Factors Associated With Delirium in Children: A Systematic Review and Meta-Analysis.

OBJECTIVES: Pediatric delirium (PD) is a neuropsychiatric syndrome caused by a complex interplay between predisposing factors (e.g., age, cognitive impairment), acute illness, and environmental triggers. PD is associated with substantial morbidity and mortality. The objective of this study is to systematically review and evaluate factors associated with PD in hospitalized pediatric patients. DATA SOURCES: A systematic search of PubMed, Embase, Ovid Medline, Web- of-Science, Cochrane, CIHNAL, and Google Scholar databases was conducted for relevant studies (1990-2022). STUDY SELECTION: We included studies that compared pediatric patients with and without delirium. Reviews, editorials, congress abstracts, or studies that did not report factors for PD were excluded. No restrictions were imposed on language. DATA EXTRACTION: Title and abstract were independently screened by two reviewers. Individual characteristics, study design, and outcomes were independently extracted. DATA SYNTHESIS: Categorical dichotomous data were summarized across groups using Mantel-Haenszel odds ratios (ORs) with 95% 95% CIs. Either fixed-effect or random effects models were used as indicated by the results of a heterogeneity test. Of 1,846 abstracts, 24 studies were included. We identified 54 factors studied in univariate analyses, and 27 of these were associated with PD in multivariable analyses. In pooled analyses, greater odds of PD were associated with developmental delay (OR 3.98; 95% CI 1.54-10.26), need for mechanical ventilation (OR 6.02; 95% CI 4.43-8.19), use of physical restraints (OR 4.67; 95% CI 1.82-11.96), and receipt of either benzodiazepines (OR 4.10; 95% CI 2.48-6.80), opiates (OR 2.88; 95% CI 1.89-4.37), steroids (OR 2.02; 95% CI 1.47-2.77), or vasoactive medication (OR 3.68; 95% CI 1.17-11.60). CONCLUSIONS: In this meta-analysis, we identified seven factors associated with greater odds of developing delirium during pediatric critical illness.

Interobserver Agreement on Clinical Judgment of Work of Breathing in Spontaneously Breathing Children in the Pediatric Intensive Care Unit.

Clinical assessment of the work of breathing (WOB) remains a cornerstone in respiratory support decision-making in the pediatric intensive care unit (PICU). In this study, we determined the interobserver agreement of 30 observers (PICU physicians and nurses) on WOB and multiple signs of effort of breathing in 10 spontaneously breathing children admitted to the PICU. By reliability analysis, the agreement on overall WOB was poor to moderate, and only three separate signs of effort of breathing (breathing rate, stridor, and grunting) showed moderate-to-good interobserver reliability. We conclude that the interobserver agreement on the clinical WOB judgment among PICU physicians and nurses is low.

Effectiveness of a Ventilator Care Bundle to Prevent Ventilator-Associated Pneumonia at the PICU: A Systematic Review and Meta-Analysis.

OBJECTIVES: Ventilator-associated pneumonia is one of the most frequent hospital-acquired infections in mechanically ventilated children. We reviewed the literature on the effectiveness of ventilator care bundles in critically ill children. DATA SOURCES: Embase, Medline OvidSP, Web-of-Science, Cochrane Library, and PubMed were searched from January 1990 until April 2017. STUDY SELECTION: Studies were included if they met the following criteria: 1) implementation of a ventilator care bundle in PICU setting; 2) quality improvement or multicomponent approach with the (primary) objective to lower the ventilator-associated pneumonia rate (expressed as ventilator-associated pneumonia episodes/1,000 ventilator days); and 3) made a comparison, for example, with or without ventilator care bundle, using an experimental randomized or nonrandomized study design, or an interrupted-times series. Exclusion criteria were (systematic) reviews, guidelines, descriptive studies, editorials, or poster publications. DATA EXTRACTION: The following data were collected from each study: design, setting, patient characteristics (if available), number of ventilator-associated pneumonia per 1,000 ventilator days, ventilator-associated pneumonia definitions used, elements of the ventilator care bundle, and implementation strategy. Ambiguities about data extraction were resolved after discussion and consulting a third reviewer (M.N., E.I.) when necessary. We quantitatively pooled the results of individual studies, where suitable. The primary outcome, reduction in ventilator-associated pneumonia per 1,000 ventilator days, was expressed as an incidence risk ratio with a 95% CI. All data for meta-analysis were pooled by using a DerSimonian and Laird random effect model. DATA SYNTHESIS: Eleven articles were included. The median ventilator-associated pneumonia incidence decreased from 9.8 (interquartile range, 5.8-18.5) per 1,000 ventilator days to 4.6 (interquartile range, 1.2-8.6) per 1,000 ventilator days after implementation of a ventilator care bundle. The meta-analysis showed that the implementation of a ventilator care bundle resulted in significantly reduced ventilator-associated pneumonia incidences (incidence risk ratio = 0.45; 95% CI, 0.33-0.60; p < 0.0001; I = 55%). CONCLUSIONS: Implementation of a ventilator-associated pneumonia bundle has the potential to reduce the prevalence of ventilator-associated pneumonia in mechanically ventilated children.

Chronic Complications After Femoral Central Venous Catheter-related Thrombosis in Critically Ill Children.

Prescription of thromboprophylaxis is not a common practice in pediatric intensive care units. Most thrombi are catheter-related and asymptomatic, without causing acute complications. However, chronic complications of these (a)symptomatic catheter-related thrombi, that is, postthrombotic syndrome (PTS) and residual thrombosis have not been studied. To investigate these complications, critically ill children of 1 tertiary center with percutaneous inserted femoral central venous catheters (FCVCs) were prospectively followed. Symptomatic FCVC-thrombosis occurred in 10 of the 134 children (7.5%; 95% confidence interval [CI], 2.4-9.5). Only FCVC-infection appeared to be independently associated (P=0.001) with FCVC-thrombosis. At follow-up 2 of the 5 survivors diagnosed with symptomatic thrombosis developed mild PTS; one of them had an occluded vein on ultrasonography. A survivor without PTS had a partial occluded vein at follow-up. Asymptomatic FCVC-thrombosis occurred in 3 of the 42 children (7.1%; 95% CI, 0.0-16.7) screened by ultrasonography within 72 hours after catheter removal. At follow-up, mild PTS was present in 6 of the 33 (18.2%; 95% CI, 6.1-30.3) screened children. Partial and total vein occlusion was present in 1 (3%) and 4 (12%) children, respectively. In conclusion, children on pediatric intensive care units are at risk for (a)symptomatic FCVC-thrombosis, especially children with FCVC-infection. Chronic complications of FCVC-thrombosis are common. Therefore, thromboprophylaxis guidelines are warranted in pediatric intensive care units to minimize morbidity as a result of FCVC-thrombosis.

Differences in the perceptions of parents and healthcare professionals on pediatric intensive care practices.

OBJECTIVE: To explore similarities and differences in perceptions on pediatric intensive care practices between parents and staff by using data from two studies. DESIGN: A two-round Delphi method among nurses and physicians followed by an empiric survey among parents. SETTINGS: Pediatric intensive care units at eight university medical centers. SUBJECTS: Parents whose child has been admitted to a pediatric intensive care unit, nurses, and physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Outcome measures were 74 satisfaction-with-care items divided into five domains: 1) information; 2) care and cure; 3) organization; 4) parental participation; and 5) professional attitude. The Delphi study was completed by 218 nurses and 46 physicians and the survey by 559 of 1042 (54%) parents. Parents rated 31 items more important than the professionals based on the standardized mean difference (Cohen's d, 0.21-1.18, p < .003). Ten of these were related to information provision. Information on the effects of medication had the largest effect size (Cohen's d 1.18, p = .001). Correct medication administration by professionals was also rated significantly more important by parents (Cohen's d 0.64, p = .001). The professionals rated 12 items more important than the parents (Cohen's d -0.23 to -0.73, p < .005), including three about multicultural care. Significant differences remained on two of the three multicultural care items when the Dutch (n = 483) and non-Dutch parents (n = 76) were separately compared with professionals. On the domain level, parents rated the domains information and parental participation more important than the professionals (Cohen's d 0.36 and 0.26, p = .001). CONCLUSIONS: Compared with the parents' perceptions, nurses and physicians undervalued a substantial number of pediatric intensive care unit care items. This finding may reflect a gap in the understanding of parental experiences as well as incongruity in recognizing the needs of parents.

Construction and psychometric testing of the EMPATHIC questionnaire measuring parent satisfaction in the pediatric intensive care unit.

PURPOSE: To construct and test the reliability and validity of the EMpowerment of PArents in THe Intensive Care (EMPATHIC) questionnaire measuring parent satisfaction in the pediatric intensive care unit (PICU). METHODS: Structured development and psychometric testing of a parent satisfaction-with-care instrument with the results of two cohorts of parents (n = 2,046) from eight PICUs in the Netherlands. RESULTS: In the first cohort, 667/1,055 (63%) parents participated followed by 551/991 (56%) parents in the second cohort. The empirical structure of the instrument was established by confirmatory factor analysis with the first sample of parents confirming 65 statements within five theoretically conceptualized domains: information, care and cure, organization, parental participation, and professional attitude. The standardized factor loadings were greater than 0.40 in 63 statements. Cronbach's α, a measure of reliability, per domain ranged from 0.73 to 0.93 in both cohorts with no significant difference documenting the reliability over time. Beside rigorous content and face validity, the congruent validity of the instrument showed adequate correlation with four gold standard questions measuring overall satisfaction. The non-differential validity was confirmed with no significant differences between the population characteristics and the domains, except that parents with a child for a surgical admission were more satisfied on information issues. CONCLUSIONS: The final EMPATHIC questionnaire incorporates 65 statements. The empirical structure of the satisfaction statements and domains was satisfactory. The reliability and validity proved to be adequate. The EMPATHIC questionnaire is a valid quality performance indicator to measure quality of care as perceived by parents.

Safety as a criterion for quality: the critical nursing situation index in paediatric critical care, an observational study.

INTRODUCTION: The Critical Nursing Situation Index (CNSI) identifies deviations from safe practice as laid down in guidelines, using an observational approach. The CNSI contains a list of predefined items that stem from nursing protocols and guidelines. Deviation from these may lead to adverse events and compromise the safety of the patient. OBJECTIVE: To prevent and reduce nursing error we applied the "Critical Nursing Situation Index" in the Paediatric Intensive Care Unit (PICU). DESIGN: Prospective observational study. SETTING: A 12-bed PICU of an academic university teaching hospital in the Netherlands. RESULTS: Out of 7147 items at risk we observed 1285 critical situations. The overall incidence of critical situations resulted in 18 per 100 items at risk. No correlation was found with effective time of direct patient care. Workload showed a significant correlation (Pearson's r .278; p=.001). CONCLUSION: In every day PICU practice an unknown set of nursing situations exist, carrying the potential for the occurrence of an adverse event. The CNSI may be a valuable tool in analysing the incidence of these situations. The CNSI is a practical instrument used to quantify and analyse the frequency of potential nursing errors. It focuses on identifying events that could reduce patient's safety, before harm occurs.

Nutritional goals, prescription and delivery in a pediatric intensive care unit.

BACKGROUND & AIMS: The aim of this study was to compare prescription and delivery of nutrition to predefined nutritional targets, and identify risk factors associated with inadequate nutritional intake. METHODS: In 84 mechanically ventilated critically ill children with length of stay on the PICU of at least 3 days, we observed prescribed and delivered percentages of predefined targets for intake of calories and macronutrients during a 10-months study period. Factors associated with inadequate intake were identified. RESULTS: On the third day of admission 92.9% of the patients received nutritional therapy. The caloric goal was reached on day 5, mainly supplied by fat and carbohydrates. Mean actual daily protein delivery was about 75% of the target during the entire study period. Use of catecholamines or neuromuscular blocking agents was a risk factor for caloric undernutrition, whereas there were no specific risk factors for overnutrition. CONCLUSIONS: Nutritional therapy should be started in the early phase of critical illness, including adequate supply of protein. In order to prevent deficits to accumulate, parenteral nutrition should be added in an early phase, if nutritional needs cannot be met by enteral nutrition.

Randomized controlled trial of aerosolized prostacyclin therapy in children with acute lung injury.

OBJECTIVES: To investigate whether aerosolized prostacyclin improves oxygenation in children with acute lung injury. DESIGN: Double-blind, randomized, and placebo-controlled trial. SETTING: Pediatric intensive care unit at a university hospital. PATIENTS: Fourteen children with acute lung injury defined by the criteria of an American-European Consensus Conference. INTERVENTIONS: Aerosolized prostacyclin (epoprostenol sodium) by stepwise increments of different doses (10, 20, 30, 40, and 50 ng x kg x min) vs. aerosolized normal saline (placebo). MEASUREMENTS AND MAIN RESULTS: Before the start of the study, and before and after each dose of prostacyclin/placebo, the following variables were measured: arterial blood gases, heart rate, mean arterial blood pressure, and ventilator settings required. Changes in oxygenation were measured by calculation of the oxygenation index (mean airway pressure x 100 x Pao2/Fio2). After treatment with aerosolized prostacyclin, there was a significant 26% (interquartile range, 3%, 35%) improvement in oxygenation index at 30 ng x kg x min compared with placebo (p =.001). The response to prostacyclin was not the same in all children. We saw an improvement of > or = 20% in eight of 14 children (i.e., responders), and the number needed to treat was 1.8 (95% confidence interval, 1.2-3.2). No adverse effects were observed. CONCLUSIONS: Aerosolized prostacyclin improves oxygenation in children with acute lung injury. Future trials should investigate whether this treatment will positively affect outcome.