Mortality in very long-stay pediatric intensive care unit patients and incidence of withdrawal of treatment

Naghib, Sara; Starre, Cynthia van der; Gischler, Saskia J.; Joosten, Koen; Tibboel, Dick

doi:10.1007/s00134-009-1693-z

Cited by 66 publications

(91 citation statements)

References 27 publications

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“…For comparison, published case fatality rates for overall medical admissions to pediatric ICUs in the United Kingdom, 13 Sweden, 14 and the Netherlands 15 range from 2% to 5%. Prior hospital series of childhood stroke have reported case fatality rates of 2%-9% for ischemic stroke 3,12,16 and 5%-34% for hemorrhagic stroke, 12,17,18 but have not stratified outcomes of strokes admitted for critical care.…”

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confidence: 99%

High critical care usage due to pediatric stroke

Fox

Fullerton

2012

Neurology

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Objectives: To measure intensive care unit (ICU) admission, intubation, decompressive craniotomy, and outcomes at discharge in a large population-based study of children with ischemic and hemorrhagic stroke. Methods:In a retrospective study of all children enrolled in a Northern Californian integrated health care plan (1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003), we identified cases of symptomatic childhood stroke (age Ͼ28 days through 19 years) from inpatient and outpatient electronic diagnoses and radiology reports, and confirmed them through chart review. Data regarding stroke evaluation, management, and outcomes at discharge were abstracted. Intensive care unit (ICU) admission, intubation, and decompressive neurosurgery rates were measured, and multivariate logistic regression was used to identify predictors of critical care usage and outcomes at discharge. Results:Of 256 cases (132 hemorrhagic and 124 ischemic), 61% were admitted to the ICU, 32% were intubated, and 11% were treated with a decompressive neurosurgery. Rates were particularly high among children with hemorrhagic stroke (73% admitted to the ICU, 42% intubated, and 19% received a decompressive neurosurgery). Altered mental status at presentation was the most robust predictor for all 3 measures of critical care utilization. Neurologic deficits at discharge were documented in 57%, and were less common after hemorrhagic than ischemic stroke: 48% vs 66% (odds ratio 0.5, 95% confidence interval 0.3-0.8). Case fatality was 4% overall, 7% among children admitted to the ICU, and was similar between ischemic and hemorrhagic stroke.Conclusions: ICU admission is frequent after childhood stroke and appears to be justified by high rates of intubation and surgical decompression. Pediatric stroke occurs in 2-13/100,000 children annually, 1,2 and while hospital case series have reported high rates of neurologic deficits and case fatality, 3,4 data from population-based cohorts are limited. After a large stroke, neurologic deterioration may progress over several days from swelling, intracranial hypertension, and secondary brain injury. Although adult neurocritical care after a stroke has received increasing attention, little has been reported regarding critical care management practices of childhood stroke. However, children may have several reasons to require critical care management of elevated intracranial pressures: 1) children have a high proportion of hemorrhagic strokes, 1,5 2) ischemic strokes in children are predominantly large-vessel, 6,7 and 3) children lack the cerebral atrophy of aging that provides space to accommodate mass effect. We hypothesized that the frequency of ICU admission and interventions such as intubation and surgical decompression would be high after pediatric stroke, even in a

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confidence: 99%

High critical care usage due to pediatric stroke

Fox

Fullerton

2012

Neurology

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“…Las características epidemiológicas de nuestros pacientes son similares a las referidas por otros autores, mostrando un predominio de pacientes masculinos y con una importante proporción de pacientes afectos de malformaciones congé-nitas, especialmente cardiopatías [1][2][3]10 . En nuestro estudio hay un gran predominio de pacientes con cardiopatías que, en parte, puede estar motivado porque nuestra UCIP es un centro de referencia para esta enfermedad.…”

Section: Discussionunclassified

“…En nuestra serie la mortalidad es 10 veces mayor, coincidiendo con lo referido en otros estudios en niños 2,3,33 . Es importante reseñar que es infrecuente el ingreso en nuestra UCIP de pacientes para la realización de técnicas o procedimientos de corta duración, cuya baja mortalidad podría alterar a la baja el dato de mortalidad global de la unidad.…”

Section: Mortalidadunclassified

“…El grupo de pacientes con un ingreso prolongado constituye una minoría, pero debido a su larga estancia y a las enfermedades que presentan, en muchas ocasiones suponen un elevado consumo de recursos asistenciales, y una mayor morbilidad y mortalidad [2][3][4] . La identificación precoz de estos pacientes podría permitir una canalización más adecuada de los recursos sociosanitarios, que permitiese una mejora en la asistencia con un mejor aprovechamiento de los recursos disponibles [5][6][7][8][9] .…”

Section: Introductionunclassified

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Ingreso prolongado en la unidad de cuidados intensivos pediátricos: mortalidad y consumo de recursos asistenciales

et al. 2011

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Variables de interés:Se analizaron la morbimortalidad y el consumo de recursos por los pacientes con ingreso prolongado. Resultados: La mortalidad de los pacientes con ingreso prolongado fue mayor (22,9%) que la del resto de los pacientes (2%) (p < 0,001). En un 52,6% de estos pacientes el fallecimiento se produjo tras la limitación del esfuerzo terapéutico o por no iniciar medidas de reanimación. Los pacientes con ingreso prolongado presentaron una elevada incidencia de infección nosocomial (96,3%) y un elevado consumo de los recursos asistenciales (el 97,6% precisó ventilación mecá-nica; el 90,2%, transfusión de hemoderivados; el 86,7% fármacos vasoactivos intravenosos, y el 22,9%, oxigenación por membrana extracorpórea (ECMO). Conclusiones: Los niños en estado crítico con ingreso prolongado en la UCIP tienen una elevada morbimortalidad y requieren un elevado consumo de recursos asistenciales. Son necesarias medidas específicas que permitan identificar precozmente a los pacientes susceptibles de presentar ingreso prolongado para adecuar las medidas terapéuticas y los recursos disponibles y mejorar la eficiencia del tratamiento.

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“…Improvements in life-sustaining treatments have resulted in increasing numbers of children hospitalized for long periods of time in the PICU and whose care requires considerable resources. Whilst there is no consensus on what constitutes a long-stay in PICU, long-stay patients (LSPs) represent the minority (3)(4). Much existing evidence regarding paediatric LSPs relates to mortality rates and quality-of-life indicators and, whilst there is a wealth of literature relating to the stresses and coping strategies of nurses in the PICU, relatively little is known about the impact of caring for children who have a prolonged stay in the PICU.…”

Section: Introductionmentioning

confidence: 99%

The Challenges of Caring for Long-Stay Patients in the PICU*

Geoghegan

Oulton

Bull

et al. 2016

Pediatric Critical Care Medicine

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Objective: Compared to shorter-stay patients, caring for long-stay patients in the ICU entails a disproportionate burden for staff. Our objective was to gain a deeper understanding of the impact on staff of caring for children who have a prolonged stay on the PICU. Design: Qualitative study based on semi-structured interviews. Data were analyzed using the Framework approach. Setting: Children’s tertiary hospital. Participants: Seventeen members of staff (7 psychosocial staff, 7 nurses, 3 consultants) working in the PICU, neonatal ICU, or cardiac ICU (PICU will be used to encompass neonatal ICU, cardiac ICU, and PICU for the remainder of this article). Interventions: Semi-structured, tape-recorded interviews. Measurements and Main Results: Staff reported both positive and challenging aspects of caring for long-stay patients in the PICU. Five key areas relating to the challenges of caring for long-stay patients were identified: staff expectations about their work, characteristics of the patient group, the impact on staff, the impact on the wider unit, and the availability of support. Staff views were often compounded by individual cases they had been involved with or had heard about which fell at either end of the spectrum of “good” and “bad”. Conclusions: Whilst there are reported benefits associated with caring for long-stay patients, there are a number of challenges reported that may have implications for staff and the wider unit. When caring for a particular sub-group of long-stay patients, staff may be more likely to experience negative impacts. A key priority for the PICU is to ensure that support mechanisms are timely, accessible, and allow staff to explore their own reactions to their work.

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Mortality in very long-stay pediatric intensive care unit patients and incidence of withdrawal of treatment

Cited by 66 publications

References 27 publications

High critical care usage due to pediatric stroke

High critical care usage due to pediatric stroke

Ingreso prolongado en la unidad de cuidados intensivos pediátricos: mortalidad y consumo de recursos asistenciales

The Challenges of Caring for Long-Stay Patients in the PICU*

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