Troch Rachel, Schwartz Jamie, Boss Renee
Department of Neonatology, Children's National Hospital, Washington, District of Columbia, United States.
Department of Ananthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.
J Pediatr Intensive Care. 2020 Dec;9(4):233-240. doi: 10.1055/s-0040-1713160. Epub 2020 Jun 17.
There is a growing population of children with prolonged intensive care unit (ICU) hospitalization. These children with chronic critical illness (CCI) have a high health care utilization. Emerging data suggest a mismatch between the ICU acute care models and the daily care needs of these patients. Clinicians and parents report that the frequent treatment alterations typical for ICU care may be interrupting and jeopardizing the slow recoveries typical for children with CCI. These frequent treatment titrations could therefore be prolonging ICU stays even further. The aim of this study is to evaluate and summarize existing literature regarding pace and consistency of ICU care for patients with CCI. We performed a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (of September 2018). PubMed (biomedical and life sciences literature), Excerpta Medica database (EMBASE), and The Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for English-language studies with data about CCI, care models, and pacing of clinical management. Four unique papers were identified. Our most important finding was that quality data on chronic ICU management, particularly for children, is sparse. All papers in this review confirmed the unique needs of chronic patients, particularly related to respiratory management, which is a common driver of ICU length of stay. Taken together, the papers support the hypothesis that protocols to reduce interdisciplinary management variability and to allow for slower management pacing should be studied for their impact on patient and health system outcomes. Optimizing value in ICU care requires mapping of resources to patient needs, particularly for patients with the most intense resource utilization. For children with CCI, parents and clinicians report that rapid treatment changes undermine recovery and prolong ICU stays. This review highlights the lack of quality pediatric research in this area and supports further investigation of a "slow and steady" approach to ICU management for children with CCI.
长期入住重症监护病房（ICU）的儿童数量日益增多。这些患有慢性危重病（CCI）的儿童医疗保健利用率很高。新出现的数据表明，ICU急性护理模式与这些患者的日常护理需求不匹配。临床医生和家长报告称，ICU护理中常见的频繁治疗调整可能会干扰并危及CCI患儿典型的缓慢康复过程。因此，这些频繁的治疗滴定可能会进一步延长ICU住院时间。本研究的目的是评估和总结关于CCI患者ICU护理的节奏和一致性的现有文献。我们使用系统评价和Meta分析的首选报告项目（PRISMA）指南（2018年9月）进行了系统评价。在PubMed（生物医学和生命科学文献）、医学文摘数据库（EMBASE）和护理及相关健康文献累积索引（CINAHL）中搜索了有关CCI、护理模式和临床管理节奏的英文研究。共识别出四篇独特的论文。我们最重要的发现是，关于慢性ICU管理的高质量数据，尤其是针对儿童的数据非常稀少。本综述中的所有论文都证实了慢性病患者的独特需求，特别是与呼吸管理相关的需求，呼吸管理是ICU住院时间的常见驱动因素。综合来看，这些论文支持这样一种假设，即应研究减少跨学科管理变异性并允许采用更缓慢管理节奏的方案对患者和卫生系统结果的影响。优化ICU护理的价值需要将资源与患者需求相匹配，特别是对于资源利用最密集的患者。对于患有CCI的儿童，家长和临床医生报告称，快速的治疗变化会破坏康复并延长ICU住院时间。本综述强调了该领域缺乏高质量的儿科研究，并支持进一步研究针对患有CCI的儿童采用“缓慢而稳定”的ICU管理方法。
