Paediatric Intensive Care Environment Research Articles

Multi-System Inflammatory Syndrome in Children (MIS-C) Following SARS-CoV-2 Infection: Review of Clinical Presentation, Hypothetical Pathogenesis, and Proposed Management.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may result in the multisystem inflammatory syndrome in children (MIS-C). The clinical presentation of MIS-C includes fever, severe illness, and the involvement of two or more organ systems, in combination with laboratory evidence of inflammation and laboratory or epidemiologic evidence of SARS-CoV-2 infection. Some features of MIS-C resemble Kawasaki Disease, toxic shock syndrome, and secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome. The relationship of MIS-C to SARS-CoV-2 infection suggests that the pathogenesis involves post-infectious immune dysregulation. Patients with MIS-C should ideally be managed in a pediatric intensive care environment since rapid clinical deterioration may occur. Specific immunomodulatory therapy depends on the clinical presentation. The relationship between the immune response to SARS-CoV-2 vaccines in development and MIS-C requires further study.

Analgesia, sedation, and delirium in pediatric surgical critical care

The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.

Pain and Sedation Management: 2018 Update for the Rogers' Textbook of Pediatric Intensive Care.

To review important articles on pain, sedation, sleep, and delirium in the field of pediatric critical care published subsequent to the fifth edition of the Rogers' Textbook of Pediatric Critical Care. The U.S. National Library of Medicine PubMed was searched for a combination of the term "pediatric" and the following terms: "sedation," "sedation protocol," "pain," "pain score," "neuromuscular blockade," "delirium," and "sleep." Titles and abstracts resulting from the search were screened for full-text review and potential inclusion. Authors also included recent key articles they were aware of with direct relevance to the topics. The authors selected articles for inclusion based on their relevance and clinical significance if they were published subsequent to the fifth edition of the textbook. Selected articles were grouped together by categories similar to specific sections of the pain and sedation chapter in the textbook and included pain, sedation, sleep, and delirium. Recent research into pediatric pain and sedation management has focused on optimizing the choice of sedative medications, in particular by increasing the use and understanding of nonopioid and nonbenzodiazepine options such as ketamine and alpha-2 agonists. Delirium has emerged as a significant morbidity in the critically ill pediatric patient, and recent articles have concentrated on the use of validated screening tools to determine the epidemiology and risk factors in specific populations, including patients with cardiac disease and those receiving extracorporeal membrane oxygenation. A consistent theme in the most recent literature is the role of titrated but effective sedation, quality improvement to increase delirium recognition, and optimizing the pediatric intensive care environment to promote sleep.

Pediatric Delirium: Early Identification of Barriers to Optimize Success of Screening and Prevention

Pediatric delirium has a 25% prevalence rate in the pediatric intensive care unit. The purpose of this project was to evaluate the impact/effect of implementing nonpharmacologic nursing bundles on the incidence of pediatric delirium. It is not yet known whether or not bundles consistently reduce the incidence of delirium. A nonpharmacologic nursing bundle was implemented for pediatric intensive care unit patients, 2 to 18years of age, admitted to an Arizona metropolitan children's hospital. Data were collected using the Cornell Assessment of Pediatric Delirium (CAP-D) screening tool. Control group scores and post-bundle CAP-D scores (mean = 5.57, standard deviation = 5.78 and mean = 7.10, standard deviation = 5.61, respectively) did not differ among the participants. Control participants required an intervention 26.7% of the time for delirium compared with 31.6% in the post-bundle population. No statistical significance was seen between the control group and the post-bundle CAP-D scores t(59) = 7.46; t(205) = 18.17 (p = .08, Fisher exact test). The use of nonpharmacologic bundles for delirium prevention have shown some promising results in helping with delirium reduction. Whether they consistently reduce the incidence has yet to be fully proven. This project shows that significant barriers exist when implementing them in a complex pediatric intensive care environment.

Opioid tapering and weaning protocols in pediatric critical care units: a systematic review.

Opioid abstinence syndrome is common in the pediatric intensive care environment because sedation is often needed during the children's treatment. There is no specific guideline regarding the management of these patients; and lately, methadone is an important drug for the prevention of abstinence symptoms during the weaning of opioids. This study gathers the available research to establish the initial dose of methadone, the rate of taper and tools to recognize this syndrome and act promptly. A systematic review was made from data of four different databases. Forty-nine articles of observational and experimental studies were selected based on the inclusion criteria (critical pediatric patients in acute use of opioids) and exclusion criteria (previous chronic use of opioids, other medications). The data regarding specific themes were separated in sections: initial dose of methadone, use of protocols in clinical practice, abstinence scales and adjuvant drugs. The articles showed a great heterogeneity of ways to calculate the initial dose of methadone. The pediatric intensive care units of the study had different weaning protocols, with a lower incidence of abstinence when a pre-defined sequence of tapering was used. The Withdrawal Assessment Tool - 1 was the most used scale for tapering the opioids, with good sensitivity and specificity for signs and symptoms. There is still little evidence of other medications that can help prevent the abstinence syndrome of opioids. This study tries to promote a better practice during opioid weaning.

3D imaging system for respiratory monitoring in pediatric intensive care environment

Assessment of respiratory activity in pediatric intensive care unit allows a comprehensive view of the patient’s condition. This allows the identification of high-risk cases for prompt and appropriate medical treatment. Numerous research works on respiration monitoring have been conducted in recent years. However, most of them are unsuitable for clinical environment or require physical contact with the patient, which limits their efficiency. In this paper, we present a novel system for measuring the breathing pattern based on a computer vision method and contactless design. Our 3D imaging system is specifically designed for pediatric intensive care environment, which distinguishes it from the other imaging methods. Indeed, previous works are mostly limited to the use of conventional video acquisition devices, in addition to not considering the constraints imposed by intensive care environment. The proposed system uses depth information captured by two (Red Green Blue-Depth) RGB-D cameras at different view angles, by considering the intensive care unit constraints. Depth information is then exploited to reconstruct a 3D surface of a patient's torso with high temporal and spatial resolution and large spatial coverage. Our system captures the motion information for the top of the torso surface as well as for its both lateral sides. For each reconstruction, the volume is estimated through a recursive subdivision of the 3D space into cubic unit elements. The volume change is then calculated through a subtraction technique between successive reconstructions. We tested our system in the pediatric intensive care unit of the Sainte-Justine university hospital center, where it was compared to the gold standard method currently used in pediatric intensive care units. The performed experiments showed a very high accuracy and precision of the proposed imaging system in estimating respiratory rate and tidal volume.

Parent perceptions of the impact of the Paediatric Intensive Care environment on delivery of family-centred care

ObjectivesTo examine parent perception of how the physical and cultural environment of the paediatric intensive care unit impacted the implementation of family-centred care as outlined by the Institute for Patient and Family Centered Care. Research designA qualitative descriptive design utilizing secondary analysis from a longitudinal study. Sixty-one interviews with three mothers and three fathers (31 interviews with mothers, 30 interviews with fathers) of infants with complex congenital heart defects treated in a paediatric intensive care unit were subjected to secondary analysis via content analysis. The previously completed individual interviews with parents took place at least monthly ranging from soon after birth of their infant to one year of age or infant death, whichever occurred first. FindingsThe family-centred care core concepts of information sharing, participation, respect and dignity were present in parent interviews. Parents indicated that the physical and cultural environment of the pediatric intensive care unit impacted their perceptions of how each of the core concepts was implemented by clinicians. The unit environment both positively and negatively impacted how parents experienced their infant’s hospitalisation. ConclusionIn the paediatric intensive care unit, family centred care operationalised as policy differed from actual parent experiences. The impact of the physical and cultural environment should be considered in the delivery of critical care, as the environment was shown to impact implementation of each of the core concepts.

Abstract P-419: THE UPPER SATURATION LIMIT IN PAEDIATRIC INTENSIVE CARE PATIENTS: A ZOMBIE PROBLEM

Aims & Objectives: Excessive oxygen can be detrimental to children requiring intensive care. However, reducing the oxygen saturation goal is not part of standard PIC culture. Oxygen is felt to be a therapy which does little harm and is beneficial for most pathologies, however evidence is mounting that excess oxygen is harmful. We investigated the set oxygen saturation limits on our patients and intervened to set them lower. Methods For one week, all monitored patients on the Critical Care unit requiring additional oxygen were analysed. Their monitor saturation limits were noted. Without informing the bedside team, the upper saturation limits were set to 98% (or 90% for a complex cardiac patient), unless the saturation limit was already below this. The following day, the same procedure was performed. Results Of 49 measurements, 38 had the upper limit set to “off” or 100%. 16/17 first measurements in an individual patient were at 100% of “off”. After setting the limit to the patient’s target, only 10/32 had an upper limit at target or less the next morning, 1/32 had an upper limit of 99%, and the 21/32 had been reset to “off” or 100%. Reasons given by the bedside nurses included alarm fatigue and a lack of medical directives.Conclusions In the complex Paediatric Intensive Care environment, there are significant behavioural drivers towards keeping the upper saturation limit off. Alarm fatigue is a real and dangerous problem, leading to substandard care if it is nor addressed. More education is necessary for teams to prioritise the correct oxygen saturations limits.

The impact of the social and physical environments on parent–healthcare provider relationships when a child dies in PICU: Findings from a grounded theory study

ObjectivesThis study explores the influences of the paediatric intensive care environment on relationships between parents and healthcare providers when children are dying. It forms part of a larger study, investigating parental experiences of the death of their child in intensive care. Research methodologyConstructivist grounded theory. SettingFour Australian paediatric intensive care units. Main outcome measuresAudio-recorded, semi-structured interviews were conducted with twenty-six bereaved parents. Data were analysed using the constant comparison and memoing techniques common to grounded theory. FindingsThe physical and social environment of the intensive care unit influenced the quality of the parent–healthcare provider relationship. When a welcoming, open environment existed, parents tended to feel respected as equal and included members of their child’s care team. In contrast, environments that restricted parental presence or lacked resources for parental self-care could leave parents feeling like ‘watchers’, excluded from their child’s care. ConclusionsThe paediatric intensive care unit environment either welcomes and includes parents of dying children into the care team, or demotes them to the status of ‘watcher’. Such environments significantly influence the relationships parents form with healthcare staff, their ability to engage in elements of their parental role, and their experiences as a whole.

The sound of potency: An observation study of nurses’ approach to sound in a pediatric intensive care unit

Objective: The objective of this study was to investigate the nurses’ approach to three sources of sound that contribute to high noise levels; alarms, doors that open and conversation.Methods: Methods used derived from a theoretical perspective based on interpretive phenomenology and caring culture. In the pediatric intensive care, the caregivers of the children work in a high-tech environment as they are surrounded by sound from several sources. How caregivers understand and acknowledge how these sounds negatively affect a child’s well-being depends on their individual knowledge and awareness of how children are affected by sound. In most cases, coming into an intensive care unit is a new experience for a child. This causes greater stress, both from the environment itself as well as from sound levels. The method was built on a phenomenological perspective and an interpretive non-participation, semi-structured observations were conducted in a pediatric intensive care unit (PICU) of one of Sweden’s metropolitan regions in the winter of 2014-2015.Results: The results show that noise is an overlooked phenomenon in the pediatric intensive care environment as it has given way to other priorities in the nurse’s work. It is also apparent that this depends on the department’s caring culture as it prioritizes other things, resulting in normalizing high levels of noise as a part of the pediatric intensive care environment.Conclusions: Noise levels are not a priority in the department’s caring culture. High noise levels are permitted unreflectedly and appears to be a token of potency and an accepted part of the health care environment.

Confessions of PCICU Leaders: Tales From the Past, Lessons for the Future.

The pediatric cardiac intensive care environment is challenging and unpredictable due to the heterogeneous patient population. Leadership within this complex environment is critical for optimal outcomes. The 10th International Meeting of the Pediatric Cardiac Intensive Care Society provided a forum for leaders to share their own practice and experience that concluded with take-home messages regarding quality, safety, clinical effectiveness, stewardship, and leadership. Presentations defined vital aspects for successful outcomes and highlighted ongoing challenges. Accomplishing exceptional outcomes requires a blend of clinical expertise, leadership, communication skills with briefing and debriefing, meaningful use of data, and transparency among peers and toward patients and their families.

G215 Setting and maintaining professional boundaries in paeditric clinical perspectives from an interprofessional perspective

Aim This study explored the manner in which paediatric nurses and hospital play specialists set professional boundaries and the challenges they faced in maintaining a therapeutic relationship when caring for children and their families in hospital. Methods A phenomenological approach was adopted, through a purposive sample of seven paediatric settings within one NHS Trust. Eight paediatric nurses and two hospital play specialists were interviewed. Thematic analysis, using field notes and transcribed tape recorded interviews, was used to identify emerging themes and generate a description of the respondents’ experience. Results The study revealed that paediatric nurses had difficulty in defining the concept of professional boundaries, therapeutic relationships and self disclosure. Although no clear definition was given for professional boundaries, respondents agreed that they were important. Paediatric nurses could recognise when boundaries were being broken but lacked the confidence to address boundary violations. Using self disclosure was seen as a balancing act which could lead to boundary crossing and boundary violation. Nurses felt unsupported by senior colleagues particularly when faced with “manipulative families” and found their code of conduct1 helped guide their practice. Hospital play specialists had a greater understanding of therapeutic relationships then paediatric nurses. Conclusions Health care professionals can recognise professional boundaries and boundary violations but they need support to address violations – especially in the paediatric intensive care environment. Reference Nursing and Midwifery Council. The code: Standards of conduct, performance and ethics for nurses and midwives. NMC. London; 2008

Family‐centred care in the paediatric intensive care unit: an integrative review of the literature

To review extant research on family-centred care in a paediatric intensive care environment and identify gaps in the literature. Family-centred care is currently a core concept in paediatric nursing, focusing on the premise that families are central to a child's well-being, and as such, should be included as equal members of the child's healthcare team. Due to the nature of critical care, family-centred care may be challenging to implement and maintain. An integrative literature review. The review was conducted using the Cumulative Index to Nursing and Allied Health Literature, PubMed, OVID MEDLINE and Google Scholar databases, from 1990 to present. The search focused on the following terms: 'p(a)ediatric critical care', 'paediatric intensive care unit', 'family cent(e)red care', 'parental needs', 'family presence' and 'family/nurse roles'. Additionally, the search was limited to studies conducted in a developed country and published in English. Eighteen studies were included in the review. The results demonstrated that implementing family-centred care into a paediatric intensive care environment posed several challenges. The discrepancy between nurses' and parents' perception of their roles, the reluctance of medical staff to share potentially negative or rapidly changing information, restrictive family presence and poor understanding of family needs emerged as the key difficulties. No studies evaluated strategies to improve family-centred care practice. Family-centred care presents many challenges in a paediatric intensive care environment; however, nurses are uniquely positioned to foster relationships with families, encourage accurate and honest information sharing and advocate for families to be present when they choose. This review outlines the extant research to enhance awareness of the unique state of family-centred care in paediatric intensive care and makes recommendations for future research.

Time series analysis as input for clinical predictive modeling: Modeling cardiac arrest in a pediatric ICU

BackgroundThousands of children experience cardiac arrest events every year in pediatric intensive care units. Most of these children die. Cardiac arrest prediction tools are used as part of medical emergency team evaluations to identify patients in standard hospital beds that are at high risk for cardiac arrest. There are no models to predict cardiac arrest in pediatric intensive care units though, where the risk of an arrest is 10 times higher than for standard hospital beds. Current tools are based on a multivariable approach that does not characterize deterioration, which often precedes cardiac arrests. Characterizing deterioration requires a time series approach. The purpose of this study is to propose a method that will allow for time series data to be used in clinical prediction models. Successful implementation of these methods has the potential to bring arrest prediction to the pediatric intensive care environment, possibly allowing for interventions that can save lives and prevent disabilities.MethodsWe reviewed prediction models from nonclinical domains that employ time series data, and identified the steps that are necessary for building predictive models using time series clinical data. We illustrate the method by applying it to the specific case of building a predictive model for cardiac arrest in a pediatric intensive care unit.ResultsTime course analysis studies from genomic analysis provided a modeling template that was compatible with the steps required to develop a model from clinical time series data. The steps include: 1) selecting candidate variables; 2) specifying measurement parameters; 3) defining data format; 4) defining time window duration and resolution; 5) calculating latent variables for candidate variables not directly measured; 6) calculating time series features as latent variables; 7) creating data subsets to measure model performance effects attributable to various classes of candidate variables; 8) reducing the number of candidate features; 9) training models for various data subsets; and 10) measuring model performance characteristics in unseen data to estimate their external validity.ConclusionsWe have proposed a ten step process that results in data sets that contain time series features and are suitable for predictive modeling by a number of methods. We illustrated the process through an example of cardiac arrest prediction in a pediatric intensive care setting.

Assessing the introduction of the COMFORT B pain assessment tool into the paediatric intensive care (PICU) environment

Introduction: Management of pain and sedation in PICU environment is critical to providing optimal care. Accurate assessment of pain and sedation improves management, decreases the likelihood of withdrawal and reduces ventilator days. The COMFORT B scale is a tool that has been validated for use in PICU.

Les bénévoles ont-ils une place dans un service de réanimation ?

Volunteers have been taking an active part in our paediatric intensive care unit for six years. Their main objective is the support of parents. The guidelines that govern their working practice are set out in an agreement between the hospital and the volunteers association to which they belong. Volunteers have a fundamental role in listening to the parents; this is facilitated by their availability and the fact they are not a part of the medical system. A paediatric intensive care environment is frightening and hostile, and volunteers can help to make it less so. They also give information about the support available and refer parents to social workers or psychologists if appropriate. Their presence can also help to prevent and reduce tensions between parents and care-givers, and keep the mood positive. Initially it can be difficult for care givers to accept volunteers; in later stages, the major problems are: 1) coping with the death of a child 2) and maintaining the balance between the confidentiality of the information given by parents and care givers need to know. Both of these explain the need for high quality training and supervision. Prior to the introduction of volunteers to a paediatric intensive care unit, interdisciplinary consultation on how best to welcome and support parents is essential.

Assessing the need for endotracheal suction

Endotracheal suction (ETS) is a common method used to remove broncho-pulmonary secretions. This study aimed to investigate whether, and how, nurses in the paediatric intensive care environment assess the need for endotracheal suction. Overt, non-participant observation and interviews were used to collect data from 12 nurses on four paediatric intensive care units. The large majority of episodes of ETS observed were performed in response to an identified clinical need based on changes in a variety of clinical signs and patient behaviour. This study highlights the complex nature of nurses' assessment of the need for ETS and has implications for training and education of nursing staff.

A report of the use of the Dynamic Objective Risk Assessment (DORA) score in the changing pediatric intensive care environment.

To assess the clinical use of the Dynamic Objective Risk Assessment (DORA) severity of illness score in a site remote from its development. Prospective chart review. Tertiary referral pediatric intensive care unit (PICU). One hundred sixty consecutive admissions involving 621 patient days. None. Pediatric Risk of Mortality (PRISM) scores were collected daily for all PICU patient days. Collection of data was performed by a physician not directly involved in the ordering of vital signs or laboratory data. The daily DORA score was calculated from the previous day's PRISM score and the admission PRISM score according to a previously described formula. The DORA score determines the patient's risk of mortality for the next 24 hrs. Also documented were the tests not ordered for each patient day. The sensitivity and specificity of the DORA score in our patient population were very similar to that previously reported using the previously described 1% cutoff for predicted mortality. We also noted that the tests ordered were related to the physician's perception of the patient's degree of sickness, and were themselves predictive of outcome. An outcome scoring system created in one group of PICUs can be applied to patients in another PICU remote from where the scoring system was developed with similar ability to predict outcome.

Parental stress in paediatric intensive care.

Family-centred care has become an important concept in paediatric nursing. However, there are factors within the paediatric intensive care environment that act as barriers to implementing family-centred care and maintaining the caring relationship between the parents and their critically ill child.