Neurologic and Functional Morbidity in the PICU

Post-intensive care syndrome (PICS) is the developoment of new or worsening psychological, neurologic, and/or functional morbidities arising after critical illness. Primarily researched in adults, an increasing body of literature describes these deficits in children. Shein et al (Pediatr Crit Care Med. 2017;18:1106-1113) sought to characterize the acute and more long-term neurofunctional outcomes of a specific population of critically ill children—those younger than 2 years old with acute bronchiolitis.

Their study findings determined that, in two large, multicenter databases, neurologic and functional morbidity were common among previously healthy children admitted to the pediatric intensive care unit (PICU) with bronchiolitis.

Read the full Concise Critical Appraisal here. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

Concise Critical Appraisal: Neurologic and Functional Morbidity in the PICU

Post-intensive care syndrome (PICS) is the development of new or worsening psychological, neurologic, and/or functional morbidities arising after critical illness. Primarily researched in adults, an increasing body of literature describes these deficits in children. One such study demonstrated that approximately 10% of critically ill children admitted to a pediatric intensive care unit (PICU) had an unfavourable outcome and were dependent on caregivers for daily care. In this study, 29% of the children discharged from the PICU had at least one disability (Taylor A, et al. Intensive Care Med. 2003;29:795-800).

Shein et al (Pediatr Crit Care Med. 2017;18:1106-1113) sought to characterize the acute and more long-term neurofunctional outcomes of a specific population of critically ill children—those younger than 2 years old with acute bronchiolitis. While mortality rates for bronchiolitis are low, it remains one of the most common admitting diagnoses to PICUs, with approximately 20% of admitted patients needing intensive care.

In order to evaluate the incidence of neurologic and functional morbidity (NFM) following the PICU admissions for acute bronchiolitis of previously healthy children, the authors looked at two separate databases: the Pediatric Health Information System (PHIS) and the Virtual Pediatric ICU Systems (VPS). PHIS is an administrative database for more than 45 pediatric hospitals in the United States that can provide information on patient encounters (both in- and outpatient), demographics, diagnoses, procedures, and resource utilization. PHIS was used to flag any encounters that contained a new code for developmental delay, brain imaging, neurologist evaluation, physical therapy, etc. by a patient who had a history of admission to a PICU for bronchiolitis. VPS is a prospectively made database containing demographics, diagnoses, Pediatric Index of Mortality (PIM) 2 scores, and Pediatric Overall Performance Category (POPC) scores of children admitted to a participating PICU. The authors included only children with acute bronchiolitis who had POPC scores of 1 (“good overall performance of activities of daily life and normal cognitive function”) on admission. They then compared the admission POPC scores of enrolled children to the discharge scores.

The authors analyzed more than 13,000 PICU admission for acute bronchiolitis (approximately 9,500 from the PHIS database and approximately 3,700 from the VPS database). They found that 1,104 children from the PHIS database had a subsequent hospital encounter suggesting an NFM. In the VPS database, the authors saw evidence of NFM at PICU discharge in 707 patients (18.6%). Of note, only three patients saw their POPC scores increase by 2 points or more.

The authors also sought to identify risk factors for the development of NFM. The use of mechanical ventilation was the main independent risk factor for NFM in both databases, although there was no difference in PIM 2 scores between ventilated and nonventilated subjects. Certain medications also increased the development of NFM, including diuretics, fentanyl, midazolam, morphine, and neuromuscular blockers. Lorazepam had no effect on NFM, and dexmedotomidine was associated with a decreased rate of NFM. Finally, among the VPS patients, lower pH, higher Pco2, and higher sodium levels were also associated with NFM.

The authors note several limitations of this study, including the ability to identify NFM using only variables available in each database. For example, the use of the POPC score may overestimate the neurologic impairment in discharged PICU patients (Baudin F, et al. Pediatric Crit Care Med. 2017;18:1178-1179), but other scales that may be more useful were not available. Another limitation is that patients may have used hospital resources from non-PHIS institutions.

The authors note that this work is important primarily because it is hypothesis-generating. Most PICU physisicans who have cared for critically ill children with bronchiolitis who seem to completely recover probably do not appreciate the long-term morbidities associated with the PICU experience and so have not considered some of the risk factors detailed in this work. The relationship between pH, Pco2, and NFM gives us pause, when permissive hypercapnia is a mainstream strategy for caring for ventilated patients. The association of NFM with various medications—including opioids and midazolam—adds more evidence for potential neurologic injury and the development and repercussions of delirium.

Author of this installment of Concise Critical Appraisal:

Daniel E. Sloniewsky, MD, is as associate professor in the Division of Pediatric Critical Care Medicine in the Department of Pediatrics at Stony Brook Long Island Children’s Hospital. Dr. Sloniewsky is an editor of Concise Critical Appraisal.

Participate in Industry Education at Congress

The Society of Critical Care Medicine’s (SCCM) 47th Critical Care Congress will be packed with essential clinical information to keep you informed on the latest groundbreaking research and developments in critical care. Each year, industry partners invest significant resources in research and development, placing them at the cutting edge of clinical practice. Take advantage of one of the many industry education opportunities offered.

Promotional Symposia
These noncontinuing medical education programs are directly sponsored by industry partners and provide insight into the latest developments, such as the introduction of Vabomere™ (meropenem and vaborbactam), management of patients with bacteremia, nasal high-flow therapy, and treatment considerations in distributive shock.

Promotional symposia take place at the Grand Hyatt San Antonio. Attendance is complimentary.

In-Booth Education
Visit the Exhibit Hall to gain new ideas and a heightened level of awareness on clinical topics and new technologies through in-booth learning opportunities. In-booth education will take place during normal Exhibit Hall hours:

Sunday, February 25, 2018: 9:00 a.m. – 3:45 p.m.
Monday, February 26, 2018: 8:30 a.m. – 2:00 p.m.
Tuesday, February 27, 2018: 8:30 a.m. – 2:00 p.m.

Exhibitor-Sponsored Industry Education Workshops
Attend sessions in either of two enclosed theaters on the show floor at the exhibitor-sponsored industry education workshops, located in the Exhibit Hall. Increase your learning opportunities and gain insight on a late-breaking technology or clinical technique.

For full details, visit the Congress Industry Education Web page.

Check Out Congress with Critical Connections Live

Can’t join us in San Antonio? You can still be part of the late-breaking and most controversial sessions from the Society of Critical Care Medicine’s (SCCM) 47th Critical Care Congress. Tune in Monday, February 26, and Tuesday, February 27, 2018 for Critical Connections Live.

Visit www.sccm.org/Live and follow hashtag #SCCMLive. Programming begins at 7:30 a.m. Central Standard Time (CST) (see more time zones).

To receive a reminder to tune in, please provide your contact information.

Critical Connections Live Program Schedule

Monday, February 26, 2018
7:30 a.m. – 9:00 a.m. CST
Congress highlights and interviews with key members of the critical care community, SCCM leaders, and attendees
Live Session: Sepsis: A Threat that Needs a Global Solution
Session Debrief Guest: Niranjan “Tex” Kissoon, MD, MCCM

9:00 a.m. – 11:00 a.m. CST
Congress highlights and interviews with key members of the critical care community, SCCM leaders, and attendees
Presidential Address: High-Value Care
Live Session: International Critical Care Trials Network: Completed and Ongoing Trials
Session Debrief Guests: Ognjen Gajic, MD, FCCM, and Craig M. Coopersmith, MD, FACS, FCCM

Tuesday, February 27, 2018
7:30 a.m. – 9:00 a.m. CST
Congress highlights and interviews with key members of the critical care community, SCCM leaders, and attendees
Live Session: Bioelectronic Medicine: A Jump-Start in Critical Illness
Session Debrief Guest: Timothy G. Buchman, MD, PhD, MCCM

9:00 a.m. – 11:00 a.m. CST
Special Guest Panel: Surviving Sepsis Collaborative Success Stories
Congress highlights and interviews with key members of the critical care community, SCCM leaders, and attendees
Live Session: Controversies in the Early Detection and Treatment of Sepsis
Session Debrief Guest: Christa A. Schorr, DNP, MSN, RN

Apply Now for THRIVE Post-ICU Clinic Grant

The Society of Critical Medicine, through the THRIVE Initiative, is offering up to seven $1,000 grants aimed at fostering a network of hospitals focused on developing post-intensive care unit (ICU) clinics to provide comprehensive care to ICU survivors. Recipients will share and gain knowledge in how to set up and sustain a post-ICU clinic and will have the opportunity to take a leadership role in growing the network. Goals of this collaborative are to:

  • Improve patient outcomes after ICU discharge
  • Address post-intensive care syndrome using a multidisciplinary team
  • Decrease readmission rates and morbidities
  • Improve quality of life for patients after critical illness
  • Collect data on quality improvement

Applications for 2018 are now open online and are due by May 1, 2018. For more information, visit the THRIVE Post-ICU Clinic Collaborative website.

Register for 2018 MCCKAP Examination

The registration deadline is February 7, 2018, for the Society of Critical Care Medicine’s (SCCM) 2018 Multidisciplinary Critical Care Knowledge Assessment Program (MCCKAP). Register online using your customer ID and password. The examination will be administered from March 6 to 13, 2018.

Held annually, the MCCKAP examination helps program directors and individual fellows:

  • Assess critical care knowledge gained during fellowship training
  • Prepare fellows for the subspecialty board examinations in critical care
  • Identify specific areas of strength and weakness with lists of references and key terms for missed questions
  • Assess results for each individual fellow and the overall program, as well as the institution’s percentile ranking (program director version only)

Available in both adult and pediatric formats, the MCCKAP online examination can be used by program directors to assess their critical care fellowship programs; it can also be used by individuals to independently assess their critical care knowledge gained during fellowship training.

Immediate preliminary scores and analysis are available upon completion of the examination. Final results will be available approximately five weeks after the examination closes.

Attend Afternoon Symposia at Congress

Learn about clinical breakthroughs and advances that lead to better patient care during these thought-provoking presentations at the Society of Critical Care Medicine’s 47th Critical Care Congress. These complimentary continuing medication education (CME)/continuing education (CE) lunch symposia are presented by leading experts in critical care and offer a thorough analysis of the developments and controversies affecting many intensive care unit (ICU) environments.

Parental Nutrition in the Critically Ill: Appropriate Administration of Intravenous Lipid Emulsions
Supported by an educational grant from Fresenius Kabi USA, LLC
This session will review the nutrition requirements of critically ill patients as well as the efficacy and safety data of intravenous lipid emulsions. The guideline recommendations for parental nutrition and intravenous lipid emulsions for the ICU patient will also be discussed.

Challenges of Using Antiplatelet and Anticoagulant Agents in the Critically Ill
Supported by an educational grant from Portola Pharmaceuticals
This session will review the unique characteristics of the new antiplatelet and anticoagulant agents and discuss indications and contraindications for their use. The benefits and potential risks of antiplatelet and anticoagulant agents will be explored. The approaches to managing critical bleeding and reversal strategies to chemical antiplatelet and anticoagulant agents will also be discussed.

These industry-supported symposia will be held Monday, February 26, 2018, in Hemisfair Ballrooms C1 and C2 in the Henry B. Gonzalez Convention Center. They are available to all Congress registrants; no additional registration is needed to attend. Lunch and seating are on a first-come, first-served basis. The sessions will start promptly at 12:30 p.m. More information is available at www.sccm.org/AfternoonSymposia.

Register for Congress online today using your Customer ID and password. For details, visit www.sccm.org/Congress.

Few Seats Remain for Pediatric Ultrasound Course

Register online for the Society of Critical Care Medicine’s (SCCM) Critical Care Ultrasound: Pediatric and Neonatal course. Just a few seats remain; secure yours today! This popular course will take place on February 28 and March 1, 2018, at the San Antonio Marriott Rivercenter in San Antonio, Texas, USA.

Participants will benefit from guided, focused skill stations and interactive presentations to reinforce key learning points. Additional course benefits include:

  • Complimentary copy of SCCM’s Comprehensive Critical Care Ultrasound eBook
  • Increased diagnostic skills and scanning proficiency
  • A significant hands-on experience, ensured by a five-to-one attendee-to-faculty ratio
  • A review of the latest strategies in ultrasound image interpretation and diagnostic challenges, as well as new innovations and procedures
  • Continuing medical education credit hours available to physicians, nurses, and physician assistants

This course will follow SCCM’s 47th Critical Care Congress. If you plan to attend this course in conjunction with Congress, register at www.sccm.org/Congress. If you wish to attend this course and not attend Congress, register online using your Customer ID and password.

Airway Pressure Release Ventilation and ARDS

Despite ubiquitous acceptance, data supporting traditional Acute Respiratory Distress Syndrome Network lung-protective strategies are far more controversial than their fabled repute. Conversely, despite its physiologically pleasing underpinning and positive preclinical data, airway pressure release ventilation (APRV) has garnered little support from the critical care community, primarily due to a lack of robust, high-quality clinical data. Therefore, Zhou et al (Intensive Care Med. 2017; 43(11):1648-1659) set out to see whether early application of APRV in patients with acute respiratory distress syndrome (ARDS) would allow pulmonary function to recover faster and would reduce the duration of mechanical ventilation compared with low tidal volume lung protective ventilation (LTV).

They found that, compared with LTV, APRV in patients with ARDS improved oxygenation and respiratory system compliance, decreased plateau pressure, and reduced the duration of both mechanical ventilation and intensive care unit stay.

Read the full Concise Critical Appraisal by logging in to the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

2019 Congress Session Proposals

Have an idea for a session at the Society of Critical Care Medicine’s (SCCM) 48th Critical Care Congress? The deadline to submit your suggestion for possible inclusion in the 2019 program is January 31, 2018.

Session proposals are submitted using the Congress Session Builder on MySCCM.org under the MY INVOLVEMENT tab. You need not be an SCCM member to submit a session. Multiple sessions may be suggested for consideration. For complete instructions and to review frequently asked questions, visit www.sccm.org/SessionProposals or contact SCCM Customer Service at +1 847 827-6888.

Please note: The Congress Program Planning Committee reserves the right to change, alter, merge, and reject sessions, titles, content, moderators, and speakers to meet programming needs. Incomplete submissions will not be reviewed.

Informing Patient Decisions Through Video

Understanding the concepts associated with deciding a patient’s code status can be difficult for patients and family members. To help overcome some of the barriers to their ability to make informed code status choices, some institutions have used videos to explain these difficult concepts. Merino et al (J Hosp Med. 2017;12(9):700-704) examined the effect of a video versus usual care on code status choice.

Their study findings provide further evidence that videos can impact code status choice and that videos may be a helpful adjunct for patients who must make informed decisions.

Read the full Concise Critical Appraisal by logging in to the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research

Optimizing Critical Care with the ABCDEF Bundle

In an article published in Beckers Healthcare (Kumar A, et al. 2017), a magazine geared toward health system executives, ICU Liberation Collaborative leaders highlight the ABCDEF bundle as a “newly packaged, high-yield opportunity” for institutions to optimize critical care services.

The ABCDEF care bundle elements, developed as part of the Society of Critical Care Medicine’s (SCCM) ICU Liberation Campaign, individually and collectively can help reduce delirium, improve pain management, and reduce long-term consequences for adult intensive care unit (ICU) patients.

Implementing the ABCDEF bundle is one way to maximize the efficiency of care, reduce costs, improve quality and optimize the safety of care associated with ICU services. This includes post-intensive care syndrome (PICS), a health condition following critical illness characterized by post-ICU-acquired dementia and physical and psychological impairments. Stressing that administrator support is essential in implementing and sustaining the ABCDEF bundle, the authors make a strong case for healthcare leaders to become better stewards of available resources, such as those provided by the ICU Liberation initiative.

For example, within seven community hospitals in California, in a study of over 6,000 patients that adjusted for severity of illness and age, the authors found a 15% higher odds of survival for every 10% improvement in overall bundle compliance by the ICU teams. They also reported a similar increase in the number of days alive without delirium or coma (thus able to have meaningful interactions with their family and loved ones).

“While policymakers and healthcare financiers are looking to improve the value of care purchased, innovations like the ICU Liberation Collaborative provide a roadmap of not only delivering such care in a location that is well-known for its high cost of care, but also aims to decrease the sequelae of such care via reductions in the toll that PICS takes on both patients and their families,” the authors conclude.

Learn more about SCCM’s ICU Liberation Campaign and access ABCDEF bundle resources by visiting www.iculiberation.org.

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