Healing Environments for Critically Ill Children: Development of a multidisciplinary and integrated approach to sleep, sedation, delirium and early mobilization

Pediatric Intensive Care Unit mortality rates have decreased significantly in the last decade, but the proportion of children surviving with significant functional morbidity is rising. For decades, hospital routines have been in place that disrupt normal sleep-wake patterns, which may have negative effects on the developing brain. Sleep disturbances during childhood negatively impact learning, memory, and psychological well-being. During critical illness, children are exposed to both intrinsic and extrinsic factors that disturb sleep, potentially increasing the risk of delirium and post-intensive care syndrome. Intubated children frequently are heavily sedated to prevent inadvertent extubation or other complications, leading a culture of immobility in the pediatric critical care setting. Furthermore, acute rehabilitation may be delayed to the perception that a child is too critically ill to engage in early mobilization activities, further fueling the cycle of immobility and increasing the risk of intensive care unit-acquired weakness and potentially impacting quality of life after discharge. While optimizing sedation approaches, sleep promotion, delirium prevention and early mobilization individually is a viable option, integrating these components to create healing environments for children recovering from critical illness is a practical approach to optimize both short and long-term outcomes. The work described in this dissertation systematically explores current PICU practice and clinician perceptions in each of these areas, and characterizes temporal sleep and activity patterns of critically ill children admitted to the PICU through hospital discharge. The dissertation concludes by demonstrating the safety and feasibility of a multicomponent, multidisciplinary early mobilization program which integrates titrated sedation, sleep promotion, and delirium prevention. The overarching goal of my research is to create a paradigm shift in PICU care prioritizing minimal but effective sedation with sleep promotion to prevent delirium and facilitate early mobilization through multidisciplinary collaboration. I hope that transforming PICU culture to liberate the critically ill child from these iatrogenic risk factors will improve both short and long-term outcomes for children undergoing active neurocognitive development

Development of a non-pharmacologic delirium management bundle in paediatric intensive care units

Background: Non-pharmacologic interventions might be effective to reduce the incidence of delirium in pediatric intensive care units (PICU). Aim: To explore expert opinions and generate informed consensus decisions regarding the content of a non-pharmacologic delirium bundle to manage delirium in PICU patients. Study design: A two-round online Delphi study was conducted from February to April 2021. PICU experts (nurses, physicians, researchers, physical therapists, play specialists, and occupational therapists) located in Europe, North America, South America, Asia, and Australia participated. Results: We developed a questionnaire based on the outcomes of a comprehensive literature search in the domains: 1) cognition support; 2) sleep support; and 3) physical activity support. Under these domains, we listed 11 strategies to promote support with 61 interventions. Participants rated the feasibility of each intervention on a 9-point Likert scale (ranging from 1 strongly disagree to 9 strongly agree). A disagreement index and panel median were calculated to determine the level of agreement among experts. In the second round, participants reassessed the revised statements and ranked the interventions in each domain in order of importance for age groups: 0–2, 3–5, and 6–18 years of age. During the first Delphi round, 53 of 74 (72%) questionnaires were completed, and in the second round 45 of 74 (61%) were completed. Five of the highest ranked interventions across the age groups were: 1) developing a daily routine, 2) adjusting light exposure according to the time of day, 3) scheduling time for sleep, 4) providing eyeglasses and hearing aids if appropriate, 5) encouraging parental presence. Conclusions: Based on expert consensus, we developed an age-specific non-pharmacologic delirium bundle of interventions to manage delirium in PICU patients. Relevance to Clinical Practice: An age-specific Non-Pharmacological Delirium bundle is now ready to be tested in the PICU and will hopefully reduce pediatric delirium