Pediatric Intensive Care Unit Survivors Research Articles

Ethnic differences in parental experiences during the first six months after PICU discharge in Singapore: a qualitative study.

Literature on parental experiences after childhood critical illness has limited representation from diverse ethnic backgrounds. Parents from global ethnic majority groups have reported worst psychological outcomes and required more social support after childhood critical illness. To explore the experiences of Chinese, Malay, and Indian parents in the first six months after Pediatric Intensive Care Unit (PICU) discharge of their child in Singapore. Sequential semi-structured qualitative interviews were conducted to collect data from a convenience sample of 28 parents at one month (n = 28) and at six months (n = 22) after their child's discharge from a multidisciplinary PICU. Framework Analysis was adopted as the qualitative analysis strategy. The PICS-p framework was applied a priori in the Framework Analysis. Three interdependent domains and seven themes framed the 28 accounts in which ethnically diverse parents reported psychological stressors (PICS-p: emotional health), support received (PICS-p: social health) and practical challenges (transitional health) in the first six months after childhood critical illness. In the emotional health domain, parents were affected by different stressors and had different priorities over their child's survivorship. Only Indian parents reported experiences of stress symptoms, at six months post discharge. Malay parents sought solace from their religion more than Chinese and Indian parents. In the social health domain, parents reported various sources and degree of support received. Familial supports were strong across all groups, while community support was more prominent in Malay as compared to Chinese and Indian parents. A third domain, transitional health, was introduced to capture the difficulties parents faced during the transition from PICU survival to home. Parents from non-Chinese families were more likely to report financial challenges and more involvement of spouses after discharge. Complementary medicine or commercial health products were utilized by Chinese and Malay families. These findings reveal preferred strategies that parents from a global ethnic employ to address the emotional, social and transitional health impacts of their child's critical illness. Future care delivery may consider tailored care plans, communication strategies, and emotional support in PICUs that address the unique ethnic needs of parents during the critical six-months post their child's illness.

Predicting long-term neurocognitive outcome after pediatric intensive care unit admission for bronchiolitis—preliminary exploration of the potential of machine learning

PurposeFor successful prevention and intervention, it is important to unravel the complex constellation of factors that affect neurocognitive functioning after pediatric intensive care unit (PICU) admission. This study aims (1) to elucidate the potential relevance of patient and PICU-related characteristics for long-term adverse neurocognitive outcome after PICU admission for bronchiolitis, and (2) to perform a preliminary exploration of the potential of machine learning as compared to linear regression to improve neurocognitive outcome prediction in a relatively small sample of children after PICU admission.MethodsThis cross-sectional observational study investigated 65 children aged 6–12 years with previous PICU admission for bronchiolitis (age ≤ 1 year). They were compared to demographically comparable healthy peers (n = 76) on neurocognitive functioning. Patient and PICU-related characteristics used for the prediction models were as follows: demographic characteristics, perinatal and disease parameters, laboratory results, and intervention characteristics, including hourly validated mechanical ventilation parameters. Neurocognitive outcome was measured by intelligence and computerized neurocognitive testing. Prediction models were developed for each of the neurocognitive outcomes using Regression Trees, k-Nearest Neighbors, and conventional linear regression analysis.ResultsThe patient group had lower intelligence than the control group (p < .001, d = −0.59) and poorer performance in neurocognitive functions, i.e., speed and attention (p = .03, d = −0.41) and verbal memory (p < .001, d = −0.60). Lower intelligence was predicted by lower birth weight and lower socioeconomic status (R2 = 25.9%). Poorer performance on the speed and attention domain was predicted by younger age at follow-up (R2 = 53.5%). Poorer verbal memory was predicted by lower birth weight, younger age at follow-up, and greater exposure to acidotic events (R2 = 50.6%). The machine learning models did not reveal added value in terms of model performance as compared to linear regression.Conclusion: The findings of this study suggest that in children with previous PICU admission for bronchiolitis, (1) lower birth weight, younger age at follow-up, and lower socioeconomic status are associated with poorer neurocognitive outcome; and (2) greater exposure to acidotic events during PICU admission is associated with poorer verbal memory outcome. The findings of this study provide no evidence for the added value of machine learning models as compared to linear regression analysis in the prediction of long-term neurocognitive outcome in a relatively small sample of children.What is Known:• Adverse neurocognitive outcomes are described in PICU survivors, which are known to interfere with development in other major domains of functioning, such as mental health, academic achievement, and socioeconomic success, highlighting neurocognition as an important outcome after PICU admission.• Machine learning is a rapidly growing field of artificial intelligence that is increasingly applied in health care settings, with great potential to capture the complexity of outcome prediction.What is New:• This study shows that lower birth weight, lower socioeconomic status, and greater exposure to acidotic events during PICU admission for bronchiolitis are associated with poorer long-term neurocognitive outcome after PICU admission. Results provide no evidence for the added value of machine learning models in a relatively small sample of children.• As bronchiolitis seldom manifests neurologically, the relation between acidotic events and neurocognitive outcome may reflect either potentially harmful effects of acidosis itself or related processes such as hypercapnia or hypoxic and/or ischemic events during PICU admission. This study further highlights the importance of structured follow-up to monitor long-term outcome of children after PICU admission.

Follow-up after PICU discharge for patients with acquired brain injury: the role of an abbreviated neuropsychological evaluation and a return-to-school program.

To present the results of an abbreviated testing protocol used to screen for neurocognitive and psychological sequelae of critical illness among pediatric intensive care unit (PICU) survivors with acquired brain injury in our post-discharge follow-up programs, and describe our process for facilitating this population's return to academic life. Retrospective cohort study. Neurocritical care follow-up programs at two U.S. academic, tertiary medical/surgical PICUs. Children age > 4 years enrolled in the neurocritical care follow-up programs (n=289) at these institutions who underwent neurocognitive and psychological testing between 2017-2021. None. One month after discharge from the hospital, nearly half of the children and/or their parents (48%) in our neurocritical care follow-up programs identified some type of emotional or behavioral concern compared to their premorbid state, and 15% reported some type of cognitive concern. On evaluation, 35% of the children were given a new neurocognitive diagnosis. Neurocognitive domains regulated by the executive functioning system were the most commonly affected, including attention (54%), memory (31%) and processing speed (27%). One-quarter of the children were given a new psychological diagnosis, most commonly post-traumatic stress disorder (PTSD) or stress-related symptoms (12%). Over 80% of patients in the programs were given new recommendations for school, for both new academic services and new classroom accommodations. Over half of children (57%) were referred for comprehensive follow-up neuropsychological evaluation. Abbreviated neurocognitive and psychological evaluation successfully identifies the same deficits commonly found among PICU survivors who undergo longer, more complete testing protocols. When combined with services aimed at successfully re-integrating PICU survivors back to school, this focused evaluation can provide an effective and efficient means of screening for cognitive and emotional deficits among PICU survivors, and establish a rationale for early academic support upon the child's return to school.

Predictors of neurocognitive and psychological disorders in children after intensive care admission: A prospective cohort study.

Children admitted in the pediatric intensive care unit (PICU) often deal with long-term morbidities affecting physical, cognitive, emotional, social, and psychiatric symptoms. We aimed to identify the internal and external factors which predict the occurrence of neurocognitive and psychological disorders in survivors at 3 months after PICU discharge. We identified 53 critically ill children, ages 4-18 years old, admitted in PICU for more than 24 h, and survived. We evaluated neurocognitive disorder with Pediatric Cerebral Perfomance Category (PCPC) and psychological disorders with Strengths and Difficulties Questionnaire (SDQ) at the time of PICU discharge and repeated in 3 months afterward. We evaluated the internal and external risk factors related to neurocognitive and psychological disorders in PICU survivors. The internal risk factors were age, gender, family composition, and socioeconomic status. The external risk factors were: surgical intervention, neurological disease, predicted death rate by pediatric index mortality (PIM)-2 score, PICU length of stay (LOS), days of mechanical ventilation, and the number of therapeutic interventions. There were significant improvement in neurocognitive disorders (p < 0.001), peer problems, (p = 0.01), and prosocial behaviors (p = 0.00) in children at 3 months after the PICU discharge. Age of 4-5 years has a significant effect on neurocognitive disorders (p = 0.04), while male gender (p = 0.02), low-social economy, non-intact family composition (p = 0.01), neurological disease (p = 0.04), surgical intervention (p = 0.01), and TISS score (p = 0.00) have a significant effect on psychological disorders in children at 3 months after the PICU discharge. Neurocognitive disorders, peer problems, and prosocial behaviors improved in a few patients 3 months after PICU discharge. Age of 4-5 years was a risk factor of the persisted neurocognitive disorder, whereas male gender, low-social economy, non-intact family composition, neurological disease, surgical intervention, and TISS score were risk factors of persisted psychological disorder at 3 months after PICU.

Supporting families during pediatric critical illness: Opportunities identified in a multicenter, qualitative study.

Critical illness resulting in a pediatric intensive care unit (PICU) admission is a profoundly stressful experience for a child and their family. Increasing evidence for emotional and behavioral sequelae post-PICU emphasizes a need to provide better support for families throughout this period of care and recovery. The aim of this qualitative investigation was to identify salient and modifiable aspects of a critical care experience that can be addressed to better support families of critically ill children. Individual semi-structured interviews were conducted with 26 caregivers of children who survived a PICU admission. Interviews were audio-recorded and transcribed verbatim; themes were identified via thematic analysis. Caregivers were enrolled using convenience sampling from seven tertiary care PICUs in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Themes from caregiver interviews were identified within two overarching categories containing three themes each. Advice for future PICU families: (1) Be intentional about caring for your own well-being, (2) speak up, ask questions, and challenge decisions you're not comfortable with, and (3) continue to engage with your child. Characteristics of a satisfactory PICU experience: (1) A caregiver-provider relationship of mutual trust established through clear communication and respectful collaboration, (2) hospital environments that provide physical and social supports to maintain humanity in healthcare, and (3) preparing families for care transitions. Targeted, interdisciplinary approaches to partner with families during critical care may improve their PICU experience and contribute to improved long-term outcomes for PICU survivors.

Pediatric Intensive Care Unit Patients: Sedation, Monitoring, and Neurodevelopmental Outcomes.

The design and conduct of pediatric sedation studies in critically ill patients have historically been challenging due to the complexity of the pediatric intensive care unit (PICU) environment and the difficulty of establishing equipoise. Clinical trials, for instance, represent 1 important means of advancing our knowledge in this field, but there is a paucity of such studies in the literature. Accounting for ground-level factors in planning for each trial phase (eg, enrollment, intervention, assessment, and follow-up) and the presence of broader system limitations is of key importance. In addition, there is a need for early planning, coordination, and obtaining buy-in from individual study sites and staff to ensure success, particularly for multicenter studies. This review synthesizes the current state of pediatric sedation research and the myriad of challenges in designing and conducting successful trials in this particular area. The review poses consideration for future research directions, including novel study designs, and discusses electroencephalography monitoring and neurodevelopmental outcomes of PICU survivors.

A-182 Depression Symptoms Predict Neurocognitive Functioning Following Pediatric Traumatic Brain Injury in the Acute Recovery Phase

Abstract Objective: Pediatric Intensive Care Unit (PICU) survivors are at elevated risk for developing neurocognitive concerns. Lower premorbid abilities, pediatric traumatic brain injury (pTBI) severity, and post-injury depression symptoms have been shown to predict greater neurocognitive deficits. However, limited extant research has focused on the acute recovery phase or used objective neuropsychological assessment measures. We examined the impact of pTBI severity and post-injury depression symptoms on neurocognitive functioning in the acute recovery phase. Method: Seventy-four trauma patients (8 to 19 years) were assessed 1-3 months after PICU discharge. Demographic and clinical data were extracted from the electronic medical record. Caregivers completed questionnaires about their children’s physical, cognitive and emotional functioning. The direct assessment included measures of WRAT5 word-reading; CMS/WISC-V/WAIS-IV digit span; WISC-V/WAIS-IV coding and symbol search; and DKEFS Trails-4, verbal phonemic and semantic fluencies. Given the high intercorrelations between aspects of executive function, principal components analysis (PCA) was conducted to create a cumulative neurocognitive index (NCI). A simple linear regression was used to test if moderate-severe Glasgow Coma scores and clinically elevated Promis Depression scores predicted NCI, controlling for reading ability. Results: Combining all participant data in the PCA yielded a single component solution accounting for 52.79% of total explained variance. The overall regression was significant (R2=.40), F(df=3,70) =15.23, p&amp;lt;.001. Elevated depression predicted NCI (p=.03) whereas greater pTBI severity was not predictive above the impact of premorbid factors. Conclusions: Neurocognitive functioning in PICU survivors within the acute recovery phase may be more related to concurrent depression symptoms than injury severity markers when premorbid factors are considered.

PICU Survivorship: Factors Affecting Feasibility and Cohort Retention in a Long-Term Outcomes Study.

Our understanding of longitudinal outcomes of Pediatric Intensive Care Unit (PICU) survivors is limited by the heterogeneity of follow-up intervals, populations, and outcomes assessed. We sought to demonstrate (1) the feasibility of longitudinal multidimensional outcome assessment and (2) methods to promote cohort retention. The objective of this presented study was to provide details of follow-up methodology in a PICU survivor cohort and not to present the outcomes at long-term follow-up for this cohort. We enrolled 152 children aged 0 to 17 years admitted to the PICU in a prospective longitudinal cohort study. We examined resource utilization, family impact of critical illness, and neurodevelopment using the PICU Outcomes Portfolio (POP) Survey which included a study-specific survey and validated tools: 1. Functional Status Scale, 2. Pediatric Evaluation of Disability Inventory Computer Adaptive Test, 3. Pediatric Quality of Life Inventory, 4. Strengths and Difficulties Questionnaire, and 5. Vanderbilt Assessment Scales for Attention Deficit-Hyperactivity Disorder. POP Survey completion rates were 89%, 78%, and 84% at 1, 3, and 6 months. Follow-up rates at 1, 2, and 3 years were 80%, 55%, and 43%. Implementing a longitudinal multidimensional outcome portfolio for PICU survivors is feasible within an urban, tertiary-care, academic hospital. Our attrition after one year demonstrates the long-term follow-up challenges in this population. Our findings inform ongoing efforts to implement core outcome sets after pediatric critical illness.

Intelligence outcome of pediatric intensive care unit survivors: a systematic meta-analysis and meta-regression

BackgroundLong-term morbidity after pediatric intensive care unit (PICU) admission is a growing concern. Both critical illness and accompanying PICU treatments may impact neurocognitive development as assessed by its gold standard measure; intelligence. This meta-analysis and meta-regression quantifies intelligence outcome after PICU admission and explores risk factors for poor intelligence outcome.MethodsPubMed, Embase, CINAHL and PsycINFO were searched for relevant studies, published from database inception until September 7, 2021. Using random-effects meta-analysis, we calculated the standardized mean difference in full-scale intelligence quotient (FSIQ) between PICU survivors and controls across all included studies and additionally distinguishing between PICU subgroups based on indications for admission. Relation between demographic and clinical risk factors and study’s FSIQ effect sizes was investigated using random-effects meta-regression analysis.ResultsA total of 123 articles was included, published between 1973 and 2021, including 8,119 PICU survivors and 1,757 controls. We found 0.47 SD (7.1 IQ-points) lower FSIQ scores in PICU survivors compared to controls (95%CI -0.55 to -0.40, p < .001). All studied PICU subgroups had lower FSIQ compared to controls (range 0.38–0.88 SD). Later year of PICU admission (range 1972–2016) and longer PICU stay were related to greater FSIQ impairment (R2 = 21%, 95%CI -0.021 to -0.007, p < .001 and R2 = 2%, 95%CI -0.027 to -0.002, p = .03, respectively), whereas male sex and higher rate of survivors were related to smaller FSIQ impairment (R2 = 5%, 95%CI 0.001 to 0.014, p = .03 and R2 = 11%, 95%CI 0.006 to 0.022, p < .001, respectively). Meta-regression in PICU subgroups showed that later year of PICU admission was related to greater FSIQ impairment in children admitted after cardiac surgery and heart- or heart–lung transplantation. Male sex was related to smaller FSIQ impairment in children admitted after cardiac surgery. Older age at PICU admission and older age at follow-up were related to smaller FSIQ impairment in children admitted after heart- or heart–lung transplantation.ConclusionsPICU survivors, distinguished in a wide range of subgroups, are at risk of intelligence impairment. Length of PICU stay, female sex and lower rate of survivors were related to greater intelligence impairment. Intelligence outcome has worsened over the years, potentially reflecting the increasing percentage of children surviving PICU admission.

Impact of the Covid-19 Pandemic on Children and Families in PICU Follow-Up Clinic

AbstractThe novel coronavirus disease 2019 (COVID-19) pandemic disrupted the lives of many families, especially those of children with chronic health problems. Little is known about the impact of this pandemic on the health and well-being of critically ill children and their families after their discharge from pediatric intensive care unit (PICU) hospitalization. This study describes the repercussions of the COVID-19-related lockdown on the physical and psychological wellbeing, quality of life, and access to resources of PICU survivors and their families. This was a prospective cohort study of children and families followed at the Centre Hospitalier Universitaire Ste-Justine PICU follow-up clinic from October 2018 to February 2020. Families were contacted by phone to complete validated questionnaires (Pediatric Quality of Life Inventory, Hospital Anxiety and Depression Scale) and to evaluate the impact of the COVID-19 pandemic on their access to medical care and extrafamilial support. Fifty-five families were contacted between November and December 2020. Quality of life scores were 88.1 ± 16.9 and 83.8 ± 13.9 for physical and psychosocial aspects, respectively. Symptoms of anxiety and depression were detected in 23.6 and 3.6% of respondent parents, respectively. A significant proportion of families reported canceled or delayed health care appointments (65.5%) and difficulty with medication access (12.7%). Twenty-five families (45.5%) reported a significant decrease in income. We could not identify any statistically significant predictors for lower quality of life scores. Difficulty accessing medical care was associated with higher symptoms of anxiety and/or depression in parents on multivariate analysis (p = 0.02). In conclusion, the COVID-19 pandemic has had a significant negative impact on PICU survivors' access to medical resources and extrafamilial support.

Survival of pediatric patients requiring admission in the intensive care unit post hematopoietic stem cell transplantation: Prognostic factors associated with mortality.

Although hematopoietic stem cell transplantation (HSCT) is the only curative option for some children with malignant and nonmalignant disorders, the procedure itself carries a high risk of complications. A proportion of children undergoing HSCT develop severe transplant-related complications requiring hospitalization in the pediatric intensive care unit (PICU). A retrospective cohort study included 793 children with malignant and nonmalignant diseases that underwent 963 HSCTs in two large pediatric hospitals over 15years. Ninety-one patients needed 105 (11%) PICU admissions. The objective of the study was to analyze the risk factors associated with morbidity and mortality in children post HSCT who were admitted to the PICU. Survival rate of a single PICU hospitalization was 43%. Long-term survival rate (classified as 1year and 3years) was 29.1% and 14.9% among PICU hospitalized patients compared with 74.6% and 53.3% among patients who had undergone HSCT and did not require PICU hospitalization. Factors found to have a significant negative association with PICU survival were respiratory failure as indication for PICU admission, neutropenia, graft-versus-host disease, mechanical ventilation, inotropic support, need for dialysis, and multiple-organ failure (MOF) with more than one systemic intensive intervention. The strongest prognostic factors associated with mortality were MOF (p<.001) and the need for inotropic support (p=.004). Neutropenia was found to be negatively associated with survival, suggesting non-engraftment and late engraftment are important risk factors for HSCT patients hospitalized in PICU. MOF and inotropic support were found to be the main negatively associated predictive factors with survival.

Acute kidney injury in the pediatric intensive care unit: outpatient follow-up.

Few studies have characterized follow-up after pediatric acute kidney injury (AKI). Our aim was to describe outpatient AKI follow-up after pediatric intensive care unit (PICU) admission. Two-center retrospective cohort study (0-18 years; PICU survivors (2003-2005); noncardiac surgery; and no baseline kidney disease). Provincial administrative databases were used to determine outcomes. AKI (KDIGO (Kidney Disease: Improving Global Outcomes) definitions). post-discharge nephrology, family physician, pediatrician, and non-nephrology specialist visits. Regression was used to evaluate factors associated with the presence of nephrology follow-up (Cox) and the number of nephrology and family physician or pediatrician visits (Poisson), among AKI survivors. Of n = 2041, 355 (17%) had any AKI; 64/355 (18%) had nephrology; 198 (56%) had family physician or pediatrician; and 338 (95%) had family physician, pediatrician, or non-nephrology specialist follow-up by 1 year post discharge. Only 44/142 (31%) stage 2-3 AKI patients had nephrology follow-up by 1 year. Inpatient nephrology consult (adjusted hazard ratio (aHR) 7.76 [95% confidence interval (CI) 4.89-12.30]), kidney admission diagnosis (aHR 4.26 [2.21-8.18]), and AKI non-recovery by discharge (aHR 2.65 [1.55-4.55]) were associated with 1-year nephrology follow-up among any AKI survivors. Nephrology follow-up after AKI was uncommon, but nearly all AKI survivors had follow-up with non-nephrologist physicians. This suggests that AKI follow-up knowledge translation strategies for non-nephrology providers should be a priority. Pediatric AKI survivors have high long-term rates of chronic kidney disease (CKD) and hypertension, justifying regular kidney health surveillance after AKI. However, there is limited pediatric data on follow-up after AKI, including the factors associated with nephrology referral and extent of non-nephrology follow-up. We found that only one-fifth of all AKI survivors and one-third of severe AKI (stage 2-3) survivors have nephrology follow-up within 1 year post discharge. However, 95% are seen by a family physician, pediatrician, or non-nephrology specialist within 1 year post discharge. This suggests that knowledge translation strategies for AKI follow-up should be targeted at non-nephrology healthcare providers.

P0044 / #597: LIVED EXPERIENCE OF DELIRIUM IN CRITICALLY ILL CHILDREN: PROTOCOL FOR A QUALITATIVE STUDY

Aims & Objectives: Delirium is a common yet under-recognized problem in the pediatric intensive care unit (PICU) that negatively impacts patient outcomes. The objective of this study is to describe the lived experience of delirium, by evaluating patient-recall and caregiver perception of delirium in critically ill children. Methods: This is a two center, descriptive, qualitative study. Eligible subjects include critically ill children 0-18 years old diagnosed with delirium during their PICU stay, and/or their caregivers (both family and healthcare providers). Operational definition of delirium for this study is a Cornell Assessment of Pediatric Delirium (CAPD) score of ≥ 9 for at least 48 hours. Face-to-face, semi-structured interviews will be conducted on subjects at different time-points: during the index hospitalization (after delirium resolution), and up to 12 months after PICU discharge. Interview transcripts will be examined using inductive content analysis, whereby codes and recurrent themes are derived directly from data. Themes and subthemes derived from the qualitative analyses will be presented. Enrollment goal is approximately 15 interviews, or until thematic saturation is achieved. NVIVO software will be used for analyses. Results: Preliminary interviews have been completed on one patient, one parent and two health care providers. An open coding process has been conducted by all five investigators, to develop codes, and a codebook has been reviewed and finalized. Conclusions: This study will identify core themes regarding the lived experience of pediatric delirium. This novel data will be used in future prospective interventional trials designed to limit the long-term impact of delirium on PICU survivors and their families.

Intelligence Outcome of Pediatric Intensive Care Unit Survivors: A Systematic Meta-Analysis and Meta-Regression

Intelligence Outcome of Pediatric Intensive Care Unit Survivors: A Systematic Meta-Analysis and Meta-Regression

Pediatric postintensive care syndrome: high burden and a gap in evaluation tools for limited-resource settings.

This article aimed to summarize the impact and burden of pediatric postintensive care syndrome (PICS-p) in the physical, mental, cognitive, and social health domains after a review of the current pediatric literature in MEDLINE and PubMed. We also aimed to elucidate the limitations of the current evaluation tools used in limited-resource settings. PICS-p can impact a child’s life for decades. Most validated tools are time-consuming, require qualifications, and expertise, are often limited to older children, and can evaluate only one domain. A novel, simple, and comprehensive surveillance tool can aid healthcare providers in the early detection and intervention of PICS-p. Further studies should validate and refine the parameters that will enhance the outcomes of pediatric intensive care unit survivors.

Hemoperfusion with Cytosorb in pediatric patients with septic shock: A retrospective observational study.

To determine the clinical effect of continuous hemoperfusion with Cytosorb associated with standard Continuous Renal Replacement Therapy on hemodynamics and on clinically relevant outcome parameters in children with septic shock. Retrospective analysis. Pediatric intensive care unit. Eight consecutive children with septic shock who received hemoperfusion with Cytosorb while on Continuous Renal Replacement Therapy. Continuous hemoperfusion with Cytosorb (adsorber was changed every 24 h). Vasoactive-Inotropic Score was measured before and after the extracorporeal blood purification treatment. Bedside refractory septic shock score was calculated before the onset of the extracorporeal blood purification treatment. Time course of cytokines interleukin-6, interleukin-10, and tumor necrosis factor-alpha was measured at Time 0, then every 12 h until the end of blood purification treatment (72 or 96 h). Pediatric intensive care unit survival in our cohort was 90%. Median bedside refractory septic shock score was 2.1. Patients showed improved Vasoactive-Inotropic Score following blood purification (pre: 40.00 post: 8.89 p = 0.0076). Measurement of cytokines level showed a significant reduction of interleukin-6 plasma levels (7977.27-210.18 pg/mL, p = 0.0077) and interleukin-10 plasma levels (from 687.19 to 36.95 pg/mL, p = 0.0180). In those patients with detectable tumor necrosis factor-alpha plasma level, its reduction was not significant (p = 0.138). The median removal ratio was 80% for interleukin-6, 90% for interleukin-10, and 29% for tumor necrosis factor-alpha. The use of Cytosorb in combination with Continuous Renal Replacement Therapy as blood purification strategy in pediatric septic shock is associated with a rapid hemodynamic stabilization in the first 48 h of treatment and a significant reduction of interleukin-6 and interleukin-10.

Gross motor developmental dysfunctional outcomes in infantile and toddler pediatric intensive care unit survivors

BackgroundIncreasing studies have focused on motor function/dysfunction in PICU survivors; however, most studies have focused on adults and older children. This study investigated gross motor developmental function outcomes in infantile and toddler pediatric intensive care unit (PICU) survivors and the factors associated with gross motor developmental functions.MethodsThis observational study was conducted in the PICU of the First Hospital of Jilin University between January 2019 and March 2019. Thirty-five eligible patients were divided into the dysfunctional (n = 24) or non-dysfunctional (n = 11) group according to the results of the Peabody Developmental Motor Scales, Second Edition (PDMS-2). Baseline gross motor function for all participants before PICU admission was measured via the Age and Stages Questionnaires, Third Edition (ASQ-3). The PDMS-2 was used to evaluate gross motor development function before PICU discharge.ResultsThe gross motor developmental dysfunction incidence was 68.6%. Linear correlation analysis showed that the gross motor quotient (GMQ) was positively correlated with the pediatric critical illness score (PCIS, r = 0.621, P < 0.001), and negatively correlated with length of PICU stay (r = − 0.556, P = 0.001), days sedated (r = − 0.602, P < 0.001), days on invasive mechanical ventilation (IMV; r = − 0.686, P < 0.001), and days on continuous renal replacement therapy (CRRT; r = − 0.538, P = 0.001). Linear regression analysis showed that IMV days (β = − 0.736, P = 0.001), sepsis (β = − 18.111, P = 0.003) and PCIS (β = 0.550, P = 0.021) were independent risk factors for gross motor developmental dysfunction.ConclusionsGross motor developmental dysfunction in infantile and toddler PICU survivors is more common and may be exacerbated by experiences associated with longer IMV days and increasing illness severity combined with sepsis.Trial registrationThe trial ‘Early rehabilitation intervention for critically ill children’ has been registered at http://www.chictr.org.cn/showproj.aspx?proj=23132. Registration number: ChiCTR1800020196.

Postintensive Care Syndrome in Pediatric Critical Care Survivors: Therapeutic Options to Improve Outcomes After Acquired Brain Injury.

Children surviving the pediatric intensive care unit (PICU) with neurologic illness or injury have long-term morbidities in physical, cognitive, emotional, and social functioning termed postintensive care syndrome (PICS). In this article, we review acute and longitudinal management strategies available to combat PICS in children with acquired brain injury. Few intervention studies in this vulnerable population target PICS morbidities. Small studies show promise for both inpatient- and outpatient-initiated therapies, mainly focusing on a single domain of PICS and evaluating heterogeneous populations. While evaluating the effects of interventions on longitudinal PICS outcomes is in its infancy, longitudinal clinical programs targeting PICS are increasing. A multidisciplinary team with inpatient and outpatient presence is necessary to deliver the holistic integrated care required to address all domains of PICS in patients and families. While PICS is increasingly recognized as a chronic problem in PICU survivors with acquired brain injury, few interventions have targeted PICS morbidities. Research is needed to improve physical, cognitive, emotional, and social outcomes in survivors and their families.

Spectrum of issues and outcomes of critically Ill pediatric hemopoietic stem cell transplant recipients requiring admission to intensive care unit in a tertiary care hospital in India

Background : Hematopoietic stem cell transplantation (HSCT) is a lifesaving therapeutic option for children with multiple hematologic, oncologic, and immunologic disorders. However, a large proportion of children undergoing HSCT develop complications that necessitate admission to the pediatric intensive care unit (PICU). Methods : Study design: Retrospective chart review Setting and patient description: All children younger than 18 years of age, who received an HSCT in our hospital between August 2013 and June 2015, were identified from the HSCT database. Patients admitted to the ICU after HSCT were identified from a prospectively maintained ICU database. Patient data collected from medical charts included demographic information, pre-existing diagnosis requiring HSCT, number and type of transplantation, type of donor and source of stem cells, any complications if associated. Consent: Prior to the start of the HSCT procedure, all parents, and when appropriate, all patients, gave written informed consent to analyse clinical data for study purposes. PICU data: Indication for PICU admission, diagnosis, ventilator and inotrope requirement, if applicable and organ dysfunction. The outcome of patients, whether survival or death at discharge and follow up at 28days were done. Statistics: Descriptive and inferential statistical analysis has been carried out in the present study using SPSS 15.0. Results : During the study period, 141 children received HSCT of which 28 children required PICU admission on 33 occasions accounting for a PICU admission rate of 23.4%. Majority of patients were in the age group of 1-5yrs - 20 (60.6%), followed by 6-10yrs- 5(15.2%). The majority had a non-malignancy indication for HCST -22 (66.6%), of which thalassemia was the commonest diagnosis, followed by severe combined immunodeficiency (SCID) and adreno-leucodystrophy. The most common indications for PICU admission were seizures (n=10, 30.3%), hypotension (n=7, 21%) and respiratory distress (n=6, 18%). Sepsis or severe sepsis occurred in 75%, with pneumonia being the commonest focus in 44%. We observed a 64% (n=21) survival following PICU admission. While 26 (80%) patients with severe sepsis were culture positive, gram-negative bacilli were the commonest organisms. The most common organ dysfunction observed was respiratory failure (n=20, 60%) followed by neurological dysfunction (n=15, 45.5%). Acute kidney injury was observed in 11 (33%) patients, of which 5 (45%) required renal replacement therapy. Circulatory failure with hypotension had the highest risk of mortality. Other risk factors significantly associated with mortality were kidney injury(p-0.005), duration of mechanical ventilation (>5days)(p-0.009) and higher inotropic score (>10)(p- 0.004)). Septic shock was the most common cause of mortality in 6 (50%), followed by GVHD in 3 (25%) children. PICU survival was unaffected by the age characteristics, underlying condition or the type of HSCT. Conclusion : Immunocompromised children who need PICU admission after HSCT have high risk of death, especially in the presence of multi-organ failure, of which circulatory dysfunction appeared to have the greatest risk. In our study we observed 64% survival, which is better than previous studies in similar cohorts and comparable to western data. However, survival can be optimized by aggressive multidisciplinary ICU support.

Pediatric Hematopoietic Cell Transplant Patients Who Survive Critical Illness Frequently Have Significant but Recoverable Decline in Functional Status

The number of pediatric hematopoietic cell transplant (HCT) patients who survive pediatric intensive care unit (PICU) admission is increasing, yet little is known about their functional morbidity after PICU discharge. We hypothesized that relative to control subjects, pediatric HCT patients who survive PICU admission would have greater rates of new functional morbidity at the time of PICU discharge and only some of these patients would return to their functional baseline by the end of the hospitalization. We performed a retrospective cohort study with secondary data analysis of the Trichotomous Outcomes in Pediatric Critical Care dataset. The pediatric HCT cohort was identified by querying International Classification of Diseases, 9th edition, diagnostic codes. A control group consisted of previously healthy patients matched 4:1 on age, sex, and illness severity, as estimated by the Pediatric Risk of Mortality (PRISM) score. We benchmarked our findings by comparing with a previously healthy group of children with lower respiratory tract infections. Functional impairment was measured by the Functional Status Scale, wherein new morbidity was defined as an increase of ≥3 points relative to the prehospital baseline. Relative to matched control subjects, HCT patients had similar admission PRISM scores (P = .516) but greater PICU mortality (12.9% [11/85] versus 6.2% [21/340], P = .035). However, among those who survived to PICU discharge, HCT patients had similar rates of new morbidity at PICU discharge (14.9% [11/74] versus 17.2% [55/319], P = .622) and similar rates of resolution of new morbidity by hospital discharge (54.5% [6/11] versus 60.0% [33/55], P = .737). Relative to the comparison group with lower respiratory tract infections, HCT patients had both greater admission PRISM scores (P < .001) and greater PICU mortality (12.9% [11/85] versus 1.6% [5/308], P < .001). However, among those who survived to PICU discharge, HCT patients again displayed similar rates of new morbidity at PICU discharge (14.9% [11/74] versus 22.1% [67/303], P = .168) as well as resolution of new morbidity by hospital discharge (54.5% [6/11] versus 71.6% [48/67], P = .299). For pediatric HCT patients PICU survival with new functional morbidity is as prevalent an outcome as PICU mortality. Although pediatric HCT patients have greater PICU mortality than age-, sex-, and PRISM-matched control subjects, they have similar rates of new functional morbidity at PICU discharge and similar resolution of new functional morbidity at hospital discharge. Future interventions focused on improving functional status in pediatric HCT survivors of critical illness are warranted.