Impact And Follow-up Study Of Physical Function Impairments Associated With Post-intensive Care Syndrome In Children On Readmission And Quality Of Life After Discharge

Background:Children admitted to the pediatric intensive care unit(PICU)may develop post-intensive care syndrome in pediatrics(PICS-p),with physical function impairments being the most common and serious complication.Physical function impairments research is limited,and although PICU-acquired weakness(PICU-AW)is the most common neuromuscular complication of physical function impairments,little is known about it,especially in terms of its prognosis.The mortality rate in PICUs is decreasing globally,and it is no longer the only criterion for measuring the quality of care or assessing prognosis internationally.Unplanned readmission to the PICU has recently been considered a reliable indicator for the quality of care and evaluation of patients’prognoses.Furthermore,the health-related quality of life(HRQOL)and functional status of daily life are reliable indicators that can evaluate the outcome of critically ill children after discharge,reflecting the opinions of children or their caregivers and subjectively evaluating the physical,psychological,and social aspects of children’s performance.There is a non-availability of validated clinical studies,that investigate the important impact of physical function impairments on the occurrence of unplanned early PICU readmission after discharge and how PICU-AW affects the HRQOL and functional status after discharge.Objective:(1)This review aimed to identify the risk factors for physical function impairments from the current literature.(2)The research studied risk factors and predicted unplanned early readmission to the PICU during different hospitalizations,and confirmed the important effect of physical function impairments on readmission to the PICU after discharge.(3)The goal of this study was to learn more about the occurrence and risk factors of PICU-AW,as well as to look into the impact of PICU-AW on the functional status and HRQOL of children discharged from the PICU at a 6-month follow-up.Methods:(1)A systematic search of Pub Med,Embase,Web of Science,and Cochrane Library databases following the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews guideline was performed.The risk factors reported in all human studies reporting physical function impairments in children admitted to the PICU were reviewed and categorized.Two investigators independently screened,evaluated,and selected studies for inclusion.Data from eligible studies were extracted by one investigator,and another investigator reviewed and verified the data.A systematic narrative approach was employed to review and summarize the data.(2)From November 2011 and August 2022,an observational retrospective case-control study was conducted in the PICU of a major tertiary care hospital in China.The case group included all children aged 1 month to 18 years who required unplanned early readmission to the PICU.In this study,unplanned early readmission was defined as patients discharged from the PICU who required non-elective or emergency readmission within 7 days of discharge.We identified the days on which children in the case group were discharged from the PICU for the controls;then we identified all other children who were discharged on that day and were not readmitted and used age-and sex-matched children among them as controls.The data were collected using electronic medical records data on first PICU admissions and divided into a developing set and a validation set.In the developing set,a nomogram was established to predict early readmission risk based on demographic and clinical characteristics by multivariable logistic regression,and its performance was assessed by receiver operating characteristic curves(ROC),calibration curves,and decision curve analysis.Finally,the model’s internal validation was completed.(3)Between May 2021 and November 2022,a prospective observational study in the PICU was conducted in which children aged 7-16 years were diagnosed with PICU-AW at discharge,and those included in the study were divided into PICU-AW and non-PICU-AW groups,and the demographic and clinical characteristics of both groups were collected and statistically analyzed.The predictive ability of inflammatory indicators for the detection of PICU-AW in children at discharge was analyzed by plotting the ROC and calculating the area(AUC)under the curve in the subgroup analysis.The prognosis of children,such as muscle strength,functional status,and HRQOL,was assessed at 1 month,3 months,and 6 months after discharge,and the effect of PICU-AW on the poor prognosis of children discharged from PICU was analyzed.Results:(1)A total of 264 studies were found to be eligible,with 19 studies meeting the inclusion criteria.Children admitted to the PICU experienced physical function impairments during their stay,which can last for years.The most frequently reported risk factors for physical function impairments were age and the severity of diseases.The studies varied primarily in the measurement timing and tools used.(2)A total of5266 patients were discharged from the PICU,with 173 eligible children in the case group and 184 in the control group.The early readmission risk assessment model included five significant risk characteristics:the presence of chronic conditions,the Pediatric Logistic Organ Dysfunction 2(PELOD2)score of more than 4 on admission,the PELOD2 score of more than 0 at discharge,the use of sedation medications,and the presence of physical function impairments at discharge.And the presence of physical function impairments at discharge was given the greatest weight in the model.The ROC curves in this model’s developing and validation sets showed good sensitivity and specificity[AUC:0.851[95%confidence interval(CI)0.805-0.898]and0.811(95%CI 0.727-0.895),respectively].The calibration curve(the developing set:λ~2=8.5,p=0.580;the validation set:λ~2=14.05,p=0.171)and decision curve analysis both demonstrated that the model performed well.Finally,the model was internally validated and demonstrated its reproducibility.(3)During the study period,a total of503 children were evaluated,and 172 children were eventually enrolled in the study who were examined for PICU-AW at discharge,44(25.6%)of whom were diagnosed with PICU-AW and 128 were not.During the follow-up period,134 people completed the 6-month follow-up study.The higher PELOD2 score on admission[Odds ratio(OR)1.337,95%CI]1.011-1.767,p=0.041),longer PICU length of stay(OR 1.222,95%CI1.133-1.318,p<0.001)and the presence of systemic inflammatory response syndrome on admission(OR 6.482,95%CI 2.245-18.712,p=0.001)were significant independent risk factors associated with the diagnosis of PICU-AW at discharge.C-reactive protein[AUC 0.784,95%CI 0.654-0.914,p=0.001]and interleukin-6[AUC 0.762,95%CI0.628-0.895,p=0.001]on admission were found to have a moderate predictive value for the diagnosis of PICU-AW at discharge in patients with systemic inflammatory response syndrome.The results of this study also support that PICU-AW was an independent risk factor for new morbidity in children discharged from the PICU(OR7.880,95%CI 1.275-48.714,p=0.026),and it was also an independent risk factor for decreased HRQOL at 1 month(OR 5.215,95%CI 1.147-23.715,p=0.033)and 3months(OR 5.318,95%CI 1.759-16.077,p=0.003)after discharge.Conclusions:(1)Physical function impairments may be persistent in PICU survivors.The most frequently reported risk factors for physical function impairments were age and the severity of diseases.(2)The physical function impairment at discharge is an important risk factor for early readmission to the PICU,and a clinical prediction model built from it and other risk factors performed well and demonstrated good capability for assessing the risk of early readmission to the PICU.(3)PICU-AW was found in25.6%of patients at discharge in this study.The more severe disease on admission,longer PICU stays,and the presence of systemic inflammatory response syndrome on admission were independent risk factors for PICU-AW.C-reactive protein and interleukin-6 levels on admission were moderately predictive of PICU-AW in patients at discharge.PICU-AW was found to be an independent risk factor for new morbidity in patients at discharge,as well as decreased HRQOL at 1 and 3 months after discharge in this study.