Acute Neurologic Dysfunction in Critically Ill Children: The PODIUM Consensus Conference

CONTEXT Acute neurologic dysfunction is common in critically ill children and contributes to outcomes and end of life decision-making. OBJECTIVE To develop consensus criteria for neurologic dysfunction in critically ill children by evaluating the evidence supporting such criteria and their association with outcomes. DATA SOURCES Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020, by using a combination of medical subject heading terms and text words to define concepts of neurologic dysfunction, pediatric critical illness, and outcomes of interest. STUDY SELECTION Studies were included if the researchers evaluated critically ill children with neurologic injury, evaluated the performance characteristics of assessment and scoring tools to screen for neurologic dysfunction, and assessed outcomes related to mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. Studies with an adult population or premature infants (≤36 weeks' gestational age), animal studies, reviews or commentaries, case series with sample size ≤10, and studies not published in English with an inability to determine eligibility criteria were excluded. DATA EXTRACTION Data were abstracted from each study meeting inclusion criteria into a standard data extraction form by task force members. DATA SYNTHESIS The systematic review supported the following criteria for neurologic dysfunction as any 1 of the following: (1) Glasgow Coma Scale score ≤8; (2) Glasgow Coma Scale motor score ≤4; (3) Cornell Assessment of Pediatric Delirium score ≥9; or (4) electroencephalography revealing attenuation, suppression, or electrographic seizures. CONCLUSIONS We present consensus criteria for neurologic dysfunction in critically ill children

Sedation, Analgesia, and Paralysis during Mechanical Ventilation of Premature Infants

To characterize administration of sedatives, analgesics, and paralytics in a large cohort of mechanically ventilated, premature infants

Family Outcomes After the Pediatric Intensive Care Unit: A Scoping Review

Background: Intensivists are increasingly attuned to the post-discharge outcomes experienced by families because patient recovery and family outcomes are interdependent after childhood critical illness. In this scoping review of international contemporary literature, we describe the evidence of family effects and functioning post-PICU as well as outcome measures used in order to identify strengths and weaknesses in the literature.Methods: We reviewed all articles published between 1970 and 2017 in PubMed, EMBASE, PsycINFO, Cumulative Index of Nursing and Allied Health Literature (CINAHL), or the Cochrane Controlled Trials Registry. Our search used a combination of terms for the concept of “critical care/illness” combined with additional terms for the pre-specified domains of social, cognitive, emotional, physical, health-related quality of life (HRQL), and family functioning.Results: We identified 71 articles reporting on the post-PICU experience of more than 2,400 parents and 3,600 families of PICU survivors in 8 countries. These articles used 101 different metrics to assess the various aspects of family outcomes; 34 articles also included open-ended interviews. Overall, most families experienced significant disruption in at least 5 out of 6 of our family outcomes subdomains, with themes of decline in mental health, physical health, family cohesion, and family finances identified. Almost all articles represented relatively small, single-center or disease-specific observational studies. There was disproportionate representation of families of higher socioeconomic status and Caucasian race, and there was much more data about mothers compared to fathers. There was also very limited information regarding outcomes for siblings and extended family members after a child’s PICU stay. Conclusions: Significant opportunities remain for research exploring family functioning after PICU discharge. We recommend that future work include more diverse populations with respect to the critically ill child as well as family characteristics, include more intervention studies, and enrich existing knowledge about outcomes for siblings and extended family

Risk Factors for the Development of Postoperative Delirium in Pediatric Intensive Care Patients

SETTING: Twenty-two bed PICU in a tertiary care academic medical center in Germany

Cornell Assessment of Pediatric Delirium: Italian cultural validation and preliminary testing - Validazione linguistica culturale italiana e analisi preliminari della Cornell Assessment of Pediatric Delirium

 INTRODUZIONE: Il delirium pediatrico è associato ad una maggior durata di degenza all'interno delle terapie intensive pediatriche ed alla comparsa di sintomi post-traumatici. Nei bambini molto piccoli, in etí  prescolare, la diagnosi del delirium appare piuttosto impegnativa. Recentemente è stato sviluppato ed individuato anche dalla letteratura internazionale uno strumento di screening del delirium pediatrico adatto ai bambini critici ricoverati in etí  prescolare, con ottimi risultati anche nei neonati critici al di sotto dei 2 anni di etí : la Cornell Assessment of Pediatric Delirium (CAPD). La CAPD fonda la valutazione del delirium pediatrico nel contesto dello sviluppo del bambino. Tale scala segue lo sviluppo del neonato rapportando la rilevazione degli item specifici della scala a punti di ancoraggio che caratterizzano lo sviluppo dei piccoli pazienti suddivisi per fasce di etí .OBIETTIVO: eseguire una validazione linguistico culturale in lingua Italiana e test preliminari della Cornell Assessment of Pediatric Delirium per la valutazione/diagnosi del delirium pediatrico all'interno delle terapie intensive pediatriche.METODO: Studio di traduzione e validazione culturale. La traduzione e l'adattamento culturale di tale strumento ha seguito le fasi del modello proposto dalla World Health Organization. Test preliminari, come item descriptive analysis, item-total correlation e alfa di Cronbach, sono stati effettuati.RISULTATI: Tutte le fasi del processo di validazione linguistico culturale sono state realizzate in modo soddisfacente. Per le analisi preliminari, la scala è stata somministrata ad un campione di 42 bambini, con etí  compresa da 0-5 anni (66.6%), con una maggiore prevalenza del sesso maschile. I test preliminari hanno mostrato una buona distribuzione di tutti gli item. Tutti i coefficienti dell'Item-total correlation avevano valori superiori rispetto il valore raccomandato di 0.30. Inoltre l'alfa di Cronbach ha mostrato valori superiori allo 0.90.CONCLUSIONI: Il processo ha minuziosamente seguito le raccomandazioni presenti nella letteratura internazionale. La versione finale è stata approvata dagli autori dello strumento originale.Parole chiave: delirium pediatrico, CAPD, validazione italianaABSTRACT - Cornell Assessment of Pediatric Delirium: Italian cultural validation and preliminary testingINTRODUCTION: Paediatric delirium is associated with a longer duration of hospitalization in paediatric intensive care units, the emergence of post-traumatic symptoms and possible neurocognitive dysfunction after discharge. In preschool children, the diagnosis of delirium appears rather challenging: their pre-verbal status and the presence of cognitive skills still in development make accurate diagnosis difficult. Recently, a pediatric delirium screening tool suitable for critical preschool children has also been developed and identified in international literature, with excellent results also in critical infants under 2 years of age: the Cornell Assessment of Pediatric Delirium (CAPD). The CAPD, using a Likert scale, bases the assessment of paediatric delirium within the context of child development. This scale follows the development of the infant by comparing the detection of specific items on the scale as the anchor points that characterize the development of infants by age groups.OBJECTIVE: Culturally and linguistically validation in Italian language and prior testing of the Cornell Assessment of Pediatric Delirium.METHOD: Translation and Cultural Validation of the Cornell Assessment of Pediatric Delirium (CAPD) for the Evaluation/Diagnosis of Pediatric Delirium within Pediatric Intensive Care. The translation and adaptation of this instrument followed the phases of the model proposed by the World Health Organization. Prior testings, such as item descriptive analysis, item-total correlation and Cronbach's alpha, were conducted.RESULTS: All phases of the cultural-linguistic validation process were carried out in a satisfactory manner. For the prior testing, the scale was administered to a sample of 42 children, with age ranged 0-5 years old (66.6%), with a higher prevalence of the male gender. All items were normally distributed and there was no excessive Skeweness and Kurtosis. Each item contributed to the scale fairly well and all coefficients of item total correlation (rjx) were higher than the recommended level of 0.30. The composite reliability index was 0.94 and Cronbach's alpha was 0.96.CONCLUSIONS: The process has meticulously followed the recommendations in international literature. The final version was approved by the authors of the original instrument. Key words: pediatric delirium, CAPD, Italian validation riassunto

“Difficult to Sedate”: Successful Implementation of a Benzodiazepine-Sparing Analgosedation-Protocol in Mechanically Ventilated Children

We sought to evaluate the success rate of a benzodiazepine-sparing analgosedation protocol (ASP) in mechanically ventilated children and determine the effect of compliance with ASP on in-hospital outcome measures. In this single center study from a quaternary pediatric intensive care unit, our objective was to evaluate the ASP protocol, which included opiate and dexmedetomidine infusions and was used as first-line sedation for all intubated patients. In this study we included 424 patients. Sixty-nine percent (n = 293) were successfully sedated with the ASP. Thirty-one percent (n = 131) deviated from the ASP and received benzodiazepine infusions. Children sedated with the ASP had decrease in opiate withdrawal (OR 0.16, 0.08–0.32), decreased duration of mechanical ventilation (adjusted mean duration 1.81 vs. 3.39 days, p = 0.018), and decreased PICU length of stay (adjusted mean 3.15 vs. 4.7 days, p = 0.011), when compared to the cohort of children who received continuous benzodiazepine infusions. Using ASP, we report that 69% of mechanically ventilated children were successfully managed with no requirement for continuous benzodiazepine infusions. The 69% who were successfully managed with ASP included infants, severely ill patients, and children with chromosomal disorders and developmental disabilities. Use of ASP was associated with decreased need for methadone use, decreased duration of mechanical ventilation, and decreased ICU and hospital length of stay