Ill Children Research Articles

Abstract O-22: SEDATION MANAGEMENT FOR CRITICALLY ILL CHILDREN WITH PRE-EXISTING COGNITIVE IMPAIRMENTS: IS IT DIFFERENT?

Aims & Objectives: While analgesia and sedation are essential for critically-ill children with pre-existing cognitive impairment (CI), the effectiveness of current strategies in this population remains unexplored. Here we compare current analgesia and sedation management practices between patients with CI and neurotypical (NT) children in the PICU. Methods Secondary analysis of existing data from the RESTORE trial of children admitted to the PICU for acute respiratory failure. We defined CI as baseline Pediatric Cerebral Performance Category (PCPC) score ≥3. Analyses adjusted for age and PRISM III-12 score. Results Of 2449 RESTORE subjects, 412 (17%) had CI. Compared to NT subjects, CI subjects were older (p<0.001) with more severe PARDS (40% vs. 33%; p=0.009), received lower cumulative doses of opioids (median, mg/kg, 14.2 vs. 16.2; p<0.001) and benzodiazepines (10.6 vs. 14.4; p<0.001), and fewer classes of sedative medications (% receiving ≥3 classes, 57% vs. 60%; p<0.001). Three non-verbal intubated subjects with CI received no analgesic or sedative medications. Subjects with CI spent more study days awake and calm (median [IQR], 80% [60–100] vs. 80% [56–100]; p=0.003) and experienced fewer days with an episode of pain (33% [13–56] vs. 38% [14–60]; p=0.005). Conclusions Subjects with CI in this study received lower doses of opioids and benzodiazepines while hospitalized in the PICU, including some who received no analgesia or sedation. These data suggest that while comfort for subjects with CI may have been achieved with less medication, the rationale for this observation is unclear. Further prospective study that includes alternative assessment strategies is warranted.

Care-giving Coping Strategies Among Mothers with Chronically Ill Children

ABSTRACTThe purpose of the study is to identify the types of stresses experienced and the coping strategies used by mothers who are responsible for providing care to their chronically ill and disabled children. A qualitative approach was selected to systematically document the experiences and highlight individual coping strategies. Purposive sampling was used in this qualitative pilot study, fifteen (15) mothers who were known to the researcher as well as two schools that specifically cater for children with disabilities were selected to participate in the study. Thirty questionnaires were handed out of which fifteen were returned. Data was collected using the coping Health Inventory for Parents (CHIP) to measure the extent to which parents perceived a number of coping strategies to be helpful in coping with the chronic illness of their child (ren). The scale comprised 45 items with 3 subscales. The results highlighted the types of stresses that were experienced by the mothers and the coping strategies practiced by these mothers when caring for their disabled children. Mothers who care for chronically ill children are faced with daily stress that relates to care as well as their personal life.

(7) Impact of a Targeted Educational Program for Delirium Screening & Prevention in Critically Ill Children

Purpose Delirium is a complex process characterized by an acute onset and fluctuating course of reduced awareness, impairments in attention, and changes in cognition. Historically delirium rates in pediatrics were ascertained solely by psychiatry consults. Improved awareness and validated screening tools for use in the PICU have provided a framework for investigating delirium in critically ill children. Delirium screening was not implemented in our PICU until adoption of the Pediatric Confusion Assessment Method for the ICU (pCAM-ICU) in July 2015 with the introduction of an online educational module. The …

(65) The Utility of Rapid Whole Exome Sequencing in the Management of Critically Ill Children: A Case Series

Purpose : Rapid whole exome sequencing (WES) is a modern tool for the diagnosis of diseases when there is a high index of suspicion for a genetic basis in a critically ill patient. WES is able to sequence a majority of all known genes, and allows one to determine if there is a disease-causing variant that explains the child’s manifestations. We describe a case series of three critically ill children who underwent rapid whole exome sequencing to achieve a diagnosis, and the implications on clinical management. Methods: Cases were identified …

Changes in Parental Hopes for Seriously Ill Children.

Hopes of parents of children with serious illness play an important role in decision-making and coping. Little is known about how parent hopes change over time. We describe the changes in parent hopes across multiple domains and time intervals, examine hopes in a subgroup of parents whose child died, and explore the maintenance of domains over time. In a mixed-methods prospective cohort study on decision-making, parents of seriously ill children reported demographic characteristics and hopes at baseline and reported any changes in hopes at 4-, 8-, 12-, 16-, and 20-month follow-up visits. Hopes were coded into 9 domains. Hope changes and domain changes were identified for each parent at each visit. One hundred and ninety-nine parents of 158 patients most often reported hopes in the domains of quality of life (75%), physical body (69%), future well-being (47%), and medical care (34%). Hope percentages increased over time for quality of life (84%), future well-being (64%), and broader meaning (21%). The hope domains reported by parents of children who died were similar to the rest of the sample. The majority of parents who completed 5 to 6 follow-up visits changed at least 1 domain. At the individual parent level, some domains revealed considerable change over time, whereas other domains were stable among a subset of parents. The specific hopes and overall areas of hope of parents of seriously ill children vary over time, although most hopes fall within 4 major areas. Accordingly, clinicians should regularly check with parents about their current hopes.

Renal Replacement Therapy in the Critically Ill Child.

Although renal replacement therapy is widely used in critically ill children, there have been few comprehensive population-based studies of its use. This article describes renal replacement therapy use, and associated outcomes, in critically ill children across the United Kingdom in the largest cohort study of this patient group. A retrospective observational study using prospectively collected data. Data from the Pediatric Intensive Care Audit Network database which collects data on all children admitted to U.K. PICUs. Children (< 16 yr) in PICU who received renal replacement therapy between January 1, 2005, and December 31, 2012, were identified. Individual-level data including age, underlying diagnosis, modality (peritoneal dialysis and continuous extracorporeal techniques [continuous renal replacement therapy]), duration of renal replacement therapy, PICU length of stay, and survival were extracted. Three-thousand eight-hundred twenty-five of 129,809 PICU admissions (2.9%) received renal replacement therapy in 30 of 33 centers. Volumes of renal replacement therapy varied considerably from 0% to 8.6% of PICU admissions per unit, but volume was not associated with patient survival. Overall survival to PICU discharge (73.8%) was higher than previous reports. Mortality risk was related to age, with lower risk in older children compared with neonates (odds ratio, 0.6; 95% CI, 0.5-0.8) although mortality did not increase over the age of 1 year; mode of renal replacement therapy, with lower risk in peritoneal dialysis than continuous renal replacement therapy methodologies (odds ratio, 0.7; 0.5-0.9); duration of renal replacement therapy (odds ratio, 1.02/d; 95% CI, 1.01-1.04); and primary diagnosis, with the lowest survival in liver disease patients (53.9%). This study describes current renal replacement therapy use across the United Kingdom and associated outcomes. We describe a number of factors associated with outcome, including age, underlying diagnosis, and renal replacement therapy modality which will need to be factored into future trial design.

Stakeholders’ Perspectives on Communication and Collaboration Following School Reintegration of a Seriously Ill Child: A Literature Review

Reintegration into school is a decisive time for children who have been absent from school due to health problems, such as survivors of brain tumours and other types of acquired brain injury or cancer in childhood. Parents, school staff and healthcare providers are important stakeholders during this phase of transition. To study the perspectives of parents, school personnel and healthcare providers on communication and collaboration following the child’s return to school, to gain insight into their experiences, and to develop recommendations for each stakeholder. We reviewed the literature on school reintegration in accordance with the configurative approach for research synthesis. Search and selection processes ended in 22 articles published between January 2000 and September 2015, consisting of quantitative, qualitative or mixed methods research. Data analysis resulted in themes with emphasis on communication and collaboration. Knowledge about the child’s condition, education and support are the main topics of consultation between parents, school personnel and healthcare providers. Based on their experiences, practices of communication and collaboration are variable and mostly inadequate. They report clear and complementary needs and expectations on how to effectively work together. Especially the need for a school liaison as connection between family, education and healthcare is commonly discussed. The often suboptimal communication and collaboration between parents, school personnel and healthcare providers needs more coordination and consistency, starting from the child’s return to school. In addition, all stakeholders should be aware of related factors that facilitate or hinder the child’s reintegration process.

Clinical Impact of External Laryngeal Manipulation during Laryngoscopy on Tracheal Intubation Success in Critically Ill Children

目的 体外喉部推压为儿童气管插管(tracheal intubation，TI)时用以暴露声门的常用手法。然而其对提高非麻醉状态下TI成功率的有效性尚不清楚。本研究旨在评估体外喉部推压与PICU患儿初次TI成功之间的关系。 设计 采用一个多中心紧急气道质量提高注册数据库进行回顾性观察性研究。 场所 综合及儿童医院内共35家PICUs(美国29家，加拿大3家，日本1家，新加坡1家，新西兰1家)。 对象 2010年7月1日至2015年12月31日间于PICU内经直接喉镜初次TI的18岁以下危重患儿。 测量方法及主要结果 采用倾向分数匹配分析法评估体外喉部推压法与初次TI成功之间的关系，校正患儿及临床医疗间的潜在差异因素，包括年龄、肥胖、TI指征、困难气道特点、操作者训练等级及应用神经肌肉阻滞剂。体外喉部推压法定义为喉镜检查过程中任意体外颈部用力。7 825例TI中，体外颈部推压法者初次TI成功1 935/3 274 (59%)例，未经体外喉部挤压者3 086/4 551 (68%)(未校正OR 0.69，95%CI 0.62-0.75，P<0.001)。倾向分数匹配分析法显示体外喉部推压与低首次TI成功率有关(校正OR 0.93，95%CI 0.90-0.95，P<0.001)。 结论 即使在调整校正患儿因素及操作者训练等级的差异后，直接喉镜检查时体外喉部推压与危重患儿初次TI低成功率有关。不推荐随意使用体外喉部推压法。

Predictors of outcome in critically Ill children admitted to a pediatric intensive care unit at a tertiary care centre in Western Maharashtra

Predictors of outcome in critically Ill children admitted to a pediatric intensive care unit at a tertiary care centre in Western Maharashtra

Epidemiology of the Critically Ill Child in the Resuscitation Bay.

Children account for approximately 33 million annual emergency department (ED) visits in the United States. The spectrum and frequency of children with a critical illness presenting to an ED has not been previously analyzed. The purpose of this study was to examine the range of critical illness presenting to a tertiary Children's Hospital ED. This study was a retrospective chart review of all pediatric patients requiring immediate care in the medical resuscitation bay during a 25-month period from August 2005 to September 2007. Data are from a single center, academic, tertiary care pediatric hospital. A log of all patients requiring immediate care is kept in the medical resuscitation bay. Patients recorded in the log for a period of 25 consecutive months were reviewed for type of critical illness, frequency of critical illness, mode of arrival, and outcome. Trauma patients were excluded. There were approximately 45,000 pediatric visits per year with a total of 87,766 patients seen during the study period. There were 249 pediatric patients who required care in the medical resuscitation bay during the reviewed period. Complete data were obtained from 242 subjects' charts. Patients requiring immediate care accounted for 0.28% of all the visits. This study documents the infrequent need for pediatric critical care in the ED of a nonacademic tertiary children's hospital in the United States and reinforces the need to provide protocols, mock codes, and simulation labs in preparation for critically ill children.

Importance of Vitamin D in Critically Ill Children with Subgroup Analyses of Sepsis and Respiratory Tract Infections: A Systematic Review and Meta-Analysis

Importance of Vitamin D in Critically Ill Children with Subgroup Analyses of Sepsis and Respiratory Tract Infections: A Systematic Review and Meta-Analysis

Validation of renal angina index to improve prediction of acute kidney injury in critically Ill children- A prospective observational cohort study

Background : Renal angina index (RAI) is a clinical guide that identifies patients at high risk for acute kidney injury (AKI) by integrating baseline, contextual and clinical evidence of renal injury. It may serve well to optimize biomarker utility. Methods : We performed a prospective observational study of 285 critically ill children aged 1 month to 18 years and followed them up for a minimum duration of 7 days to 28 days with daily documentation of fluid overload, creatinine values, need for renal replacement therapy(RRT), total duration of mechanical ventilation and hospital stay. RAI score of 8 or more was considered as fulfillment of renal angina. Results : Incidence rate for a Day 0 RAI of 8 or more was 49.4% and Day-3 AKI was 10.2%. Day-3 AKI rates were higher in patients with an RAI of 8 or more with the area under the curve of RAI for predicting Day-3 and Day-7 AKI of 0.815 and 0.727 respectively. An RAI under 8 had high negative predictive values (96.5%) for Day-3 AKI. RAI outperformed traditional markers of pediatric severity of illness (Pediatric Index of Mortality-II) for prediction of Day-3 AKI. Additionally, the RAI outperformed all Kidney diseases improving global outcomes (KDIGO) stages for prediction of Day-3 AKI. Conclusion : Renal angina index can predict development of subsequent severe AKI. Fulfillment of renal angina was associated with longer hospital stay, higher mortality, longer duration of mechanical ventilation and higher need for renal replacement therapy.

Validation of renal angina index to improve prediction of acute kidney injury in critically Ill children- A prospective observational cohort study

Validation of renal angina index to improve prediction of acute kidney injury in critically Ill children- A prospective observational cohort study

CRRT in critically Ill children: Clinical profile from a tertiary care hospital in South India

Background : Continuous renal replacement therapy (CRRT) is a valuable tool in a pediatric intensive care unit (PICU), however the literature available from developing countries is scarce. Methods : Retrospective analysis of children who underwent CRRT during the past 1 year (June 2016 to May 2017). 24 sessions of CRRT was performed in 22 patients using Prismaflex® Baxter. Serum levels of urea, creatinine, and liver function tests were done in all patients. Activated clotting time (ACT) was monitored in all patients every 1 hourly till target ACT was achieved (180 – 220 seconds), thereafter every 4 hourly if the ACT continues in the target range. Unfractionated heparin was used for anticoagulation. Blood priming was done in patients with hematocrit less than 30% or in infants weighing less than 10 kg. Hemodialysis catheter (8.5Fr) was used in all patients, placed in the right internal jugular vein (IJV) under ultrasound guidance. Transthoracic echocardiography was used in all patients to confirm the position of the catheter tip within the right atrium. Central venous access in the femoral vein and arterial blood pressure monitoring was done in all patients as per unit protocol. Primary outcome measure was death during the procedure. Data collected were part of PRBC transfusion in pediatric ICU study and fluid balance study at JIPMER. Results : The median age of patients was 2 years (1 to 6 IQR). Mean bodyweight was 13.4 kg, 6.6 SD. Continuous venovenous hemofiltration (CVVH) was done in 5 patients (22.7%) and 17 patients (67.3%) were started on continuous venovenous hemodiafiltration (CVVHDF). Mortality during the procedure among the patients who underwent CRRT was 50% (n=11). Mean PRISM III score was 14. Out of 22 patients, 15 patients (68.7%) were on vasoactive medications at the time of initiation of CRRT. Median fluid overload (FO%) was 0.62 (0.45 to 1.62 IQR). Average time to start CRRT since PICU admission was 55 hours. The common indications were acute kidney injury with fluid overload (n=9), acute liver failure with hyperammonemia (n=3), organic acidemia with severe high anion gap acidosis (n=1), unknown poisoning with high anion gap acidosis (n=2), pigment nephropathy following wasp sting (n=1) and electrocution (n=1). CRRT along with venovenous extra corporeal membrane oxygenation (vv ECMO) (n=1) was done in a case of hemophagolymphohistiocytosis syndrome with ARDS. Effluent dose 35ml/kg/hour in all patients except in 2 cases of acute liver failure where the effluent dose was increased up to 42ml/kg/hour due to persistent hyperammonemia. CRRT with plasma exchange using P2 plasma filter was done with CRRT circuit modification in 2 cases of thrombocytopenia associated multiorgan failure (TAMOF). Mean duration of CRRT was (55 hours, SD 23.8). Maximum circuit life with systemic heparin as anticoagulant was 92 hours. Filter clotting and new circuit requirement was encountered in 6 patients (27.7%). Conclusion : CRRT can be used safely in critically ill children. The circuit life can be prolonged with serial ACT monitoring and titration of anticoagulation.

The Effect of Different Enteral Feeding Protocols on Feeding Tolerance in Critically Ill Children

Objectives: To evaluate different enteral tube Feeding Protocols (FP) on feeding tolerance and achieving the goal feeds (GF) duration in pediatric intensive care unit (PICU) among 2 groups of patients with different risks of feeding intolerance. Design: Prospective randomized study. Settings & Patients: The study is conducted in 20 bed capacity medical/surgical PICU at king Fahad Medical City in Saudi Arabia over 1-year period. We included children from 1 month to 12 years old who are admitted to PICU >48 hours after obtaining informed consent signed by either parent or legal guardian. All patients with medical indication of admission were included except of gastroenterology related illness. Interventions: We categorize PICU patients into either low risk group or high-risk group because we think the severity of illness and medical management in the high-risk group, put them into a higher risk of early development of feeding intolerance. The patients were assigned into the high-risk group if they meet certain criteria that includes 1) need for inotropes/vasopressors >24 hours and/or 2) need for muscle relaxant infusion and/or 3) having severe metabolic acidosis with PH of less than 7.2, HCO3 serum level less than 10 mmol/L at the day of randomization to start the feeding. After assigning the patient into the risk group, then we blindly randomized each patient into one of the two feeding protocols, the continuous versus intermittent enteral NG/ OG tube feeding. Different variables were tracked to monitor the feeding tolerance of the feeding protocol like the frequency of vomiting and change in bowel motion. We determine the duration needed to reach the goal feeds recommended by a registered dietitian and we record any interruptions of the feeding protocol, duration of interruption and the reason. Measurements and Main Results: Total of eighty-five patients were recruited in our study. Sixty-two patients in the low risk group (35 patients fed continuously & 27 fed intermittently) and twenty-three patients in the high-risk group (11 patients fed continuously & 12 intermittently). All patients were fed regular formula for age with goal feeds decided by registered dietitians. No significant differences in patients’ characteristics. 65.7% of the low risk group who were continuously fed reached the goal feeds faster; within 2-3 days from feeding initiation vs 37% of the intermittent feeding group (P-value 0.025). 54.57% of the high-risk group who were continuously fed reached the goal feeds faster within 4-5 days vs 8.3% only of the intermittent feeding group (P-value 0.016). Both feeding protocols, continuous and intermittent feeding in both groups tolerate the feeds with no statistically differences. Feeding interruptions were not significantly different between both groups in each protocol with average interruption days of two days. Conclusion: Implementation of the proposed continuous enteral tube feeding protocol significantly improve the delivery of nutrition in critically ill children in shorter duration than the intermittent boluses feeding protocol with good tolerance of both in different patients’ risk groups. This is the first paper taking in consideration high risk factors because of the substantial risk of feeding intolerance that can affect early decision for feeding.

Determinants of Change in Home Participation Among Critically Ill Children

Determinants of Change in Home Participation Among Critically Ill Children

Prospective Evaluation of Physical Contact with Critically Ill Child on Caregiver Spiritual Wellbeing

To evaluate whether a pediatric intensive care unit initiative promoting physical contact between caregiver and patient improves caregiver spiritual wellbeing. The secondary objectives were to evaluate caregiver perceptions of care before and after the initiative and to follow unplanned extubation rate as a marker of safety of the initiative. We hypothesized that caregiver spiritual wellbeing and caregiver perceptions of care would improve with implementation of our physical contact initiative known as Project ROSE (Reach Out, Soothe, and Embrace). Project ROSE was a practice change initiative promoting physical contact between caregiver and hospitalized child in an academic quaternary care pediatric intensive care unit. Caregivers' spiritual wellbeing and perceptions of care were surveyed at days 1 and 4, then compared pre- and postimplementation of the unit-wide initiative. Wilcoxon rank sum tests compared groups (pre- and post-Project ROSE). A total of 331 caregivers returned surveys. We analyzed 331 surveys (pre, n = 174/post, n = 157). Caregiver spiritual wellbeing at enrollment (day 1) was no different between groups (P = .47). Caregiver spiritual wellbeing on day 4 was greater in the postintervention group (pre 40.0 [32.0, 44.0] vs post 42.0 [37.5, 45.0] P = .03). Caregiver perceptions of care improved postintervention. There was no change in the unplanned extubation rate between groups. Project ROSE improved caregiver spiritual wellbeing and perceptions of care, was implemented safely, addresses a need in family-centered care of critically ill pediatric patients, and merits consideration for integration into practice.

79.0 Psychotherapy Techniques for Treating the Medically Ill or Injured Child

79.0 Psychotherapy Techniques for Treating the Medically Ill or Injured Child

79.1 Interactive Play: A Tool to Communicate With the Physically Ill Child

79.1 Interactive Play: A Tool to Communicate With the Physically Ill Child

4.0 Family-Based Psychiatric Interventions for Physically Ill Children

4.0 Family-Based Psychiatric Interventions for Physically Ill Children