Novas morbidades em unidades de terapia intensiva pediátrica no Rio de Janeiro

Abstract

Introduction: Pediatric intensive care has evolved drastically since its beginning, reducing mortality rates but increasing morbidity rates, making the definition of new pediatric outcomes important. However, morbidity is more challenging to define and assess, making studies that evaluate this outcome extremely heterogeneous. Also, there are few longitudinal studies on the subject in Brazil and Latin America. The consequences of hospitalization in the PICU have already been defined as the post-intensive care syndrome in pediatrics (PICS-p). In this context, the Functional Status Scale (FSS) was created, which encompasses activities of daily living, evaluating patients' functionality, including mental status, sensory functioning, communication, motor functioning, feeding, respiratory status. New morbidity is defined by an increase of three or more points on this scale compared to baseline status. In this study, we used this definition to assess the incidence of new morbidities in pediatric intensive care units (PICUs). Objectives: To describe the incidence of new morbidities upon discharge from the PICU and in the 60-day follow-up, as well as the characteristics of the population that developed new morbidities, their trajectories, and associated factors. Also, describe witch domains were most affected. Methods: A prospective longitudinal study was conducted in four PICUs in Rio de Janeiro from December 2019 to December 2021. Children aged 29 days to 12 years who remained more than 36 hours in the PICU were included. This is a secondary analysis of an interventional study with PICU Diaries. Patients were analyzed at three distinct time points: 1- within the first 48 hours of admission, collecting demographic, clinical, and baseline FSS data; 2- at PICU discharge, collecting discharge FSS data, along with clinical and critical care data from the hospitalization; 3- after 60 days post-PICU discharge, follow-up FSS was assessed. The primary outcome was the incidence of new morbidities, defined as an increase in the Functional Status Scale (FSS) score ≥ 3 points from baseline, in follow-up. Secondary outcomes were the incidence of new morbidities at PICU discharge, FSS values at PICU discharge and follow-up, description of general characteristics of patients with new morbidities, factors associated with new morbidities and description of the most affected functional domains. Results: There were 414 patients analyzed at discharge and 360 at follow-up. The incidence of new morbidity at PICU discharge was 14% (59/414) and 2.8% at follow-up (10/360). Demographic characteristics such as baseline FSS, gender, age, and prior chronic conditions were not associated with new morbidity at follow-up. Median FSS was 6 in the three assessment times, with 82% of patients having good functionality at baseline, 20% of them declining in functionality at PICU discharge, and then recovering at follow-up to 83% of them categorized as good. Factors associated with new morbidities at follow-up were admissions from referring hospitals (OR 10; 95% CI, 2.1-48), worse mortality scores, organ dysfunctions, mechanical ventilation duration, and PICU length of stay (OR 1.02; 95% CI 1-1.05). Neurologic diagnoses at admission and neurologic dysfunction were more present in those with new morbidities at follow-up (40% and 50% respectively, both p<0.001) as well as were associated with them (OR 11.8; 95% CI 3-46 and OR 16.5; 95% CI 4.4-61.7, respectively, both p<0.01). The most affected functional domains were the respiratory and feeding ones at PICU discharge and the motor function and communication at follow-up. Conclusion: In our cohort of children admitted to general PICUs, we found low levels of new morbidity at short-term follow-up, and that new morbidities at PICU discharge might be temporary. It is imperative to address and predict factors that may be related to the quality of care, and therefore, modifiable. This highlights that morbidity assessments by FSS should be a core pediatric outcome measure but also underscores the question of whether we should integrate other areas of evaluation to improve outcome measurements in the PICS-p as a whole, like family-centered outcomes and health-related quality-of-life tools, improving post-discharge follow-up strategies.