Objective: Although more children are surviving critical illness, little is known about long-term physical impairment. This scoping review aims to critically appraise existing literature on functional outcome measurement tools, prevalence, and risk factors for physical impairments in pediatric critical care survivors. Data Sources: PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature, using a combination of MeSH terms and keywords (critical illness, intensive care, and functional outcomes/status). Study Selection: All human studies reporting functional outcomes in children 0–18 years old admitted to the PICU. Non-English language, adult and preterm infant studies were excluded. Data Synthesis: Three global assessment tools and eight multidimensional measures were used to measure functional outcome in pediatric survivors of critical illness. Rates of acquired functional impairment in a general pediatric intensive care cohort ranged from 10% to 36% at discharge and 10% to 13% after more than 2 years. Risk factors for acquired functional impairment include illness severity, the presence of organ dysfunction, length of ICU stay, and younger age. There is some evidence that physical impairment may be more severe and persistent than psychosocial components. Conclusions: Functional impairment may be persistent in pediatric survivors of critical care. Unfortunately, studies varied largely in measurement timing and tools used. The lack of differentiation between impairment in different functional domains limited the generalizability of data. Further studies using a combination of standardized measures at various time points of the disease process can help establish more comprehensive rates of physical impairment.

The impact of multiple tracheal intubation (TI) attempts on outcomes in critically ill children with acute respiratory failure is not known. The objective of our study is to determine the association between number of TI attempts and severe desaturation (SpO2 < 70 %) and adverse TI associated events (TIAEs). We performed an analysis of a prospective multicenter TI database (National Emergency Airway Registry for Children: NEAR4KIDS). Primary exposure variable was number of TI attempts trichotomized as one, two, or ≥3 attempts. Estimates were adjusted for history of difficult airway, upper airway obstruction, and age. We included all children with initial TI performed with direct laryngoscopy for acute respiratory failure between 7/2010-3/2013. Our main outcome measures were desaturation (<80 % during TI attempt), severe desaturation (<70 %), adverse and severe TIAEs (e.g., cardiac arrest, hypotension requiring treatment). Of 3382 TIs, 2080(65 %) were for acute respiratory failure. First attempt success was achieved in 1256/2080(60 %), second attempt in 503/2080(24 %), and ≥3 attempts in 321/2080(15 %). Higher number of attempts was associated with younger age, history of difficult airway, signs of upper airway obstruction, and first provider training level. The proportion of TIs with desaturation increased with increasing number of attempts (1 attempt:16 %, 2 attempts:36 %, ≥3 attempts:56 %, p < 0.001; adjusted OR for 2 attempts: 2.9[95 % CI:2.3–3.7]; ≥3 attempts: 6.5[95 % CI: 5.0–8.5], adjusted for patient factors). Proportion of TIs with severe desaturation also increased with increasing number of attempts (1 attempt:12 %, 2 attempts:30 %, ≥3 attempts:44 %, p < 0.001); adjusted OR for 2 attempts: 3.1[95 % CI:2.4–4.0]; ≥3 attempts: 5.7[95 % CI: 4.3–7.5] ). TIAE rates increased from 10 to 29 to 38 % with increasing number of attempts (p < 0.001); adjusted OR for 2 attempts: 3.7[95 % CI:2.9–4.9] ; ≥3 attempts: 5.5[95 % CI: 4.1–7.4]. Severe TIAE rates went from 5 to 8 to 9 % (p = 0.008); adjusted OR for 2 attempts: 1.6 [95 % CI:1.1–2.4]; ≥3 attempts: 1.8[95 % CI:1.1–2.8]. Number of TI attempts was associated with desaturations and increased occurrence of TIAEs in critically ill children with acute respiratory failure. Thoughtful attention to initial provider as well as optimal setting/preparation is important to maximize the chance for first attempt success and to avoid desaturation.

Mortality rates in the pediatric intensive care unit (PICU) have been decreasing despite increasing admissions over the past decade.¹ Most children admitted to the PICU survive and experience good physical recovery.^2,3 Despite these improvements, long-term psychological morbidities among children admitted to the PICU are increasing.⁴ There is an increasing body of evidence to suggest that PICU experiences^5,6 and interventions⁷ are associated with negative long-term psychological outcomes. Focus on survivorship after PICU admission would benefit from including a consideration of the psychological well-being of these children.

Objective: To evaluate the impact of sedation guidelines, protocols, and algorithms on clinical outcomes in PICUs. Data Sources: CINAHL, Medline, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews, Study Selection: English-only publications from 1966 to December 2013, which included keywords “sedation,” ”guideline,” “algorithm,” “protocol,” and “pediatric intensive care.” We included all primary studies involving critically ill children on sedation guidelines, protocols, and algorithms and excluded those which focused mainly on diagnostic or procedural purposes. Data Extraction: Two authors independently screened each article for inclusion. A standardized data extraction sheet was used to extract data from all included studies. Data Synthesis: Among the 1,283 citations yielded from our search strategy, six observational studies were included in the final review. Due to the heterogeneity of the studies included, clinical outcomes were not combined into a meta-analysis. A descriptive account of the studies was formulated to characterize all included studies. The three outcomes of interest were clinical outcomes, patients’ comfort and safety, and sedative use. We found an association between the use of sedation guidelines, protocols, and algorithms and reduced PICU length of stay, frequency of unplanned extubation, prevalence of patients experiencing drug withdrawal, total sedation duration, and doses. Overall, the quality of identified studies is low. Conclusions: Despite widespread recommendation for the use of sedation guidelines, protocols, and algorithms in critically ill children, our systematic review revealed a paucity of high-quality evidence to guide this practice. More robust studies are urgently needed for this important aspect of PICU care.