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Evidence-Based Strategies for Common Clinical Questions

March 2019

A Pediatrician’s Role in Addressing Psychological Trauma Following Discharge from the ICU

 

Author: James Odum, MD | Chief Resident, Children’s Mercy Kansas City

Column Editor: Rupal Gupta, MD | Medical Director, Operation Breakthrough Clinic | General Academic Pediatrics | Assistant Professor, UMKC School of Medicine

Most providers in the intensive care unit (ICU) setting are trained to focus primarily on acute physiologic derangements that can be corrected and stabilized. In this state, where a child is acutely under the threat of death and permanent disability, patients and their caregivers can experience psychological impairments as well. Once stable, pediatric patients ultimately transition back to their homes into the care of their families and primary care providers. As part of recovery, primary care providers need to be equipped to help treat these multifaceted consequences, which can persist long after the patient’s physical injuries and physiologic insults have stabilized.

As researchers learn more about the recovery process, awareness has arisen for a condition called Post-Intensive Care Syndrome (PICS or PICS-p) in children and their families. This condition describes the persistent impairment in physical, emotional, cognitive, and social domains that can occur in children and their family members after PICU stays.1,2 Functional impairment in physical function can include respiratory difficulties, impaired self-care, and reduced mobility, and can continue for months to years. Cognitive impairment—including developmental delays and declines in IQ — is also common and is of highest risk in those admitted for trauma, injury, poisoning, neurologic problems, cancers, and in patients who experience mechanical ventilation, extracorporeal life support, or a long PICU stay.2

After hospitalization, children may suffer emotional sequelae including irritability, avoidance of memories of the hospitalization, and fear. In a recent study, 20% were found to be at higher risk for psychiatric disorders, and 34% were found to have high levels of post-traumatic stress symptoms.3 Additionally, family-related consequences can be far-reaching, including adverse effects on siblings, and approximately one-third of parents experience acute stress disorder after a child’s PICU stay. Risk of long-term challenges increases in children who underwent unexpected medical procedures, have experienced traumatic events, or prior psychiatric illness. Families with limited social support, or negative memories of the PICU stay are also more likely to face challenges.2 One study estimates that 21% of children and 27% of parents experience post-traumatic stress disorder (PTSD) symptoms at six and 12 months post-discharge from the ICU.4

While it is recognized that some families can be resilient and recover quickly from PICS, others have more difficulty.  The sequelae of cumulative stress on a family can present in a variety of ways. Some families may avoid health care settings that remind them of the ICU admission altogether, thus making it more challenging for primary care providers to successfully intervene.5 On the flip side, children with a recent history of ICU admission are more likely to be readmitted without objective evidence supporting an indication for admission when compared to patients who were discharged following an exclusively inpatient floor-status stay.4 This suggests that parental anxiety may also increase health care utilization post-ICU discharge. This makes it particularly challenging to identify the children and parents who are struggling with resilience and acclimation to the child’s baseline health status following discharge from the ICU.

Mitigating the long-term effects of PICU stays takes a multi-faceted approach. In the ICU, efforts at early mobilization and reduction of sedation serve to help reduce negative sequelae. After discharge, the responsibility of care transitions from the ICU physicians to primary care providers. There are a few key areas to focus on in the immediate post-discharge timeframe:

  1. Identify previously established patients who have recently been discharged following an ICU stay.
  2. Ensure that the patient is scheduled for a follow-up appointment, which may require clinic staff proactively calling families who are hesitant to re-engage the health care system after the ICU experience.
  3. Review the physical health needs of the patient, including needs for subspecialty referrals and therapies.
  4. Importantly, consider screening the child’s current cognitive and mental health status using tools that are familiar to the provider’s practice. The Davidson Trauma Scale has been validated to screen for symptoms of PTSD and has been used by at least one study looking at PTSD in families following ICU admissions.6,7
  5. If a patient has a positive screen, the provider should refer to mental health resources either within their own practice, or within the community.

It is also important to keep in mind that symptoms of depression, anxiety and PTSD may persist 6 to 12 months post-ICU discharge, so regular follow-up with additional considerations to rescreen high-risk children is reasonable. PTSD rates are higher in children who experienced multiple PICU admissions as compared to those with first-time ICU stays. Parents who are single/divorced, those who had a history of receiving prior psychiatric treatment, and those with self-reported economic difficulty, are also at higher risk of PTSD.5,6

Gender differences in stress response suggest that fathers and mothers experiencing psychologic sequelae may require different interventions. In one study, fathers derived stress from feeling unable to protect a child in the ICU, as well as balancing employment obligations with the desire to support the family emotionally.8 When compared to mothers, fathers more commonly engaged work peers as a support system, and were less likely to use hospital-based resources or peer-to-peer support groups. Since only one parent may be present at the follow-up visit, consider including other prominent caregivers in the conversation by phone when reviewing the medical information and screening for anxiety, depression, or PTSD.

Data suggests that successful interventions directed toward parents can have a positive impact on the mental health outcomes in their children.9 Primary care providers can encourage appropriate physical activity and cognitive interventions for children, as well as screen patients and their caregivers for symptoms of psychological comorbidities and refer accordingly. Frequent follow-up can be beneficial in patients recovering from PICU stays. Although no clear recipe can completely mitigate the psychological impact of a pediatric ICU admission, having an opportunity to treat the family unit as a whole longitudinally plays into the strengths of primary care providers, and cements ambulatory providers as vital members of the child’s trauma team.

 

References

1. Conceptualizing Post Intensive Care Syndrome in Children—The PICS-p Framework. Manning JC, et al. Pediatr Crit Care Med. 2018 Apr;19(4): 298-300.

2. Life after Critical Illness in Children—Toward an Understanding of Pediatric Post-intensive Care Syndrome. Watson RS, et al. The Journal of Pediatrics. 2018 Jul;198:16-24.

3. Mental and Physical Well-Being Following Admission to Pediatric Intensive Care. Al, LC, et al. Pediatr Crit Care Med. 2015 Jun;15(5):3141-9.

4. Psychiatric Outcome Following Paediatric Intensive Care Unit (PICU) Admission: A Cohort Study. Rees G, Gledhill J, Garralda ME. Intensive Care Med. 2004; 30:1607-1614.

5. Systematic Review of Interventions to Reduce Psychiatric Morbidity in Parents and Children after PICU Admissions. Baker SC, Gledhill JA. Pediatric Crit Care Med. 2017; 18:343-348.

6. Prediction of Parental Post-Traumatic Stress, Anxiety and Depression after a Child’s Critical Hospitalization. Rodriguez-Rey R, et al. Journal of Crit Care. 2018; 45:149-155.

7. Assessment of a New Self-rating Scale for Post-Traumatic Stress Disorder. Davidson JRT, et al. Psychol Med. 1997; 27:153-160.

8. Mothers and Fathers Experience Stress of Congenital Heart Disease Differentially: Recommendations for Pediatric Critical Care. Sood E, et al. Pediatr Crit Care Med. 2018; 19(7):626-634.

9. Treatment of Parental Post-Traumatic Stress Disorder After PICU Admission: Who, What, Where, When? Als LC, Garralda ME. Pediatr Crit Care Med. 2015; 16(9): 877-878.