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Persistence of Neuropsychological Deficits Following Pediatric Critical Illness
Abstract
To study 12-month persistence of neuropsychological deficits in PICU survivors.
Prospective follow-up study.
Two PICUs.
Children 5-16 years old with neuropsychological deficits 3-6 months following PICU care for meningoencephalitis, sepsis, and other critical illnesses (excluding other primary neurological disorders).
None.
Neuropsychological function was assessed using the Cambridge Neuropsychological Test Automated Battery, the Children's Memory Scale, and the Wechsler Abbreviated Scale of Intelligence or Wide Range Intelligence Test. Forty-seven of 88 PICU admitted children (53%) were identified as neuropsychologically impaired 3-6 months after discharge; of these, 23 provided 12-month follow-up data. In spite of significant improvements in measures of memory, there was little change in intelligence quotient and visual attention over the study period, and children's educational progress remained below expectation.
We found persistently reduced neuropsychological function following PICU admission in the critical illnesses under study.
... tion [1][2][3]. Several previous prospective and descriptive studies were conducted to illustrate the burden of physical, cognitive, and mental problems in PICU survivors [4][5][6][7][8][9][10][11][12]. ...
... This study revealed an incidence of 26.3% for cognitive dysfunction. Previous studies by Als et al. [8,9] revealed that children surviving critical illness scored lower on neuropsychologic and school performance measures that persisted until 12 months post-intensive care discharge. Another study by Ong et al. [2] demonstrated new cognitive problems in 3%-73% of PICU survivors using the Pediatric Cerebral Performance Category. ...
... The reason for the differences in incidence among the studies may be the various evaluation tools utilized. The Children Memory Scale implemented in the studies by Als et al. [8,9] was limited to children and adolescents ages five to 16 years and is not suitable for young children. Furthermore, the test consists of four batteries of subtests, which were time-consuming and required a high level of expertise [25]. ...
Background:
A novel comprehensive model called the VSCAREMD model has been proposed to detect post-intensive care syndrome (PICS) in children. This study aimed to outline the incidence of PICS in children using the VSCAREMD model and to describe the associated factors.
Methods.:
All children ages 1 month to 15 years and admitted to the intensive care unit for at least 48 hours were evaluated using the VSCAREMD model within 1 week of intensive care discharge. The VSCAREMD model is used for evaluating vaccination, sleep, and parental care burden, which includes daily activity and social interaction, rehabilitation requirements, hearing, mood, and development. Abnormal findings were assorted into four domains: physical, cognitive, mental, and social. Descriptive statistics were performed using chi-square, univariate, and multivariate analyses.
Results.:
A total of 78 of 95 children (82.1%) had at least one abnormal domain. Physical, cognitive, mental, and social morbidity were found in 64.2%, 26.3%, 13.7%, and 38.9% of the children, respectively. Prolonged intensive care unit stay greater than 7 days was associated with dysfunction in physical (adjusted odds ratio [aOR], 3.80; 95% confidence interval [CI], 1.31-11.00), cognitive (aOR, 10.11; 95% CI, 3.01-33.89), and social domains (aOR, 5.01; 95% CI, 2.01-12.73). Underlying medical conditions were associated with cognitive (aOR, 13.63; 95% CI, 2.64-70.26) and social morbidity (aOR, 2.81; 95% CI, 1.06-7.47).
Conclusion.:
: The incidence of PICS using the VSCAREMD model was substantially high and associated with prolonged intensive care. This model could help evaluate PICS in children.
... Recent paediatric studies have investigated physical [1,[10][11][12][13][14][15], neurocognitive [16][17][18], and psychological morbidities [19]. Significant study population variability and their outcome measures have caused many confounding factors [9]. ...
... Studies that have evaluated the PICU admission impact on health-related QoL, and cognitive abilities in children without pre-existing or concurrent neurological disorders are scarce [16][17][18]. We observed no statistically significant difference in IQ between patients and controls. ...
... As in our cohort, a slight male preponderance was observed in most paediatric PICU studies (54-65%) [12,13,16,18,22]. Our medical patients constituted only 38% of the cohort, and the rest were surgical patients. ...
Background
Advances in paediatric critical care have resulted in a reduction in mortality. This has shifted the focus to paediatric intensive care unit (PICU)-related morbidities and how to reduce or prevent them. In this study, we aimed to study the impact of paediatric intensive care unit (PICU) admission on neurocognitive performance.
Methods
Intelligence quotient (IQ) was tested in 50 children (27 boys, 23 girls; mean age 6.98 years) 3 months after PICU discharge and in 75 controls using the Stanford-Binet IQ test.
Results
There was no statistically significant difference between patients and controls with regard to IQ scores, and no difference between medical and surgical patients ( p > 0.05). IQ was unaffected by sedation, blood transfusion, or blood product transfusion. Patients who underwent a major surgical procedure, needed inotropic support, and needed mechanical ventilation had non-significantly lower IQ scores than those who did not. A non-significant negative correlation was observed between the length of PICU stay, mechanical ventilation duration, sedative use, and inotropic support.
Conclusions
PICU admission does not appear to significantly affect cognitive outcomes in paediatric survivors.
... Children have deficits in neuropsychologic performance and school performance Als et al [9] Prospective cohort 23 Jones et al [17] assessed outcomes at 6 mo after PICU admission based on the Health Utilities Index questionnaires returned by 1455 families of children six months and older. The Health Utilities Index examines sensation, cognition, emotion, pain, mobility and self care attributes. ...
... Interestingly, the nonneurologic/nonseptic critical care cohort did not show any difference in school performance compared to healthy controls. Finally, in a subsequent prospective followup study by Als et al [9] , the 23 of 47 children who were identified as neuropsychologically impaired at three to six months following PICU admission were then evaluated 12 mo after PICU discharge in order to better understand the persistence of these impairments. At the three to six month followup vs twelve month followup, there was no significant change in IQ scores; however, there was improvement in some verbal and visual memory domains. ...
... Of the three broad types of morbidity included in the definition of PICS, this review yielded the fewest number of articles related to neurocognitive morbidity after pediatric critical illness. The same team of authors published two papers assessing the neurocognitive function of schoolaged children at 3 to 6 mo and 12 mo after critical illness [7,9] . These patients were compared to healthy controls. ...
Aim:
To synthesize the available evidence focusing on morbidities in pediatric survivors of critical illness that fall within the defined construct of postintensive care syndrome (PICS) in adults, including physical, neurocognitive and psychological morbidities.
Methods:
A comprehensive search was conducted in MEDLINE, EMBASE, the Cochrane Library, PsycINFO, and CINAHL using controlled vocabulary and key word terms to identify studies reporting characteristics of PICS in pediatric intensive care unit (PICU) patients. Two reviewers independently screened all titles and abstracts and performed data extraction. From the 3176 articles identified in the search, 252 abstracts were identified for full text review and nineteen were identified for inclusion in the review. All studies reporting characteristics of PICS in PICU patients were included in the final synthesis.
Results:
Nineteen studies meeting inclusion criteria published between 1995 and 2016 were identified and categorized into studies reporting morbidities in each of three categories-physical, neurocognitive and psychological. The majority of included articles reported prospective cohort studies, and there was significant variability in the outcome measures utilized. A synthesis of the studies indicate that morbidities encompassing PICS are well-described in children who have survived critical illness, often resolving over time. Risk factors for development of these morbidities include younger age, lower socioeconomic status, increased number of invasive procedures or interventions, type of illness, and increased benzodiazepine and narcotic administration.
Conclusion:
PICS-related morbidities impact a significant proportion of children discharged from PICUs. In order to further define PICS in children, more research is needed using standardized tools to better understand the scope and natural history of morbidities after hospital discharge. Improving our understanding of physical, neurocognitive, and psychological morbidities after critical illness in the pediatric population is imperative for designing interventions to improve long-term outcomes in PICU patients.
... The pediatric intensive care unit (PICU) literature reflects a shift of focus from short term outcomes to what we now know as 'Post-Intensive Care Syndrome in pediatrics' (PICSp), which encompasses the four domains of cognitive, physical, socioemotional and communication impairments [69]. Whilst this evidence is still evolving, the current summary of work suggests an incidence of up to approximately 30% in PICU survivors [54,[70][71][72][73][74][75][76][77][78][79][80]. Retrospective studies exploring the impact of a PICU admission show a significantly higher incidence of mental health diagnoses and psychotropic medication use in survivors [81], particularly in those with respiratory illness requiring invasive mechanical ventilation. ...
... Evidence suggests that psychosocial support during hospitalization, including mindfulness [136][137][138] and education to improve problem-based coping strategies [139,140] and mental health literacy [141,142], is associated with improved psychological symptoms and post-traumatic stress symptoms [143,144], in addition to child externalizing and internalizing behaviors [70,145]. PICU parent interventions encouraging soothing touch and talk while their child undergoes invasive procedures [146], increasing parents' involvement in decision-making regarding their child's care [147], and combinations of psychoeducation during admission with follow-up post-discharge [148], have reduced physiological arousal in children, and resulted in better psychological outcomes in both parents and children post-discharge. ...
Major advances in pediatric intensive care (PICU) have led to increased child survival. However, the long-term outcomes among these children following PICU discharge are a concern. Most children admitted to PICU are under five years of age, and the stressors of critical illness and necessary interventions can affect their ability to meet crucial developmental milestones. Understanding the neuroscience of brain development and vulnerability can inform PICU clinicians of new ways to enhance and support the care of these most vulnerable children and families. This review paper first explores the evidence-based neuroscience principles of brain development and vulnerability and the impact of illness and care on children’s brains and ultimately wellbeing. Implications for clinical practice and training are further discussed to help optimize brain health in children who are experiencing and surviving a critical illness or injury.
... Twelve articles ( Fig. 1; and Supplemental Table 1, Supplemental Digital Content 1, http://links.lww.com/PCC/A590) met the established inclusion/exclusion criteria and were rated for quality (46)(47)(48)(49)(50)(51)(52)(53)(54)(55)(56)(57). The studies were all observational studiessix case-control and six prospective cohort. ...
... Seven studies assessed some aspect of memory, with three (all case-control) finding a significantly lower score in spatial working memory (47,49,56). These three studies all used either the CMS and/or the Cambridge Neuropsychological Test Automated Battery, both of which include many subtests. ...
Objectives:
To identify risk factors associated with cognitive impairment as assessed by neuropsychologic tests in neurotypical children after critical illness.
Data sources:
For this systematic review, we searched the Cochrane Library, Scopus, PubMed, Ovid, Embase, and CINAHL databases from January 1960 to March 2017.
Study selection:
Included were studies with subjects 3-18 years old at the time of post PICU follow-up evaluation and use of an objective standardized neuropsychologic test with at least one cognitive functioning dimension. Excluded were studies featuring patients with a history of cardiac arrest, traumatic brain injury, or genetic anomalies associated with neurocognitive impairment.
Data extraction:
Twelve studies met the sampling criteria and were rated using the Newcastle-Ottawa Quality Assessment Scale.
Data synthesis:
Ten studies reported significantly lower scores in at least one cognitive domain as compared to healthy controls or normed population data; seven of these-four case-control and three prospective cohort studies-reported significant lower scores in more than one cognitive domain. Risk factors associated with post critical illness cognitive impairment included younger age at critical illness and/or older age at follow-up, low socioeconomic status, high oxygen requirements, and use of mechanical ventilation, sedation, and pain medications.
Conclusions:
Identifying risk factors for poor cognitive outcomes post critical illness may help healthcare teams modify patient risk and/or provide follow-up services to improve long-term cognitive outcomes in high-risk children.
... HADS is a self-assessment tool validated for measuring nonphysical symptoms in clinical settings. 51 Pooling HADS anxiety subscale scores from 4 studies, 20,22,24,52 no significant difference in anxiety scores were found between PICU parents at 3 to 6 months versus 6 to 12 months followup (7.7 [7.1 to 8.2] vs 8.2 [5.9 to 10.4], P 5 .67) (Fig 3A). ...
BACKGROUND
Pediatric critical illness exposes family members to stressful experiences that may lead to subsequent psychological repercussions.
OBJECTIVE
To systematically review psychological outcomes among PICU survivors’ family members.
DATA SOURCES
Four medical databases (PubMed, Embase, CINAHL and PsycInfo) were searched from inception till October 2023.
STUDY SELECTION
Studies reporting psychological disorders in family members of PICU patients with at least 3 months follow-up were included. Family members of nonsurvivors and palliative care patients were excluded.
DATA EXTRACTION
Screening and data extraction was performed according to PRISMA guidelines. Data were pooled using a random-effects model.
RESULTS
Of 5360 articles identified, 4 randomized controlled trials, 16 cohort studies, and 2 cross-sectional studies were included (total patients = 55 597; total family members = 97 506). Psychological distress was reported in 35.2% to 64.3% and 40.9% to 53% of family members 3 to 6 months and 1 year after their child’s PICU admission, respectively. Post-traumatic stress disorder was diagnosed in 10% to 48% of parents 3 to 9 months later. Parents that experienced moderate to severe anxiety and depression 3 to 6 months later was 20.9% to 42% and 6.1% to 42.6%, respectively. Uptake of mental counseling among parents was disproportionately low at 0.7% to 29%. Risk factors for psychiatric morbidity include mothers, parents of younger children, and longer duration of PICU stay.
LIMITATIONS
The majority of studies were on parents with limited data on siblings and second degree relatives.
CONCLUSIONS
There is a high burden of psychological sequelae in family members of PICU survivors. Risk stratification to identify high-risk groups and early interventions are needed.
... In relation to child cognitive outcomes after PICU discharge, a systematic review reported cognitive impairment ranges from 3% (significant cognitive decline) to 73% (some degree of impairment), depending on the child's age and the specific outcome measured [10]. Cognitive outcomes included impairment in cognitive ability [10,17], impaired neuropsychological function up to 6 months after discharge, and changes in intelligence quotient and visual attention up to 12 months after PICU discharge [10,18]. Underperformance in school and impaired neuropsychological measures have been reported in PICU survivors aged 5 to 16 years [19]. ...
Background
The post-intensive care syndrome in pediatrics (PICS-p) framework offers a new understanding of the long-term impact of critical illness on child’s and family’s health. However, a comprehensive theoretical guide to investigate potential factors influencing these outcomes and recoveries is needed.
Objective
The aim of the study is to conceptualize post-intensive care outcomes in children and their families after PICU discharge in the context of the child’s surrounding environment and systems.
Method
We used Theory Adaptation, a shift in the use and perspective of the Bioecological Theory of Human Development (BTHD), and Theory Synthesis, the integration of BTHD and the PICS-p, to provide a novel PICSS-PF perspective for understanding PICS-p within the broader context of the child and family. This integration helps to see higher-order perspectives to link post-PICU outcomes and child development within the context of child’s surroundings.
Results
While PICS-p is a model for understanding and studying post-PICU outcomes and recovery in four domains of physical, cognitive, emotional, and social health, the BTHD offers a new lens for a holistic view of the contextual systems and factors affecting the outcomes and recovery. The BTHD contextual systems include intrapersonal (demographics, clinical), interpersonal (adjacent people’s characteristics and interactions), institutional (family situations, PICU environment), community, social resources, and networks.
Conclusions
Knowing the complex nature of post-PICU outcomes in children and their families, the PICSS-PF helps in the better understanding of the complex interplay of factors that contribute to PICS in children and their families, leading to the development of more effective interventions to address this condition.
... In addition, norepinephrine, while increasing mean arterial pressure (MAP), has been shown to restore cerebral blood flow (CBF), when estimated using TCD not NIRS (9). Critically ill children without previous neurologic dysfunction are exposed to acute brain injury and subsequent neurodevelopmental challenges that may be attributed to many factors including poor oxygen delivery (10)(11)(12), while norepinephrine hemodynamic effects are highly variable and unpredictable in this population (13). ...
Background:
Cerebral hypoperfusion and impaired oxygen delivery during pediatric critical illness may result in acute neurologic injury with subsequent long-term effects on neurodevelopmental outcome. Yet, the impact of norepinephrine on cerebral hemodynamics is unknown in children with shock. We aimed to describe the norepinephrine effects on cerebral perfusion and oxygenation during pediatric shock.
Patients and methods:
We conducted an observational multicentre prospective study in 3 French pediatric intensive care units. Children <18 years of age excluding traumatic brain injury were included in the study if they need norepinephrine for shock. Systemic and cerebral hemodynamics were compared between the time of initiation of norepinephrine (T0), and the steady-state (Tss). Cardiac output (CO) was measured using ultrasound. Cerebral perfusion was assessed on middle cerebral arteries (MCA) using transcranial doppler ultrasound. Cerebral tissue oxygen saturation (rScO2) was recorded using near infrared spectroscopy, and we calculated cerebral fractional tissue oxygen extraction (cFTOE = SpO2-rScO2/SpO2).
Main results:
Fourteen children (median [IQR] age of 3.5[1; 13.5] years) were included. Norepinephrine at 0.2[0.1; 0.32] μg/kg/min significantly increased mean arterial blood pressure (61[56; 73] mmHg at Tss vs. 49[42;54] mmHg at T0, p=10-3) without change of CO. MCA velocities, pulsatility index, rScO2, and cFTOE did not significantly change between T0 and Tss. Some individuals observed variations in estimated CBF, which slightly improved in 7 patients, remained unchanged in 5, and was impaired in 2. No patient experienced significant variations of rScO2.
Conclusions:
Low-dosing norepinephrine, despite a homogeneous and significant increase in arterial blood pressure, had little effects on cerebral perfusion and oxygenation during pediatric shock. This reinforces the need for personalized tailored therapies in this population.
Trial registration:
Clinicaltrials.gov, NCT03731104. Registered 6 November, 2018. https://clinicaltrials.gov/ct2/show/NCT03731104.
... In patients one year or older at PICU admission, 11 studies were done (Supplemental Table 1a). Overall, studies reported lower scores compared to normative data regarding intelligence, processing speed, executive functioning, memory, attention, and (visuo)motor functioning (Table 1) [20][21][22][23][24][25][26][27][28][29][30]. In children with traumatic brain injury, 3 studies found lower scores than normative data regarding general intelligence [25][26][27], processing speed [26], executive functioning [26], working memory [26], and attention [25]. ...
Objective
This study systematically reviewed recent findings on neurocognitive functioning and health-related quality of life (HRQoL) of children after pediatric intensive care unit admission (PICU).
Data sources
Electronic databases searched included Embase, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar. The search was limited to studies published in the last five years (2015–2019).
Study selection
Original studies assessing neurocognitive functioning or HRQoL in children who were previously admitted to the PICU were included in this systematic review.
Data extraction
Of the 3649 identified studies, 299 met the inclusion criteria based on title abstract screening. After full-text screening, 75 articles were included in the qualitative data reviewing: 38 on neurocognitive functioning, 33 on HRQoL, and 4 on both outcomes.
Data synthesis
Studies examining neurocognitive functioning found overall worse scores for general intellectual functioning, attention, processing speed, memory, and executive functioning. Studies investigating HRQoL found overall worse scores for both physical and psychosocial HRQoL. On the short term (≤ 12 months), most studies reported HRQoL impairments, whereas in some long-term studies HRQoL normalized. The effectiveness of the few intervention studies during and after PICU admission on long-term outcomes varied.
Conclusions
PICU survivors have lower scores for neurocognitive functioning and HRQoL than children from the general population. A structured follow-up program after a PICU admission is needed to identify those children and parents who are at risk. However, more research is needed into testing interventions in randomized controlled trials aiming on preventing or improving impairments in critically ill children during and after PICU admission.
... T he PICU Up! quality-improvement (QI) initiative was developed and implemented by an interdisciplinary team in the Johns Hopkins PICU in 2015 (1). The program was developed in response to the increasing awareness that the established culture of sedation, immobility, and bed rest, coupled with the critical illness itself, was associated with numerous complications, including delirium and critical-illness acquired weakness, which may adversely affect physical, psychologic, and neurocognitive functions long after PICU discharge (2)(3)(4). This "postintensive care syndrome" not only affects the child's quality of life but also substantially impacts on their family (5). ...
... They reported some improvement in memory scores but that children still under performed at school. 77 Elison et al. conducted a small study on 16 patients with 16 healthy controls (children of hospital staff or recruited from a local school) using similar tests and also found poorer outcomes in the children admitted to PICU. 78 (7) CANTAB, Cambridge neuropsychological test-automated battery; IQ, intelligence quotient; PICU, paediatric intensive care unit; RCT, randomised controlled trial. ...
Aim:
To describe the long-term health outcomes of children admitted to a paediatric intensive care unit.
Methods:
A systematic review of the literature was performed. Studies of children under 18 years of age admitted to a paediatric intensive care unit were included. Studies focussed on neonatal admissions and investigating specific paediatric intensive care unit interventions or admission diagnoses were excluded. A table was created summarising the study characteristics and main findings. Risk of bias was assessed using the Newcastle Ottawa Quality Assessment Scale for observational studies. Primary outcome was short-, medium- and long-term mortality. Secondary outcomes included measures of neurodevelopment, cognition, physical, behavioural and psychosocial function as well as quality of life.
Results:
One hundred and eleven studies were included, most were conducted in high-income countries and focussed on short-term outcomes. Mortality during admission ranged from 1.3 to 50%. Mortality in high-income countries reduced over time but this trend was not evident for lower income countries. Higher income countries had lower standardised mortality rates than lower income countries. Children had an ongoing increased risk of death for up to 10 years following intensive care admission as well as increased physical and psychosocial morbidity compared to healthy controls, with associated poorer quality of life.
Conclusions:
There is limited high-level evidence for the long-term health outcomes of children after intensive care admission, with the burden of related morbidity remaining greater in poorly resourced regions. Further research is recommended to identify risk factors and modifiable factors for poor outcomes, which could be targeted in practice improvement initiatives.
... Search results are presented in Fig. 1. The patient populations and/or pathologies evaluated in the 66 studies included in the final review were: general PICU patients (n = 15 studies) [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23], seizures and/or status epilepticus (SE) (n = 7) [24-30], traumatic brain injury (TBI) (n = 17) [31-47], cardiac arrest (n = 22) , and infectious diseases (n = 5) [70][71][72][73][74]. ...
Purpose of review:
With increasing survival of children requiring admission to pediatric intensive care units (PICU), neurodevelopmental outcomes of these patients are an area of increased attention. Our goal was to systematically review recently published literature on neurologic outcomes of PICU patients.
Recent findings:
Decline in neurofunctional status occurs in 3%-20% of children requiring PICU care. This proportion varies based on primary diagnosis and severity of illness, with children admitted for primary neurologic diagnosis, children who suffer cardiac arrest or who require invasive interventions during the PICU admission, having worse outcomes. Recent research focuses on early identification and treatment of modifiable risk factors for unfavorable outcomes, and on long-term follow-up that moves beyond global cognitive outcomes and is increasingly including tests assessing multidimensional aspects of neurodevelopment.
Summary:
The pediatric critical care research community has shifted focus from survival to survival with favorable neurologic outcomes of children admitted to the PICU.
Pediatric intensive care is a rapidly developing medical specialty and with evolving understanding of pediatric pathophysiology and advances in technology, most children in the developed world are now surviving to intensive care and hospital discharge. As mortality rates for children with critical illness continue to improve, increasing PICU survivorship is resulting in significant long-term consequences of intensive care in these vulnerable patients. Although impairments in physical, psychosocial and cognitive function are well documented in the literature and the importance of establishing follow-up programs is acknowledged, no standardized or evidence-based approach to long-term follow-up in the PICU exists. This narrative review explores pediatric post-intensive care syndrome and summarizes the multifactorial deficits and morbidity that can occur in these patients following recovery from critical illness and subsequent discharge from hospital. Current practices around long-term follow-up are explored with discussion focusing on gaps in research and understanding with suggested ways forward and future directions.
To assess the effect of the Infant intensive care unit (InICU), a specialized unit for critically ill infants established in 2016 in authors’ hospital, on infant mortality and compare the outcome with the current Pediatric intensive care units (PICU).
In this retrospective cross-sectional study, two groups were defined; the first included expired patients aged 1 mo to 2 y admitted to PICU before the establishment of the InICU (the PICU group). The second included age-matched expired patients admitted to the InICU (the InICU group). Data were recorded using a questionnaire.
The authors found that the age, sex, underlying diseases, the leading cause of admission to the ICU, time of death, hospital and ICU length of stay, and the pediatric index of mortality 2 (PIM 2) score were same between the two groups. The incidence of mortality in the PICU group was 10.66 in 1000 person-month. This value was 6.37 for the InICU group (P-value <0.001). The relative risk of mortality of patients admitted to the PICU group compared to the InICU group was 1.67 (P-value <0.001).
Establishment of age specific InICU for infants may be beneficial in reducing infant mortality.
OBJECTIVES
To present the results of an abbreviated testing protocol used to screen for neurocognitive and psychological sequelae of critical illness among PICU survivors with acquired brain injury in our post-discharge follow-up programs and describe our process for facilitating this population’s return to academic life.
DESIGN
Retrospective cohort study.
SETTING
Neurocritical care follow-up programs at two U.S. academic, tertiary medical/surgical PICUs.
PATIENTS
Children greater than 4 years old enrolled in the neurocritical care follow-up programs ( n = 289) at these institutions who underwent neurocognitive and psychological testing between 2017 and 2021.
INTERVENTIONS
None.
MEASUREMENTS AND MAIN RESULTS
One month after discharge from the hospital, nearly half of the children and/or their parents (48%) in our neurocritical care follow-up programs identified some type of emotional or behavioral concern compared to their premorbid state, and 15% reported some type of cognitive concern. On evaluation, 35% of the children were given a new neurocognitive diagnosis. Neurocognitive domains regulated by the executive functioning system were the most commonly affected, including attention (54%), memory (31%), and processing speed (27%). One-quarter of the children were given a new psychological diagnosis, most commonly post-traumatic stress disorder or stress-related symptoms (12%). Over 80% of patients in the programs were given new recommendations for school, for both new academic services and new classroom accommodations. Over half of children (57%) were referred for comprehensive follow-up neuropsychological evaluation.
CONCLUSIONS
Abbreviated neurocognitive and psychological evaluation successfully identifies the same deficits commonly found among PICU survivors who undergo longer, more complete testing protocols. When combined with services aimed at successfully reintegrating PICU survivors back to school, this focused evaluation can provide an effective and efficient means of screening for cognitive and emotional deficits among PICU survivors and establish a rationale for early academic support upon the child’s return to school.
Introduction
Despite growing awareness of neurodevelopmental impairments in children with congenital heart disease (CHD), there is a lack of large, longitudinal, population-based cohorts. Little is known about the contemporary neurodevelopmental profile and the emergence of specific impairments in children with CHD entering school. The performance of standardised screening tools to predict neurodevelopmental outcomes at school age in this high-risk population remains poorly understood. The NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC) trial randomised 1371 children <2 years of age, investigating the effect of gaseous nitric oxide applied into the cardiopulmonary bypass oxygenator during heart surgery. The NITRIC follow-up study will follow this cohort annually until 5 years of age to assess outcomes related to cognition and socioemotional behaviour at school entry, identify risk factors for adverse outcomes and evaluate the performance of screening tools.
Methods and analysis
Approximately 1150 children from the NITRIC trial across five sites in Australia and New Zealand will be eligible. Follow-up assessments will occur in two stages: (1) annual online screening of global neurodevelopment, socioemotional and executive functioning, health-related quality of life and parenting stress at ages 2–5 years; and (2) face-to-face assessment at age 5 years assessing intellectual ability, attention, memory and processing speed; fine motor skills; language and communication; and socioemotional outcomes. Cognitive and socioemotional outcomes and trajectories of neurodevelopment will be described and demographic, clinical, genetic and environmental predictors of these outcomes will be explored.
Ethics and dissemination
Ethical approval has been obtained from the Children’s Health Queensland (HREC/20/QCHQ/70626) and New Zealand Health and Disability (21/NTA/83) Research Ethics Committees. The findings will inform the development of clinical decision tools and improve preventative and intervention strategies in children with CHD. Dissemination of the outcomes of the study is expected via publications in peer-reviewed journals, presentation at conferences, via social media, podcast presentations and medical education resources, and through CHD family partners.
Trial registration number
The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry as ‘Gene Expression to Predict Long-Term Neurodevelopmental Outcome in Infants from the NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC) Study – A Multicentre Prospective Trial’. Trial registration: ACTRN12621000904875.
Over two-thirds of pediatric critical illness survivors will experience functional impairments that persist after discharge, that is, post-intensive care syndrome in pediatrics (PICS-p). Risk factors include child and family characteristics, invasive procedures, and social determinants of health. Approaches to remediate PICS-p include early rehabilitation, minimizing sedation, psychosocial resources for caregivers, delivery of family-centered care, and longitudinal screening for PICS-p. Challenges include feasible and validated approaches to screening, and resources and coordination for multidisciplinary care. Next steps should include resources to identify and address adverse social determinants of health and examination of treatment efficacy and implementation equity.
The culture of sedation and immobilization in the pediatric intensive care unit (PICU) is associated with PICU-acquired weakness, delirium, and poor functional, neurocognitive and psychosocial outcomes. A structured approach to introducing physical activity, as early as possible after PICU admission, may prevent these complications and optimize the holistic outcomes of critically ill children. Changing culture and introducing new clinical practice in PICU is complex, but can be approached systematically, using a "nuts and bolts" approach targeting the basic, practical considerations and essential required elements or components. Extending the construction analogy, this article reviews the relevant literature to describe the essential elements required to build and sustain a successful and safe early mobility program in the PICU. Effective early mobilization requires individual patient assessment and goal setting, using a collaborative inter-disciplinary, patient- and family-centered approach, to ensure mobility goals and physical activities are appropriate for the patient's age, condition/s, premorbid function, strength, endurance and developmental level. Early mobility activities for the pediatric age spectrum include active or active-assisted range of motion exercises, neurodevelopmental play, use of mobility devices, in-bed exercises, transfers, sitting or standing tolerance, crawling, pre-gait activities, ambulation and activities of daily living, with a focus on play as function. Although there are few complete contraindications to early mobilization, appropriate precautions and preparation should be taken to mitigate potential safety concerns. Although there are many perceived barriers to early mobilization in the PICU, at the level of patient, provider, institution and knowledge translation; these are not objectively associated with increased risk during mobilization and can be overcome through an engaged process of practice change by all members of the interprofessional clinical team. Early mobility programs could be initiated in PICU as systematic quality improvement initiatives, with established processes to optimize structural, process and system elements and to provide continual feedback, measurement, benchmarking and collaboration; to ultimately impact on measurable patient outcomes. Early, graded, and individually prescribed mobilization should be considered as part of the standard PICU "package of care" for all critically ill and injured children, in order to improve their functional status and quality of life after PICU discharge.
This article aimed to summarize the impact and burden of pediatric post-intensive care syndrome (PICS-p) in the physical, mental, cognitive, and social health domains after a review of the current pediatric literature in MEDLINE and PubMed. We also aimed to elucidate the limitations of the current evaluation tools used in limited-resource settings. PICS-p can impact a child's life for decades. Most validated tools are time-consuming, require qualifications and expertise, are often limited to older children, and can evaluate only one domain. A novel, simple, and comprehensive surveillance tool can aid healthcare providers in the early detection and intervention of PICS-p. Further studies should validate and refine the parameters that will enhance the outcomes of pediatric intensive care unit survivors.
Objective:
To study the features of new-onset organ dysfunction in children with sepsis in the pediatric intensive care unit (PICU).
Methods:
A retrospective analysis was performed for the clinical data of children with sepsis who were admitted to the PICU from 2015 to 2016. There were 34 children with severe sepsis and 69 with non-severe sepsis, and the two groups were compared in terms of the incidence rate of new-onset organ dysfunction and the functional status on admission and at discharge.
Results:
The severe sepsis group had a significantly higher incidence rate of new-onset organ dysfunction than the non-severe sepsis group (38% vs 6%; P<0.05). The children in the non-severe sepsis group had a relatively good functional status on admission, with marked improvement in the overall functional status at discharge. The children in the severe sepsis group had a poor functional status on admission, with mild/moderate abnormalities in consciousness, sensation, communication and respiratory function at discharge.
Conclusions:
Children with non-severe sepsis have a low incidence rate of new-onset organ dysfunction and a good prognosis, and those with severe sepsis often have a high incidence rate of new-onset organ dysfunction and a poor prognosis.
Background:
Pediatric severe sepsis is a public health problem with significant morbidities in those who survive. In this article, we aim to present an overview of the important studies highlighting the limited data available pertaining to long-term outcomes of survivors of pediatric severe sepsis.
Materials and methods:
A review of literature available was conducted using PUBMED/Medline on pediatric severe sepsis outcomes. Long-term outcomes and health-related quality of life (HRQL) following severe sepsis was defined as any outcome occurring after discharge from the hospital following an episode of severe sepsis which affected either the survivor or the survivor's family members.
Results:
Many children are discharged with worse clinical and functional outcomes, depending on their diagnosis, treatments received, psychological effects, and the impact of their illness on their parents. Additionally, they utilize healthcare services more than their peers and are often readmitted soon after discharge. However, pediatric HRQL studies with worthwhile outcome measures are limited and the current data on pediatric sepsis is mainly retrospective.
Conclusions:
There is significant and longstanding morbidity seen in children and their families following a severe sepsis illness. Further prospective data are required to study the long-term outcomes of sepsis in the pediatric population.
The focus of critical care has evolved from saving lives to preservation of function. Morbidity rates in pediatric critical care are approximately double mortality rates. Morbidity includes complications of disease and medical care. In pediatric critical care, functional status morbidity is an intermediate outcome in the progression toward death and is the result of the same factors associated with mortality, including physiologic profiles and case-mix factors. The Functional Status Scale developed by Collaborative Pediatric Critical Care Research Network is a validated, granular, age-independent measure of functional status that has proved valuable and practical even in large outcome studies.
Objectives:
Delirium is prevalent among critically ill children, yet associated outcomes and modifiable risk factors are not well defined. The objective of this study was to determine associations between pediatric delirium and modifiable risk factors such as benzodiazepine exposure and short-term outcomes.
Design:
Secondary analysis of collected data from the prospective validation study of the Preschool Confusion Assessment Method for the ICU.
Setting:
Tertiary-level PICU.
Patients:
Critically ill patients 6 months to 5 years old.
Interventions:
None.
Measurements and main results:
Daily delirium assessments were completed using the Preschool Confusion Assessment Method for the ICU. Associations between baseline and in-hospital risk factors were analyzed for likelihood of ICU discharge using Cox proportional hazards regression and delirium duration using negative binomial regression. Multinomial logistic regression was used to determine associations between daily risk factors and delirium presence the following day. Our 300-patient cohort had a median (interquartile range) age of 20 months (11-37 mo), and 44% had delirium for at least 1 day (1-2 d). Delirium was significantly associated with a decreased likelihood of ICU discharge in preschool-aged children (age-specific hazard ratios at 60, 36, and 12 mo old were 0.17 [95% CI, 0.05-0.61], 0.50 [0.32-0.80], and 0.98 [0.68-1.41], respectively). Greater benzodiazepine exposure (75-25th percentile) was significantly associated with a lower likelihood of ICU discharge (hazard ratio, 0.65 [0.42-1.00]; p = 0.01), longer delirium duration (incidence rate ratio, 2.47 [1.36-4.49]; p = 0.005), and increased risk for delirium the following day (odds ratio, 2.83 [1.27-6.59]; p = 0.02).
Conclusions:
Delirium is associated with a lower likelihood of ICU discharge in preschool-aged children. Benzodiazepine exposure is associated with the development and longer duration of delirium, and lower likelihood of ICU discharge. These findings advocate for future studies targeting modifiable risk factors, such as reduction in benzodiazepine exposure, to mitigate iatrogenic harm in pediatric patients.
Longitudinal neuropsychological outcomes of traumatic brain injury (TBI) were investigated in 53 children with severe TBI, 56 children with moderate TBI, and 80 children with orthopedic injuries only. Neuropsychological functioning was assessed at baseline, at 6- and 12-month follow-ups, and at an extended follow-up (a mean of 4 years postinjury). Mixed model analyses revealed persistent neuropsychological sequelae of TBI that generally did not vary as a function of time postinjury. Some recovery occurred during the first year postinjury, but recovery reached a plateau after that time, and deficits were still apparent at the extended follow-up. Further recovery was uncommon after the first year postinjury. Family factors did not moderate neuropsychological outcomes, despite their demonstrated influence on behavior and academic achievement after childhood TBI.
The development of paediatric intensive care has contributed to the improved survival of critically ill children. Physical and psychological sequelae and consequences for quality of life (QoL) in survivors might be significant, as has been determined in adult intensive care unit (ICU) survivors. Awareness of sequelae due to the original illness and its treatment may result in changes in treatment and support during and after the acute phase. To determine the current knowledge on physical and psychological sequelae and the quality of life in survivors of paediatric intensive care, we undertook a computerised comprehensive search of online databases for studies reporting sequelae in survivors of paediatric intensive care. Studies reporting sequelae in paediatric survivors of cardiothoracic surgery and trauma were excluded, as were studies reporting only mortality. All other studies reporting aspects of physical and psychological sequelae were analysed. Twenty-seven studies consisting of 3,444 survivors met the selection criteria. Distinct physical and psychological sequelae in patients have been determined and seemed to interfere with quality of life. Psychological sequelae in parents seem to be common. Small numbers, methodological limitations and quantitative and qualitative heterogeneity hamper the interpretation of data. We conclude that paediatric intensive care survivors and their parents have physical and psychological sequelae affecting quality of life. Further well-designed prospective studies evaluating sequelae of the original illness and its treatment are warranted.
Background
Survivors of critical illness often have a prolonged and disabling form of cognitive impairment that remains inadequately characterized. Methods
We enrolled adults with respiratory failure or shock in the medical or surgical intensive care unit (ICU), evaluated them for in-hospital delirium, and assessed global cognition and executive function 3 and 12 months after discharge with the use of the Repeatable Battery for the Assessment of Neuropsychological Status (population age-adjusted mean [SD] score, 10015, with lower values indicating worse global cognition) and the Trail Making Test, Part B (population age-, sex-, and education-adjusted mean score, 5010, with lower scores indicating worse executive function). Associations of the duration of delirium and the use of sedative or analgesic agents with the outcomes were assessed with the use of linear regression, with adjustment for potential confounders. ResultsOf the 821 patients enrolled, 6% had cognitive impairment at baseline, and delirium developed in 74% during the hospital stay. At 3 months, 40% of the patients had global cognition scores that were 1.5 SD below the population means (similar to scores for patients with moderate traumatic brain injury), and 26% had scores 2 SD below the population means (similar to scores for patients with mild Alzheimer's disease). Deficits occurred in both older and younger patients and persisted, with 34% and 24% of all patients with assessments at 12 months that were similar to scores for patients with moderate traumatic brain injury and scores for patients with mild Alzheimer's disease, respectively. A longer duration of delirium was independently associated with worse global cognition at 3 and 12 months (P=0.001 and P=0.04, respectively) and worse executive function at 3 and 12 months (P=0.004 and P=0.007, respectively). Use of sedative or analgesic medications was not consistently associated with cognitive impairment at 3 and 12 months. Conclusions
Patients in medical and surgical ICUs are at high risk for long-term cognitive impairment. A longer duration of delirium in the hospital was associated with worse global cognition and executive function scores at 3 and 12 months. (Funded by the National Institutes of Health and others; BRAIN-ICU ClinicalTrials.gov number, NCT00392795.) In this study, patients treated in ICUs were at high risk for new cognitive impairment during 12 months of follow-up, with 24% of patients having deficits similar in severity to those in Alzheimer's disease. A longer duration of delirium was associated with worse cognitive scores. Survivors of critical illness frequently have a prolonged and poorly understood form of cognitive dysfunction,(1)-(4) which is characterized by new deficits (or exacerbations of preexisting mild deficits) in global cognition or executive function. This long-term cognitive impairment after critical illness may be a growing public health problem, given the large number of acutely ill patients being treated in intensive care units (ICUs) globally.(5) Among older adults, cognitive decline is associated with institutionalization,(6) hospitalization,(7) and considerable annual societal costs.(8),(9) Yet little is known about the epidemiology of long-term cognitive impairment after critical illness. Delirium, a form of acute brain ...
Objective:
To assess short-term neuropsychological function and academic performance in school children following admission to intensive care and to explore the role of critical neurologic and systemic infection.
Design:
A prospective observational case-control study.
Setting:
Two PICUs.
Subjects:
A consecutive sample of 88 children aged 5-16 years (median age=10.00, interquartile range=6.00-13.00) who were admitted to intensive care between 2007 and 2010 with meningoencephalitis, septic illness, or other critical illnesses. They were assessed 3 to 6 months following discharge, and their performance was compared with that of 100 healthy controls. Patients were without prior neurologic or neurodevelopmental disorder.
Interventions:
None.
Measurements and main results:
Data encompassing demographic and critical illness details were obtained, and children were assessed using tests of intellectual function, memory, and attention. Questionnaires addressing academic performance were returned by teachers. After adjusting for covariates, the children admitted to PICUs significantly underperformed on neuropsychological measures in comparison to healthy controls (p<0.02). Teachers deemed more children admitted to PICUs than controls as performing educationally worse and having problems with school work (ps=0.001), as well as performing below average on aspects of executive function and attention (ps<0.04). Analysis of the effect of illness type on outcome revealed that aspects of neuropsychological function, such as memory function, and teacher-rated academic performance were most reduced in children with meningoencephalitis and septic illness. In the PICU group, multivariable linear regression revealed that worse performance on a composite score of neuropsychologic impairment was more prevalent when children were younger, from a lower social class, and had experienced seizures during their admission (ps<0.02).
Conclusions:
Admission to intensive care is followed by deficits in neuropsychologic performance and educational difficulties, with more severe difficulties noted following meningoencephalitis and septic illness. These results highlight the importance of future studies on cognition and educational outcome incorporating type of illness as a moderating factor.
To describe the characteristics of children admitted to intensive care in 1982, 1995, and 2005-2006, and their long-term outcome.
Pediatric intensive care unit in a university-affiliated children's hospital.
Information for 2005-2006 admissions was obtained from pediatric intensive care unit database, and long-term outcome was ascertained through telephone interviews. Results were compared to previous cohorts from 1982 and 1995.
A total of 4010 children were admitted on 5250 occasions. Readmissions increased from 11% for 1982 to 31% in 2005 to 2006 (p < .001). In 2005-2006, fewer children were admitted after accidents (p < .001), or with croup (p < .001), or epiglottitis (p = .01), and 8% were treated with noninvasive ventilation compared to none in 1982 (p < .0001). Among children aged > or =1 month, pediatric intensive care unit length of stay remained constant. The risk of death predicted by the Pediatric Index of Mortality (PIM) remained constant (approximately 6%) between 1995 and 2005-2006.The proportion that died in the pediatric intensive care unit fell from 11.0% in 1982 to 4.8% in 2005-2006 (p < .001). Among children aged >/=1 month, proportion admitted with a preexisting moderate or severe disability was similar: 12.0% in 1982 and 14.6% in 2005-2006 (p = .11), but the proportion with a moderate or severe disability at follow-up increased from 8.4% in 1982 to 17.9% in 2005-2006 (p < .001). The proportion of children aged > or =1 month who either died in the pediatric intensive care unit or survived with disability did not improve: it was 19.4% in 1982 and 22.7% in 2005-2006.
Over the last three decades, the length of stay in the pediatric intensive care unit and the severity of illness have not changed, but there has been a substantial reduction in pediatric intensive care unit mortality. However, the proportion of survivors with moderate or severe disability increased significantly. Some children who would have been allowed to die in 1982 and 1995 were kept alive in 2005-2006, but survived with disability. This trend has important implications for our patients and their families, and for the community as a whole.
A 2 1/4-year prospective study of children suffering head injury is described. Three groups of children were studied: (a) 31 children with 'severe' head injuries resulting in a post-traumatic amnesia (PTA) of at least 7 days; (b) an individually matched control group of 28 children with hospital treated orthopaedic injuries; and (c) 29 children with 'mild' head injuries resulting in a PTA exceeding 1 hour but less than 1 week. Individual psychological testing was carried out as soon as the child recovered from PTA, and then again 4 months, 1 year, and 2 1/4 years after the injury. A shortened version of the Wechsler Intelligence Scale for Children (WISC), the Neale Analysis of Reading Ability and a battery of tests of specific cognitive functions were employed. The mild head injury group had a mean level of cognitive functioning below the control group, but the lack of any recovery; during the follow-up period indicated that the intellectual impairment was not a consequence of the injury. In the severe head injury group, the presence of cognitive recovery and a 'dose-response' relationship with the degree of brain injury showed that the intellectual deficits were caused by brain damage. Some degree of cognitive impairment was common following head injuries giving rise to a PTA of at least 2 weeks. Conversely no cognitive sequelae, transient or persistent, could be detected when the PTA was less than 24 hours. The results were less consistent in the 1-day to 2-week PTA range, but the evidence suggested that a broadly defined threshold for impairment operated at about that level of severity of injury. Timed measures of visuo-spatial and visuo-motor skills tended to show more impairment than verbal skills but otherwise there was no suggestion of a specific pattern of cognitive deficit. Recovery was most rapid in the early months after injury, but substantial recovery continued for 1 year with some improvement continuing n the second year in some children, especially those with the most severe injuries. Age, sex and social class showed no significant effects on the course of recovery.
Manual for the Children's Memory Scale
- Mj Cohen
Cohen MJ: Manual for the Children's Memory Scale. San Antonio, TX,
Psychological Corporation, 1997
Manual for the Wide Range Intelligence Test
- J Glutting
- W Adams
- D Sheslow
Glutting J, Adams W, Sheslow D: Manual for the Wide Range Intelligence Test. Lutz, FL, Psychological Assessment Resources, 2000