Christopher S. Parshuram

Objective: To describe function up to 12-months after critical illness with an overall prognosis systematic review and meta-analysis. Data sources: We searched MEDLINE, Cochrane and Embase on May 10, 2021. Study selection: Cohorts and trials, published after 1994, in English, describing function after discharge and within 12-months of critical illness were independently assessed by two reviewers. Data extraction: The 163 included publications described function in 15 662 children from 114 studied cohorts. Following the PRISMA guidelines, data extraction, risk of bias and GRADE assessments were independently performed by two physician reviewers. Our primary outcomes were overall, cognitive, physical, and socioemotional function after critical illness. Function was reported as raw data or categorized as normal, independent, mild to moderate impairment, moderate impairment, severe impairment, or death. Independent functioning included normal and mild to moderate impairment. Function was reported at baseline (before ICU), discharge, < 6 months, 6-months, and 12-months after critical illness. Random-effects proportional meta-analyses were used to calculate proportions at specified time periods. Mixed-effects logistic regression models were used to compare function using discharge as the reference. Data synthesis: The most frequent diagnoses were cardiac arrest (CPA) and traumatic brain injury (TBI). At discharge independent overall functioning in patients with CPA was less frequent than at baseline, and remained similar 12 months later. Compared with discharge the Odds Ratio (95% CI, p-value) of independent overall function at baseline was 25.3 (2.3–121, p = 0.007) and was 0.75 (0.43–1.33, p = 0.2) at 12-months with a pooled percentage (95% CI) of independent function of 22 (11- 37)% at 12 months. Independent overall functioning in patients with TBI improved from discharge to 12-months. Compared with discharge the Odds Ratio (95% CI, p-value) of independent overall function at 6 months was 1.8 (1.4–2.4, p = 0.003) and was 1.6 (1.1–2.4), p = 0.03 at 12-months with a pooled percentage (95% CI) of independent function of 67 (53–78)% at 12 months. Conclusions: Paediatric critical illness is associated with population-specific acquired functional impairment disability and variable recovery of function. These findings can help inform prognostication discussions and provide rationale for follow up and support programs for survivors of critical illness.

Background: Though 60–80% of hospitalized patients have an intravascular device placed during hospitalization, there is a substantial risk of complication related to the placement, maintenance and removal of these devices. The objectives of this study were to describe vascular access device use, device complications and lumen dysfunction. Methods: An observational cohort study was conducted over a 4.5 years period, in two quaternary, university-affiliated paediatric intensive care units (ICU). Eligible patients were admitted to either the paediatric or cardiac ICU and had one or more vascular access devices in-situ at the time of enrolment. Vascular access devices were defined as any external connection directly into the circulation including peripheral and central veins, arteries or bone marrow. Consistent with practice in the studied ICUs removal of peripheral catheters was regarded as due to dysfunction or complication. Results: 220 patients, 683 devices and 924 lumens were observed. The device complication rate was 21% and the lumen complication rate was 25%. The median duration without complication was 18 days for arterial catheters, 14 days for central venous catheters; 13 days for peripherally inserted central catheters and 4 days for peripheral intravenous catheters. On one third of all patient days, the volume of fluid administered to maintain VADs was equal to or greater than 20% of the total hourly total fluid intake. Conclusion: Approximately 1 in 5 vascular devices had one or more complications in ICU, most devices continued to be used without removal, and some complications resolved. The implications of the fluids infused to maintain device function warrants further study, as do strategies to resolve or limit the their complications in children.

Critically ill children are intensively monitored and receive many drugs, fluids, and other therapies while in paediatric intensive care unit(PICU). The operational aspects of the provision of these therapies are not well understood. The objective of this study was to characterise the activities supporting fluid and drug administration in critically ill paediatric patients. This prospective, single centre, observational study used multi-modal direct observation approach (video, audio, and direct bedside observation) to understand the clinical activities associated with care of critically ill children. Administration was separated into the broad and varied activities required for drug and fluid administration ranging from drug information review through disposal. 43 patients, 84 nurses, 43 doctors, 27 respiratory therapists and 4 nurse practitioners were observed over 48 epochs and 143.15 h. The 23.61(16%) hours of drug and fluid therapy observed were comprised of 660 specific clinical administrations of drug and fluid therapy that took a median(IQR) 64.45(17.10–163.62) seconds and were comprised of 4396 administration activities. Interruptions to the process of drug and fluid administration were also counted and observed 261 times, occurring in 148(22%) of unique administrations and lasted a median(IQR) of 7.95(3.82–14.88) seconds each. This study has implications on safety measures pertaining to sources and duration of interruptions within administration, as well as considerations around nursing tasks, ratios and sheer workload of drug and fluid administration. Further work could explore targeting strategies that optimize efficiency, workflow, and safety in the PICU as it pertains to layout, staffing and ease of medication administration.

Purpose: To determine whether late admission to pediatric intensive care (ICU) from hospital wards is associated with patient outcomes. Methods: Secondary analysis of prospectively collected data from an international multicenter cluster-randomized trial. Clinical deterioration events with urgent ICU admission were defined as late if the Children’s Resuscitation Intensity Scale was > 2 (indicating critical care interventions started from 12 h pre- to 1 h post-urgent ICU admission). The association of late admission with primary outcomes (ICU and hospital mortality) was estimated using logistically generalized estimating equation models adjusted for PIM2 probability of death. Results: There were 2979 clinical deterioration events in 2502 patients, including 620 (20.8%) late ICU admissions. ICU mortality of the last urgent ICU admission was 15.4% for late compared to 4.5% for non-late ICU admission (PIM-adjusted OR (95%CI) 1.63 (1.14, 2.33), p < 0.01). Hospital mortality was 19.7% in late compared to 6.0% for non-late urgent ICU admission (PIM-adjusted OR 1.56 (1.12, 2.16), p < 0.01). Late ICU admissions accounted for 20.9% of clinical deterioration events, and 90/179 (50.2.0%) of ICU and 103/222 (46.4%) of hospital deaths after clinical deterioration events. Secondary outcomes associated with late ICU admission included longer ICU stay (2.3 days, p = 0.02), more ventilation days (407/1000 ICU days, p < 0.0001), and more frequent treatment with dialysis, inhaled nitric oxide, and extracorporeal membrane oxygenation (p < 0.01). Conclusion: Late ICU admission from hospital wards was associated with higher ICU and hospital mortality, greater use of ICU technologies, and longer ICU stays. How to prevent late ICU admission and its consequences requires further study.

Aim: Infants and children who require specialized medical attention are admitted to neonatal and pediatric intensive care units (ICUs) for continuous and closely supervised care. Overnight in-house physician coverage is frequently considered the ideal staffing model. It remains unclear how often this is achieved in both pediatric and neonatal ICUs in Canada. The aim of this study is to describe overnight in-house physician staffing in Canadian pediatric and level-3 neonatal ICUs (NICUs) in the pre-COVID-19 era.Methods: A national cross-sectional survey was conducted in 34 NICUs and 19 pediatric ICUs (PICUs). ICU directors or their delegates completed a 29-question survey describing overnight staffing by resident physicians, fellow physicians, nurse practitioners, and attending physicians. A comparative analysis was conducted between ICUs with and without in-house physicians.Results: We obtained responses from all 34 NICUs and 19 PICUs included in this study. A total of 44 ICUs (83%) with in-house overnight physician coverage provided advanced technologies, such as extracorporeal life support, and included all ICUs that catered to patients with cardiac, transplant, or trauma conditions. Residents provided the majority of overnight coverage, followed by the Critical Care Medicine fellows. An attending physician was in-house overnight in eight (15%) out of the 53 ICUs, seven of which were NICUs. Residents participating in rotations in the ICU would often have rotation durations of less than 6 weeks and were often responsible for providing care during shifts lasting 20–24 h.Conclusion: Most PICUs and level-3 NICUs in Canada have a dedicated in-house physician overnight. These physicians are mainly residents or fellows, but a notable variation exists in this arrangement. The potential effects on patient outcomes, resident learning, and physician satisfaction remain unclear and warrant further investigation.