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Defining Pediatric Chronic Critical Illness: A Scoping Review
David J Zorko1,2, James Dayre McNally3,4, Bram Rochwerg5,6
1Department of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
Insights
Pediatric chronic critical illness (CCI) lacks a clear definition, hindering research. This review found varied definitions for CCI and prolonged PICU stays, highlighting the need for a consensus to advance care.
Area of Science:
- Pediatric critical care medicine
- Clinical definitions and research methodology
Background:
- Children with chronic critical illness (CCI) are a high-risk group with potential for prolonged organ dysfunction and recurrent critical care needs.
- However, a standardized definition for pediatric CCI is currently lacking, creating challenges in research and clinical practice.
Purpose of the Study:
- To conduct a scoping review of existing literature to identify and evaluate case definitions for pediatric chronic critical illness (CCI).
- To examine definitions of prolonged pediatric intensive care unit (PICU) admission and the methodologies used to derive these definitions.
Main Methods:
- A comprehensive search of four electronic databases (Ovid Medline, Embase, CINAHL, Web of Science) was performed up to March 2021.
- A hybrid approach combining crowdsourcing and machine learning was employed for efficient and accurate screening of over 6,000 citations.
- Studies providing specific case definitions for CCI or prolonged PICU admission were included for data extraction.
Main Results:
- Twelve of 67 included studies (18%) offered definitions for pediatric CCI, incorporating elements like PICU length of stay, medical complexity, chronic conditions, recurrent admissions, and technology dependence.
- Definitions for CCI were often referenced or opinion-based.
- The majority of studies (82%) defined prolonged PICU admission, typically as 14 or 28 days or longer, with definitions derived from investigator opinion or statistical methods.
Conclusions:
- Existing definitions for pediatric chronic critical illness are inconsistent, varying in their consideration of patient complexity and illness chronicity.
- The lack of a consensus definition impedes research in this critical area of pediatric critical care.
- Establishing a standardized definition for pediatric CCI is crucial for advancing research and improving patient outcomes.
Objectives:
Children with chronic critical illness (CCI) are hypothesized to be a high-risk patient population with persistent multiple organ dysfunction and functional morbidities resulting in recurrent or prolonged critical care; however, it is unclear how CCI should be defined. The aim of this scoping review was to evaluate the existing literature for case definitions of pediatric CCI and case definitions of prolonged PICU admission and to explore the methodologies used to derive these definitions.
Data Sources:
Four electronic databases (Ovid Medline, Embase, CINAHL, and Web of Science) from inception to March 3, 2021.
Study Selection:
We included studies that provided a specific case definition for CCI or prolonged PICU admission. Crowdsourcing was used to screen citations independently and in duplicate. A machine-learning algorithm was developed and validated using 6,284 citations assessed in duplicate by trained crowd reviewers. A hybrid of crowdsourcing and machine-learning methods was used to complete the remaining citation screening.
Data Extraction:
We extracted details of case definitions, study demographics, participant characteristics, and outcomes assessed.
Data Synthesis:
Sixty-seven studies were included. Twelve studies (18%) provided a definition for CCI that included concepts of PICU length of stay (n = 12), medical complexity or chronic conditions (n = 9), recurrent admissions (n = 9), technology dependence (n = 5), and uncertain prognosis (n = 1). Definitions were commonly referenced from another source (n = 6) or opinion-based (n = 5). The remaining 55 studies (82%) provided a definition for prolonged PICU admission, most frequently greater than or equal to 14 (n = 11) or greater than or equal to 28 days (n = 10). Most of these definitions were derived by investigator opinion (n = 24) or statistical method (n = 18).
Conclusions:
Pediatric CCI has been variably defined with regard to the concepts of patient complexity and chronicity of critical illness. A consensus definition is needed to advance this emerging and important area of pediatric critical care research.
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