Mobilization Safety of Critically Ill Children.

BACKGROUND: Children in PICUs experience negative sequelae of immobility; however, interprofessional staff concerns about safety are a barrier to early mobilization. Our objective was to determine the safety profile of early mobilization in PICU patients. METHODS: We conducted a secondary analysis of a 2-day study focused on physical rehabilitation in 82 PICUs in 65 US hospitals. Patients who had ≥72-hour admissions and participated in a mobility event were included. The primary outcome was occurrence of a potential safety event during mobilizations. RESULTS: On 1433 patient days, 4658 mobility events occurred with a potential safety event rate of 4% (95% confidence interval [CI], 3.6%-4.7%). Most potential safety events were transient physiologic changes. Medical equipment dislodgement was rare (0.3%), with no falls or cardiac arrests. Potential safety event rates did not differ by patient age or sex. Patients had higher potential safety event rates if they screened positive for delirium (7.8%; adjusted odds ratio, 5.86; 95% CI, 2.17-15.86) or were not screened for delirium (4.7%; adjusted odds ratio, 3.98; 95% CI, 1.82-8.72). There were no differences in potential safety event rates by PICU intervention, including respiratory support or vasoactive support. CONCLUSIONS: Early PICU mobilization has a strong safety profile and medical equipment dislodgement is rare. No PICU interventions were associated with increased potential safety event rates. Delirium is associated with higher potential safety event rates. These findings highlight the need to improve provider education and confidence in mobilizing critically ill children.

Sedation protocols in the pediatric intensive care unit: fact or fiction?

Comfort of the critically unwell pediatric patient is paramount to ensuring good outcomes. Analgesia-based, multimodal sedative approaches are the foundation for comfort, whereby pain is addressed first and then sedation titrated to a predefined target based on the goals of care. Given the heterogeneity of patients within the pediatric critical care population, the approach must be individualized based on the age and developmental stage of the child, physiologic status, and degree of invasive treatment required. In both the adult and pediatric intensive care unit (PICU), sedation titration is practiced as standard of care to meet therapeutic goals with a focus on facilitating early rehabilitation and extubation while avoiding under- and over-sedation. Sedation protocols have been developed as methods to reduce variability and optimize goal-directed therapy. Components of a sedation protocol include routine analgesia and sedation scoring with validated tools at specified intervals and a predefined algorithm that allows the titration of analgesia and sedation based on those assessments. Sedation protocols are designed to improve communication and documentation of sedation goals while also empowering the bedside team to respond rapidly to changes in a patient's clinical status. Previously it was thought that sedation protocols would consistently reduce duration of mechanical ventilation (MV) and length of stay (LOS) for patients in the PICU, however, this has not been the case. Nonetheless, introduction of sedation protocols has provided several benefits, including: (I) reduction in benzodiazepine usage; (II) improvements in interprofessional communication surrounding sedation goals and management of sedation goals; and (III) reductions in iatrogenic withdrawal symptoms. Successful implementation of sedation protocols requires passionate clinical champions and a robust implementation, education, and sustainability plan. Emerging evidence suggests that sedation protocols as part of a bundle of quality improvement initiatives will form the basis of future studies to improve short- and long-term outcomes after PICU discharge. In this review, we aim to define sedation protocols in the context of pediatric critical care and highlight important considerations for clinical practice and research.

The Impact of Parental Presence on Trainee Education During PICU Rounds: A Brief Report.

OBJECTIVES: To determine the impact of parental presence on the number and types of educational questions asked of and by medical trainees during PICU rounds. METHODS: An investigator joined bedside rounds in a 14-bed medical-surgical PICU on 20 weekdays between December 2016 and June 2017. For each patient, the investigator recorded the time devoted to education. Educational questions were recorded verbatim. Questions were categorized as "teaching" (senior team member to a trainee) or "learning" (trainee to a more senior team member) and by content (eg, physiology, imaging, prognosis). Two blinded investigators independently assigned codes to each educational question; discrepancies were resolved to the satisfaction of both. RESULTS: Data include 151 patient-specific rounding events, involving 92 patients. At least 1 parent attended the entirety of 59/151 rounding events (39%). There were no significant differences between the duration of education or the number of educational questions asked when parents were present (1 minute; 2 questions) versus absent (2 minutes; 2 questions). When parents were present, 20% questions were learning versus 25% when parents were absent. Zero percent of rounding events included ≥1 question about prognosis when parents were present versus 9% when absent (P = .02). There was no statistically significant difference in the frequency of questions related to complications of management or social factors. CONCLUSIONS: Parent participation in rounds did not impact the quantity of education during rounds but did impact the type of educational questions asked, specifically restricting the discussion of patient prognosis.