Defining Pediatric Chronic Critical Illness: A Scoping Review.

OBJECTIVES: Children with chronic critical illness (CCI) are hypothesized to be a high-risk patient population with persistent multiple organ dysfunction and functional morbidities resulting in recurrent or prolonged critical care; however, it is unclear how CCI should be defined. The aim of this scoping review was to evaluate the existing literature for case definitions of pediatric CCI and case definitions of prolonged PICU admission and to explore the methodologies used to derive these definitions. DATA SOURCES: Four electronic databases (Ovid Medline, Embase, CINAHL, and Web of Science) from inception to March 3, 2021. STUDY SELECTION: We included studies that provided a specific case definition for CCI or prolonged PICU admission. Crowdsourcing was used to screen citations independently and in duplicate. A machine-learning algorithm was developed and validated using 6,284 citations assessed in duplicate by trained crowd reviewers. A hybrid of crowdsourcing and machine-learning methods was used to complete the remaining citation screening. DATA EXTRACTION: We extracted details of case definitions, study demographics, participant characteristics, and outcomes assessed. DATA SYNTHESIS: Sixty-seven studies were included. Twelve studies (18%) provided a definition for CCI that included concepts of PICU length of stay (n = 12), medical complexity or chronic conditions (n = 9), recurrent admissions (n = 9), technology dependence (n = 5), and uncertain prognosis (n = 1). Definitions were commonly referenced from another source (n = 6) or opinion-based (n = 5). The remaining 55 studies (82%) provided a definition for prolonged PICU admission, most frequently greater than or equal to 14 (n = 11) or greater than or equal to 28 days (n = 10). Most of these definitions were derived by investigator opinion (n = 24) or statistical method (n = 18). CONCLUSIONS: Pediatric CCI has been variably defined with regard to the concepts of patient complexity and chronicity of critical illness. A consensus definition is needed to advance this emerging and important area of pediatric critical care research.

Autoresuscitation after circulatory arrest: an updated systematic review.

PURPOSE: Current practice in organ donation after death determination by circulatory criteria (DCD) advises a five-minute observation period following circulatory arrest, monitoring for unassisted resumption of spontaneous circulation (i.e., autoresuscitation). In light of newer data, the objective of this updated systematic review was to determine whether a five-minute observation time was still adequate for death determination by circulatory criteria. SOURCE: We searched four electronic databases from inception to 28 August 2021, for studies evaluating or describing autoresuscitation events after circulatory arrest. Citation screening and data abstraction were conducted independently and in duplicate. We assessed certainty in evidence using the GRADE framework. PRINCIPAL FINDINGS: Eighteen new studies on autoresuscitation were identified, consisting of 14 case reports and four observational studies. Most studies evaluated adults (n = 15, 83%) and patients with unsuccessful resuscitation following cardiac arrest (n = 11, 61%). Overall, autoresuscitation was reported to occur between one and 20 min after circulatory arrest. Among all eligible studies identified by our reviews (n = 73), seven observational studies were identified. In observational studies of controlled withdrawal of life-sustaining measures with or without DCD (n = 6), 19 autoresuscitation events were reported in 1,049 patients (incidence 1.8%; 95% confidence interval, 1.1 to 2.8). All resumptions occurred within five minutes of circulatory arrest and all patients with autoresuscitation died. CONCLUSION: A five-minute observation time is sufficient for controlled DCD (moderate certainty). An observation time greater than five minutes may be needed for uncontrolled DCD (low certainty). The findings of this systematic review will be incorporated into a Canadian guideline on death determination. STUDY REGISTRATION: PROSPERO (CRD42021257827); registered 9 July 2021.

RéSUMé: OBJECTIF: La pratique actuelle en matière de don d'organes après une détermination du décès par critères circulatoires (DCC) préconise une période d'observation de cinq minutes après l'arrêt circulatoire et le monitorage de la reprise non assistée de la circulation spontanée (c.-à-d. l'auto-réanimation). À la lumière de données plus récentes, l'objectif de cette revue systématique mise à jour était de déterminer si un temps d'observation de cinq minutes était toujours suffisant pour une détermination de décès selon des critères circulatoires (DCC). SOURCES: Nous avons effectué des recherches dans quatre bases de données électroniques depuis leur création jusqu'au 28 août 2021 pour en tirer les études évaluant ou décrivant des événements d'autoréanimation après un arrêt circulatoire. L'examen des citations et l'extraction des données ont été réalisés de manière indépendante et en double. Nous avons évalué la certitude des données probantes à l'aide de la méthodologie GRADE. CONSTATATIONS PRINCIPALES: Dix-huit nouvelles études sur l'autoréanimation ont été identifiées, comprenant 14 présentations de cas et quatre études observationnelles. La plupart des études ont évalué des adultes (n = 15, 83 %) et les patients dont la réanimation avait échoué à la suite d'un arrêt cardiaque (n = 11, 61 %). Dans l'ensemble, l'autoréanimation a été signalée entre une et 20 minutes après l'arrêt circulatoire. Parmi toutes les études admissibles identifiées par nos comptes rendus (n = 73), sept études observationnelles ont été identifiées. Dans les études observationnelles sur l'interruption contrôlée des thérapies de maintien des fonctions vitales avec ou sans DCC (n = 6), 19 événements d'autoréanimation ont été rapportés chez 1049 patients (incidence 1,8 % ; intervalle de confiance à 95 %, 1,1 à 2,8). Toutes les reprises ont eu lieu dans les cinq minutes suivant l'arrêt circulatoire et tous les patients en autoréanimation sont décédés. CONCLUSION: Un temps d'observation de cinq minutes est suffisant pour un DCC contrôlé (certitude modérée). Un temps d'observation supérieur à cinq minutes peut être nécessaire en cas de DDC non contrôlé (faible certitude). Les résultats de cette revue systématique seront intégrés à des lignes directrices canadienne de pratique clinique sur la détermination du décès. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42021257827); enregistrée le 9 juillet 2021.

Prevalence of Acute Rehabilitation for Kids in the PICU: A Canadian Multicenter Point Prevalence Study.

OBJECTIVES: To evaluate mobilization practices, barriers, and mobility-related adverse events in Canadian PICUs. DESIGN: National 2-day point prevalence study. SETTING: Thirteen PICUs across Canada. PATIENTS: Children with a minimum 72-hour PICU length of stay on the allocated study day. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Outcomes of interest were the prevalence and nature of mobilization activities, rehabilitation resources, adverse events, and factors associated with out-of-bed mobility and therapist-provided mobility. Two PICUs (15%) had early mobilization practice guidelines, and one PICU (8%) reported a formal process for engaging families in the mobilization of patients. The prevalence of mobilization was 110 of 137 patient-days (80%). The commonest activity was out-of-bed mobility (87/137; 64% patient-days); there was no active mobilization on 46 patient-days (34%). Therapists provided mobility on 33% of patient-days. Mobility was most commonly facilitated by nurses (74% events) and family (49% events). Family participation was strongly associated with out-of-bed mobility (odds ratio 6.4; p = 0.001). Intubated, mechanically ventilated patients were mobilized out-of-bed on 18 of 50 patient-days (36%). However, the presence of an endotracheal tube, vasoactive infusions, and age greater than or equal to 3 years were independently associated with not being mobilized out-of-bed. Barriers were reported on 58 of 137 patient-days (42%), and adverse events occurred in 22 of 387 mobility events (6%). CONCLUSIONS: Mobilization is common and safe, and the majority of children in Canadian PICUs are being mobilized out-of-bed, even when mechanically ventilated. Family engagement in PICU-based rehabilitation is increasing. This study provides encouraging evidence that common barriers can be overcome in order to safely mobilize children in PICUs.

Vomiting and Cardiac Arrest in a 10-Year-Old Girl.

ABSTRACT: Primary adrenal insufficiency is a potentially life-threatening condition that provides a diagnostic challenge because many patients have months to years of insidious symptomatology. Adrenal crisis is the extreme acute manifestation of primary adrenal insufficiency, presenting with any, or all, of severe weakness, altered mental status, hypotension, and rarely cardiorespiratory arrest. Primary adrenal insufficiency should be considered in patients with clinical features of glucocorticoid and/or mineralocorticoid deficiency. These features however, such as hyperpigmentation, may be subtle, and so a degree of suspicion is needed to make the diagnosis. In extremis, children may present with fluid and catecholamine refractory shock. The management of an adrenal crisis includes prompt delivery of stress-dose corticosteroids together with aggressive organ support and correction of metabolic and electrolyte disturbances. We report the case of a previously healthy 10-year-old child that presented to a community emergency department in pulseless arrest, in whom adrenal crisis was suspected as well as treated early, and was subsequently successfully resuscitated.

Comparator Groups in ICU-Based Studies of Physical Rehabilitation: A Scoping Review of 125 Studies.

To characterize comparator groups (CGs) in ICU-based studies of physical rehabilitation (PR), including the type, content, and reporting. DATA SOURCES: We followed a five-stage scoping review methodology, searching five databases from inception to June 30, 2022. Study selection and data extraction were completed independently, in duplicate. STUDY SELECTION: We screened studies by title and abstract, then full-text. We included prospective studies with greater than or equal to two arms enrolling mechanically ventilated adults (≥ 18 yr), with any planned PR intervention initiated in the ICU. DATA EXTRACTION: We conducted a quantitative content analysis of authors' description of CG type and content. We categorized similar CG types (e.g., usual care), classified content into unique activities (e.g., positioning), and summarized these data using counts (proportions). We assessed reporting using Consensus on Exercise Reporting Template (CERT; proportion of reported items/total applicable). DATA SYNTHESIS: One hundred twenty-five studies were included, representing 127 CGs. PR was planned in 112 CGs (88.2%; 110 studies), representing four types: usual care (n = 81, 63.8%), alternative treatment than usual care (e.g., different from intervention; n = 18, 14.2%), alternative treatment plus usual care (n = 7, 5.5%), and sham (n = 6, 4.7%). Of 112 CGs with planned PR, 90 CGs (88 studies) reported 60 unique activities, most commonly passive range of motion (n = 47, 52.2%). The remaining 22 CGs (19.6%; 22 studies) reported vague descriptions. PR was not planned in 12 CGs (9.5%; 12 studies), and three CGs (2.4%; three studies) reported no details. Studies reported a median (Q1-Q3) of 46.6% (25.0-73.3%) CERT items. Overall, 20.0% of studies reported no detail to understand planned CG activities. CONCLUSIONS: The most common type of CG was usual care. We identified heterogeneity in planned activities and CERT reporting deficiencies. Our results could help guide the selection, design, and reporting of CGs in future ICU-based PR studies.

Measurement and reporting of physical rehabilitation interventions in pediatric critical care: a scoping review.

PURPOSE: To describe and evaluate physical rehabilitation research in critically ill children, including physical rehabilitation intervention reporting. METHODS: We searched five electronic databases to 31 December 2018 for prospective physical rehabilitation studies conducted in pediatric intensive care units (PICU). Screening was conducted independently in duplicate. Study characteristics, outcomes, and interventions were extracted from included studies. Quality of study reporting was assessed using standardized tools. Completeness of physical rehabilitation intervention reporting was assessed using the Consensus on Exercise Reporting Template (CERT). RESULTS: We included 20 studies enrolling a total of 2644 patients. Median (Q1,Q3) sample size was 57 (44,104). Seven studies (35%) were randomized controlled trials. Eleven studies (55%) evaluated respiratory interventions, most commonly multicomponent chest physiotherapy (73%). Nine studies (45%) evaluated physical activity interventions, most commonly progressive mobility (56%). The majority of stated outcomes (92.5%) were limited to the PICU setting. Median [Q1,Q3] quality of study reporting was good (77.2% [66.7%,87.4%]), and completeness of physical rehabilitation intervention reporting was moderate (61.9% [45.9%,71.5%]). CONCLUSION: Physical rehabilitation studies in critically ill children were small, and focused on evaluating respiratory-based interventions and short-term PICU-based outcomes. Reporting of physical rehabilitation interventions was suboptimal. Use of CERT may improve design and reporting in future studies.Implications for rehabilitationWhile physical rehabilitation research in critically ill children is a growing field, there are currently few studies evaluating physical rehabilitation interventions in this population.Physical rehabilitation studies to date have been small, focused on evaluating respiratory-based interventions and short-term outcomes limited to the PICU setting.The reporting of physical rehabilitation interventions in this population is suboptimal, making it challenging for clinicians to reproduce interventions and appraise their efficacy or safety.

Physical rehabilitation interventions in the intensive care unit: a scoping review of 117 studies.

BACKGROUND: Physical rehabilitation (PR) interventions in the intensive care unit (ICU) can improve patients' functional outcomes, yet systematic reviews identified discordant effects and poor reporting. We conducted a scoping review to determine the extent of ICU PR interventions and how they were reported and measured. METHODS: We searched five databases from inception to December 2016 for prospective studies evaluating adult ICU PR interventions. Two independent reviewers screened titles, abstracts, and full texts for inclusion. We assessed completeness of reporting using the Consolidated Standards of Reporting Trials, Strengthening the Reporting of Observational Studies in Epidemiology, or Standards for Quality Improvement Reporting Excellence guidelines, as appropriate. For planned PR interventions, we evaluated reporting with the Consensus on Exercise Reporting Template (CERT) and assessed intervention and control groups separately. We calculated completeness of reporting scores for each study; scores represented the proportion of reported items. We compared reporting between groups using Kruskal-Wallis with Bonferroni corrections and t tests, α = 0.05. RESULTS: We screened 61,774 unique citations, reviewed 1429 full-text publications, and included 117: 39 randomized trials, 30 case series, 9 two-group comparison, 14 before-after, and 25 cohort. Interventions included neuromuscular electrical stimulation (NMES) (14.5%), passive/active exercises (15.4%), cycling (6.8%), progressive mobility (32.5%), and multicomponent (29.9%). The median (first,third quartiles) study reporting score was 75.9% (62.5, 86.7) with no significant differences between reporting guidelines. Of 87 planned intervention studies, the median CERT score was 55.6%(44.7,75.0); cycling had the highest (85.0%(62.2,93.8)), and NMES and multicomponent the lowest (50.0% (39.5, 70.3) and 50.0% (41.5, 58.8), respectively) scores. Authors reported intervention groups better than controls (p < 0.001). CONCLUSIONS: We identified important reporting deficiencies in ICU PR interventions, limiting clinical implementation and future trial development.

Urgent ultrasound guided hemodynamic assessments by a pediatric medical emergency team: a pilot study.

PURPOSE: To determine the feasibility of using the Ultrasound Cardiac Output Monitor (USCOM) as an adjunct during hemodynamic assessments by a pediatric medical emergency team (PMET). METHODS: Pediatric in-patients at McMaster Children's Hospital aged under 18 years requiring urgent PMET consultation, were eligible. Patients with known cardiac outflow valve defects, Pediatric Critical Care Unit in-patients, and those in cardiorespiratory arrest, were excluded. The primary outcome was feasibility, and the ease of USCOM transport and application as assessed by a self-administered user questionnaire. Secondary outcomes included the quality of USCOM measurements, and agreement in clinical versus USCOM-derived assessments. RESULTS: Forty-one patients from 85 eligible PMET consultations were enrolled between March and August 2011. A total of 55 USCOM assessments were performed on 36 of 41 (87.8%) participants. USCOM could not be completed in 5 (12.2%) participants due to patient agitation (n = 4) and emergent care (n = 1). USCOM was reported as easy to transport and apply by 97.4% and 94.7% of respondents respectively, not obstructive to patient care by 94.7%, and yielded timely measurements by 84.2% respondents. USCOM tracings were of good quality in 41 (75.9%) assessments. Agreement between clinical and USCOM-derived hemodynamic assessments by two independent raters was poor (Rater 1: κ = 0.094; Rater 2: κ = 0.146). CONCLUSION: USCOM can be applied by a PMET during urgent hemodynamic assessments in children. While USCOM has been validated in stable children, its role in guiding hemodynamic resuscitation and informing therapeutic goals in a hemodynamically unstable pediatric population requires further investigation.