Post Intensive Care Syndrome in Pediatrics | What to Know and How to Help

While the practice of medicine itself has been present throughout essentially all of human history, it is only within the last century that the specialty of critical care has been cultivated. Increasing medical advancement has brought with it more opportunities for recovery from illness. However, it has also presented the challenge of more intense and prolonged illness periods. From this need, critical care medicine was born. Although today an intensive care unit (ICU) is something that might be taken for granted, these specialty units have actually only been in use within the last century. This holds true in pediatrics as well, where the first pediatric critical care unit (PICU) was opened in 1955, and pediatric critical care medicine as a specialty was officially recognized in 1981.

Because pediatric critical care is such a new and evolving field, there is a quickly expanding body of literature regarding everything from treatments to outcomes. As research in this field improves, so does the opportunity to prevent mortality. However, as is currently becoming evident in the field, prevention of mortality does not prevent the creation of morbidity. With this being said, the study and prevention of pediatric morbidity following admission to the intensive care unit has become a topic of conversation and research. Already a noted concern in adult critical care medicine, the topic of morbidity, officially referred to as Post Intensive Care Syndrome (PICS), is one of increasing importance in pediatric medicine. 

PICS was defined in 2010 at a stakeholders meeting as "new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization." This meeting primarily focused on the concern of PICS in adult critical care medicine. So, to begin to conceptualize this idea in relation to the PICU, an interprofessional group of healthcare providers gathered and created the PICS in pediatrics framework. As seen in the image below, this new framework identifies four areas of concern for recovery of children admitted to the PICU – physical, cognitive, emotional, and social health. While each section of the framework relates to different long-term consequences of critical illness, many of the issues can be traced back to a few core elements. These include sedation exposure (opioids and benzodiazepines), invasive procedures (central line/arterial line placement, chest tube, intubation), severity of illness, length of stay, ICU-induced delirium, and sleep deprivation. These factors have been shown to impact post-PICU health, with some impacting patients for up to a year following discharge and some lasting lifelong.

Physical Health

In many illnesses, such as the common cold, a small, temporary decline in physical health is a side effect that is frequently expected – e.g. short-lived fatigue, weakness, lack of appetite, etc. However, following PICU admission for serious illness, current literature is highlighting a more marked, potentially permanent/semi-permanent decline in physical health in children. This potential decline in functional status can involve many symptoms, including chronic organ dysfunction or failure, technology dependence, chronic pain, feeding problems or malnutrition, fatigue/weakness, and sleep disturbances. While gathering objective information on pre-admission functional status is difficult, current studies suggest that 4.6-10.3% of children admitted to the PICU experience some form of long-term decline in physical health. Although some instances of this are unavoidable, early mobilization and proactive use of occupational/physical therapy have been proven as the best way to combat such declines. 

Cognitive Health

Deficits in cognitive health may include a decline in any of these areas – attention, memory, communication abilities, school achievements, and processing speed. Recent research has identified that some diagnoses or treatments used may increase the likelihood of such deficits. For instance, 22.5-42% of children diagnosed with sepsis or meningitis report some form of cognitive decline. In addition, for those who required use of extracorporeal membranous oxygenation (ECMO), 45.8% reported concern regarding cognition, while 29.2% reported the need for some form of special education post-hospital discharge. Overall, including all diagnoses and treatments, there is a 3.4% rate of cognition concerns in children following PICU admission. While it can be difficult to prevent the impact of some illnesses or treatments on cognition, increasing awareness of the potential for decline and offering resources early on can be the best way to help combat long-term impacts of such deficits. 

Emotional Health

While emotional health of children is always a consideration regardless of hospital admission, the presence of critical illness and a PICU stay can greatly increase the likelihood of a child experiencing mental health concerns. Several psychological disorders have been reported following PICU admission, including depression, post-traumatic stress disorder (PTSD), anxiety, delusional memories/fears, behavioral problems, sleep disturbances, and hyperactivity. 

In particular, PTSD is a diagnosis commonly seen following PICU discharge. 84.6% of children discharged meet criteria that make them probable for the disorder, while 13-32% screen positive within the first year post-PICU. Symptoms that are reported include the inability to recall aspects of events, hypervigilance, intrusive thoughts, avoidance of thoughts/feelings, and reaction to trauma reminders. Younger age, severity of illness, and higher number of invasive procedures are all factors that make PTSD more probable. In addition to this, an increase in delusional memories, which can be caused by prolonged use of opioids and benzodiazepines resulting in ICU-induced delirium, can increase the risk for this as well. 

Regardless of diagnoses, there are a few interventions that have been found to aid in the prevention or lessening of symptoms of psychological disorders relating to PICU admission. These include increasing awareness and early recognition of the disorders, keeping PICU diaries to help children remember what happened and why during their stay, and providing both children and their families with counseling and support groups following discharge if needed. 

Social Health

When a child is admitted to the PICU, the entire structure of their life is changed during their admission. From their daily schedule to the people they see, many aspects of a child's life are altered in relation to critical illness and being in the hospital. Because of this, time in the PICU can impact the social health of not only the child involved but also all of the family members. Social concerns in relation to the admitted child include loss of peer relationships, loss of social identity, school absences, decreased participation in activities, strained family relationships, and social anxiety. The difficulties do not stop here, as family concerns include parent/guardian psychological issues in relation to their sick child (e.g. anxiety, depression), job loss, financial strain, and food or lodging insecurity. While there is still not much research regarding the prevalence of such occurrences, identification of concerns and an offering of resources is one way to help decrease the strain of these impacts.

Implications

Essentially, as mortality is decreasing, morbidity is appearing to increase. Although more children are now surviving their PICU admissions, it is becoming clear that there can be lasting effects following critical illness and intensive care. These outcomes can be classified under four categories – physical, cognitive, emotional, and social health. While this phenomenon has been greatly studied in adults, it is a fairly new topic of research in the pediatric realm. Awareness of the potential deficits following intensive care, ways to help decrease the risk of the deficits, and availability of resources following PICU admission are all important components of helping to prevent Post Intensive Care Syndrome in the pediatric population.

References

Characteristics of post intensive care syndrome in survivors of pediatric critical illness: A systematic review

Conceptualizing Post Intensive Care Syndrome in Children—The PICS-p Framework

Long-Term Outcomes and the Post-Intensive Care Syndrome in Critically Ill Children: A North American Perspective

The Post-Intensive Care Syndrome in Children