims of this focused review of the literature on children surviving critical illness were to (1) determine whether health-related quality of life (HRQL) represents a clinically meaningful outcome measure for children surviving critical illness and (2) evaluate the HRQL measures implemented in pediatric critical care studies to date.

METHODS

This was a focused review of the literature from 1980 to 2015 based on a search of EMBASE/PubMed, MEDLINE and PsycInfo assessing trends and determinants of HRQL outcomes in children surviving critical illness. We also evaluated the psychometric properties of the HRQL instruments used in the studies identified by examining each measure's reported reliability, validity and sensitivity to clinical change.

RESULTS

The literature search identified 253 pediatric articles for potential inclusion in the review, among which data from 78 studies were ultimately selected for inclusion. Of the 22 measures utilized in the studies reviewed, only four demonstrated excellent psychometric properties for use in pediatric critical care trials. Trends in HRQL identified in the studies reviewed suggest significant ongoing morbidity for children surviving critical illness. Key determinants of poor HRQL outcomes include reason for PICU admission (sepsis, meningoencephalitis, trauma), antecedents (chronic comorbid conditions), treatments received (prolonged cardiopulmonary resuscitation, long-stay patients, invasive technology), psychological outcomes (post-traumatic stress disorder, parent anxiety/depression) and social and environmental characteristics (low socioeconomic status, parental education and functioning).

CONCLUSIONS

Validated pediatric HRQL instruments are now available. Significant impact on HRQL has been demonstrated in acute and acute on chronic critical illness. Future pediatric critical care interventional trials should include both mortality as well as long-term HRQL measurements to truly ascertain the full impact of critical illness in children.

Targeted Temperature Management in Pediatric Central Nervous System Disease

Acute central nervous system conditions due to hypoxic-ischemic encephalopathy, traumatic brain injury (TBI), status epilepticus, and central nervous system infection/inflammation, are a leading cause of death and disability in childhood. There is a critical need for effective neuroprotective therapies to improve outcome targeting distinct disease pathology. Fever, defined as patient temperature > 38°C, has been clearly shown to exacerbate brain injury. Therapeutic hypothermia (HT) is an intervention using targeted temperature management that has multiple mechanisms of action and robust evidence of efficacy in multiple experimental models of brain injury. Prospective clinical evidence for its neuroprotective efficacy exists in narrowly-defined populations with hypoxic-ischemic injury outside of the pediatric age range while trials comparing hypothermia to normothermia after TBI have failed to demonstrate a benefit on outcome but consistently demonstrate potential use in decreasing refractory intracranial pressure. Data in children from prospective, randomized controlled trials using different strategies of targeted temperature management for various outcomes are few but a large study examining HT versus controlled normothermia to improve neurological outcome in cardiac arrest is underway.

Relationship between the functional status scale and the pediatric overall performance category and pediatric cerebral performance category scales

IMPORTANCE

Functional status assessment methods are important as outcome measures for pediatric critical care studies.

OBJECTIVE

To investigate the relationships between the 2 functional status assessment methods appropriate for large-sample studies, the Functional Status Scale (FSS) and the Pediatric Overall Performance Category and Pediatric Cerebral Performance Category (POPC/PCPC) scales.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study with random patient selection at 7 sites and 8 children's hospitals with general/medical and cardiac/cardiovascular pediatric intensive care units (PICUs) in the Collaborative Pediatric Critical Care Research Network. Participants included all PICU patients younger than 18 years.

MAIN OUTCOMES AND MEASURES

Functional Status Scale and POPC/PCPC scores determined at PICU admission (baseline) and PICU discharge. We investigated the association between the baseline and PICU discharge POPC/PCPC scores and the baseline and PICU discharge FSS scores, the dispersion of FSS scores within each of the POPC/PCPC ratings, and the relationship between the FSS neurologic components (FSS-CNS) and the PCPC.

RESULTS

We included 5017 patients. We found a significant (P < .001) difference between FSS scores in each POPC or PCPC interval, with an FSS score increase with each worsening POPC/PCPC rating. The FSS scores for the good and mild disability POPC/PCPC ratings were similar and increased by 2 to 3 points for the POPC/PCPC change from mild to moderate disability, 5 to 6 points for moderate to severe disability, and 8 to 9 points for severe disability to vegetative state or coma. The dispersion of FSS scores within each POPC and PCPC rating was substantial and increased with worsening POPC and PCPC scores. We also found a significant (P < .001) difference between the FSS-CNS scores between each of the PCPC ratings with increases in the FSS-CNS score for each higher PCPC rating.

CONCLUSIONS AND RELEVANCE

The FSS and POPC/PCPC system are closely associated. Increases in FSS scores occur with each higher POPC and PCPC rating and with greater magnitudes of change as the dysfunction severity increases. However, the dispersion of the FSS scores indicated a lack of precision in the POPC/PCPC system when compared with the more objective and granular FSS. The relationship between the PCPC and the FSS-CNS paralleled the relationship between the FSS and POPC/PCPC system.

Protocol for a longitudinal qualitative study: survivors of childhood critical illness exploring long-term psychosocial well-being and needs--The SCETCH Project

INTRODUCTION

Life-threatening critical illness affects over a quarter of a million children and adolescents (0-18 years old) annually in the USA and the UK. Death from critical illness is rare; however, survivors and their families can be exposed to a complex array of negative physical, psychological and social problems. Currently, within the literature, there is a distinct paucity of child and adolescent survivor self-reports, thus limiting our understanding of how survivors perceive this adversity and subsequently cope and grow in the long-term following their critical illness. This study aims to explore and understand psychosocial well-being and needs of critical illness survivors, 6-20 months post paediatric intensive care admission.

METHODS AND ANALYSIS

A longitudinal, qualitative approach will provide a platform for a holistic and contextualised exploration of outcomes and mechanisms at an individual level. Up to 80 participants, including 20 childhood critical illness survivors and 60 associated family members or health professionals/teachers, will be recruited. Three interviews, 7-9 weeks apart, will be conducted with critical illness survivors, allowing for the exploration of psychosocial well-being over time. A single interview will be conducted with the other participants enabling the exploration of contextual information and how psychosocial well-being may inter-relate between critical illness survivors and themselves. A 'tool box' of qualitative methods (semi-structured interviews, draw and tell, photo-elicitation, graphic-elicitation) will be used to collect data. Narrative analysis and pattern matching will be used to identify emergent themes across participants.

ETHICS AND DISSEMINATION

This study will provide an insight and understanding of participants' experiences and perspectives of surviving critical illness in the long term with specific relation to their psychosocial well-being. Multiple methods will be used to ensure that the findings are effectively disseminated to service users, clinicians, policy and academic audiences. The study has full ethical approval from the East Midlands Research Ethics Committee and has received National Health Service (NHS) governance clearance.

Neuropsychologic function three to six months following admission to the PICU with meningoencephalitis, sepsis, and other disorders: a prospective study of school-aged children

OBJECTIVE

To assess short-term neuropsychological function and academic performance in school children following admission to intensive care and to explore the role of critical neurologic and systemic infection.

DESIGN

A prospective observational case-control study.

SETTING

Two PICUs.

SUBJECTS

A consecutive sample of 88 children aged 5-16 years (median age=10.00, interquartile range=6.00-13.00) who were admitted to intensive care between 2007 and 2010 with meningoencephalitis, septic illness, or other critical illnesses. They were assessed 3 to 6 months following discharge, and their performance was compared with that of 100 healthy controls. Patients were without prior neurologic or neurodevelopmental disorder.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data encompassing demographic and critical illness details were obtained, and children were assessed using tests of intellectual function, memory, and attention. Questionnaires addressing academic performance were returned by teachers. After adjusting for covariates, the children admitted to PICUs significantly underperformed on neuropsychological measures in comparison to healthy controls (p<0.02). Teachers deemed more children admitted to PICUs than controls as performing educationally worse and having problems with school work (ps=0.001), as well as performing below average on aspects of executive function and attention (ps<0.04). Analysis of the effect of illness type on outcome revealed that aspects of neuropsychological function, such as memory function, and teacher-rated academic performance were most reduced in children with meningoencephalitis and septic illness. In the PICU group, multivariable linear regression revealed that worse performance on a composite score of neuropsychologic impairment was more prevalent when children were younger, from a lower social class, and had experienced seizures during their admission (ps<0.02).

CONCLUSIONS

Admission to intensive care is followed by deficits in neuropsychologic performance and educational difficulties, with more severe difficulties noted following meningoencephalitis and septic illness. These results highlight the importance of future studies on cognition and educational outcome incorporating type of illness as a moderating factor.

Children's self-reported quality of life after intensive care treatment

OBJECTIVES

A number of studies have reported on parental/clinician reports of children's quality of life after intensive care treatment. The aim of this study was to establish children's own views of their outcome. [corrected].

DESIGN

Prospective cohort study. [corrected].

SETTING

Twenty-one bed PICU in a tertiary Children's Hospital.

PATIENTS

Ninety-seven children aged over 7 yr, with no preexisting learning difficulties, consecutively admitted to PICU over an 18 month period

INTERVENTIONS

Patients completed the Pediatric Quality of Life Inventory and a post-traumatic stress screener, at 3 months and again at 1 year (n = 72) after discharge from PICU.

MEASUREMENTS AND MAIN RESULTS

At 3 months post-discharge, the mean total Pediatric Quality of Life Inventory score reported by the PICU group was lower than that reported in the literature for a non-clinical community sample (PICU mean = 79.1 vs community mean = 83.9, p = 0.003), but by 1 year, they were comparable (82.2, p = 0.388). The mean physical functioning subscale score remained lower (PICU mean=81.6 vs. community mean=88.5, p = 0.01), but improved significantly from 73.4 at 3 months (p = 0.001).Sub-group analyses revealed that the elective group reported higher emotional functioning than the community sample (91.0, p=0.005 at 3 months and 88.2, p = 0.038 at 1 year vs community mean=78.5), and made significant gains in social functioning between timepoints (79.1 to 91.4, p = 0.015).Finally, although total PedsQL scores at 1 year were not associated with measures of severity of illness during admission, they were significantly negatively associated with concurrent post-traumatic stress symptom scores (r = -0.40, p = 0.001).

CONCLUSIONS

The self-report version of the Pediatric Quality of Life Inventory proved to be a feasible and sensitive tool for assessing health related quality of life in this group of PICU survivors.

Long-term quality of life of patients treated in paediatric intensive care unit

The changes in long-term quality of life (QOL) of children treated in paediatric intensive care unit (PICU) were investigated in relation to their QOL before critical illness together with the influence of underlying chronic health condition and severity of illness estimated by Paediatric Index of Mortality 2 on the long-term outcome. This study included 189 children treated in PICU and 179 children from outpatient clinics as controls. QOL was evaluated according to the Royal Alexandra Hospital for Children Measure of Function (RAHC MOF). The long-term QOL in 70 % of children treated in PICU was good, although there was a significant diminution of QOL in children treated in PICU in comparison with their preadmission scores and with the children from outpatient clinics who served as controls (p < 0.001). Severity of illness had a significant impact on children's QOL (p = 0.016) 6 months after treatment in PICU. Twenty-four months after discharge, the RAHC MOF score was still decreased in 19 % of children treated in PICU, and in significantly more patients with a chronic health condition (CHC) treated in PICU, than in their peers from outpatient clinics (p = 0.029). Reduced QOL was significantly more frequent in children with neurodevelopmental disability than in children without CHC 24 months after discharge from PICU (p = 0.013).

CONCLUSION

Acute illness has a significant impact both on children with and without CHC after treatment in PICU 6 months after discharge. Twenty-four months after discharge, comorbidity was identified as the decisive factor for diminished QOL in children after PICU treatment.