DOI: 10.1097/CCM.0000000000001100

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PMID: 26274715

Issn Print: 0090-3493

Publication Date: 2015/09/01


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It Seems Like the Resuscitation Happened Ages Ago—Chronic Critical Illness in Children: Digging in for the Long Haul*

Ericka L. Fink; Patrick M. Kochanek

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Excerpt

Many of us in critical care entered the specialty with an affinity for acute resuscitation. However, as Namachivayam et al (1) in this issue of Critical Care Medicine and other groups have pointed out, a growing part of our duty is to care for children who require prolonged stays to achieve PICU discharge. Accordingly, the Society of Critical Care Medicine defines chronic critical illness as a prolonged need for mechanical ventilation, whether in an ICU or not, in which the patient is not back to his or her prior functioning and remains at increased risk of mortality (http://www.myicucare.org/Adult-Support/Pages/Chronic-Critical-Illness.aspx). Research has shown that this group of patients requires special attention as they consume a sizeable amount of resources and frequently have poor long-term health outcomes after PICU discharge (2, 3).
Pollack et al (3) first described “long-stay” patients (those with a PICU length of stay > 95% [12 d]) as encompassing 7% of PICU admissions at a single center. They were younger, sicker, and having more chronic disease versus shorter stay patients and consumed more than 50% of ICU resources. Expanding to a 32-site U.S. study, they found that long-stay patients accounted for between 2% and 8% of PICU admissions and occupied between 15% and 58% of PICU bed days (4). Predictors of long stay included age less than 12 months; previous ICU or emergency admission; no need for cardiopulmonary resuscitation before admission; admission from another ICU; chronic care requirements; diagnosed with acquired cardiac disease, pneumonia, and other respiratory disorders; having never been discharged from the hospital; need for ventilatory support or an intracranial catheter; and a Pediatric Risk of Mortality III score between 10 and 33. Echoing the notion that children with chronic illness often had lengthy PICU stays, another multicenter study in the United States found that moderate and severe baseline deficits for both the Pediatric Overall Performance Category and Pediatric Cerebral Performance Category scores predicted children who would have a prolonged length of PICU stay (5).
In this multicenter (n = 8) study of PICUs in Australia and New Zealand by Namachivayam et al (1), children with chronic critical illness were defined as those requiring greater than or equal to 28 PICU days. Although accounting for only 1.3% of PICU admissions, these children’s longer lengths of stay amounted to 24% of PICU bed days. Children had a mean duration of mechanical ventilation of over 3 weeks, length of PICU stay of 40 days, and hospital stay of 75 days. Further stressing the singularity of the “long-stay” cohort, mortality was six times higher than overall PICU mortality and remained flat over the two study epochs (2000–2005 and 2006–2011). Subsequently, another 129 children (15%) who survived to PICU discharge died within the 5-year follow-up period. Although site differences were not reported in this article, one of the study’s centers previously published a 20-year retrospective analysis of long-stay patients, finding that PICU bed days had rocketed from 8% to 21% over the study period, highlighting an important trend (2).
The most frequent primary diagnosis in the early epoch was sepsis but cardiac/respiratory arrest led the second epoch, increasing from 12% to 20%. Children with single-ventricle physiology (5–9%) and acute renal failure (7–14%) doubled. The reason for these changes were not explored, but likely represent technological advances and corresponding culture change by clinicians and/or caregivers over time toward pursuing survival, risking an increase in more children surviving with short- or long-term disability (6–8). Notably, the proportion of children who required extracorporeal membrane oxygenation was not reported in the current study but comprised a substantial 24% of study patients in the 20-year single-center analysis (2).
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