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Intracranial pressure: A role for a surrogate measurement?

I n this issue of Pediatric Critical Care Medicine, Namachivayam et al (1) at the Royal Children’s Hospital in Melbourne have published a single-center comparison of the characteristics and outcomes of patients admitted to the pediatric intensive care unit (PICU) in three cohorts of patients from different decades (1982, 1995, and 2005– 2006). Their major findings were that PICU mortality dropped significantly over the three time periods (even though the predicted mortality by Pediatric Index of Mortality was unchanged), but that the proportion of patients with moderate-tosevere disability at follow up conversely rose. Other interesting findings included an increase in readmission rate over time, an increase in the use of noninvasive ventilation, and a decrease in the frequency of trauma, croup, and epiglottitis. Namachivayam and colleagues (1) speculate that mortality decreased because improved lifesaving interventions are available in PICUs, but that disability increased because children with severe underlying conditions or severe sequelae of illness are now surviving when they would not have done so two decades ago. There are little published populationbased data to support the perception of many that more children are living with complex chronic conditions. Variability in definitions of chronic illness and disability makes comparisons between studies challenging (2), and true prevalence data are difficult to obtain as most reports are from hospital cohorts where complex chronic conditions are likely overrepresented. What we can say is that, in the United States, the number of children receiving federal Supplemental Security Income has increased by a factor of 10 from the mid-1970s, from approximately 100,000 children nationally to 1 million children in recent years (3). Although this finding implies that there are more children living with chronic disabilities, the change could also reflect shifts in government eligibility criteria or in public awareness that such programs exist. Others (4) have reported that children with chronic conditions make up as many as 67% of PICU patients, suggesting that the trends reported in the study from Melbourne are not isolated to their institution. The strengths of this manuscript are that the authors used a database with prospectively collected information that also includes follow-up data. Although many intensive care units have databases, few have taken this next logical step of including information about outcomes after discharge from the intensive care unit. One of the main limitations of the study is that the most recent cohort of patients (2005–2006) had a much lower rate of complete follow-up information (43%) than the prior years. Incomplete follow-up could obviously bias some of their comparisons—if children who did particularly well or particularly poorly were, for some reason, less likely to be contacted by the follow-up phone call, the estimates of disability and even mortality for that cohort could be erroneous. The authors, therefore, appropriately present a range of possible mortality and disability rates for the postdischarge data, and their conclusions are supported by the fact that they were able to track more accurately the changes in outcome at the time of PICU discharge, which showed similar trends. One other limitation of the study is that the first cohort of patients (1982) also included premature neonates, who were cared for in the same unit at that time. The authors account for this by also presenting an analysis that excludes all patients aged 1 month old at the time of admission, which has the disadvantage of also being likely to exclude a large group of patients with congenital heart disease, a group for whom long-term morbidities are a serious concern. An implicit question in the paper is whether it benefits children, families, and society to improve survival in pediatric critical illness if this leads to having more survivors with moderate-to-severe disabilities or long-term health problems. For many of these children, however, as well as for their families, a life with significant morbidities is still a life worth living. In addition, in other studies of children discharged from the PICU, the majority have a normal or relatively good quality of life (5, 6). In the current study, most of the increase in disability was seen in the moderate, not severe, range. Clinicians are also not always skilled at assessing who will have a good functional outcome early on in an intensive care unit stay or at assessing the quality of life of impaired patients (7). For all of these reasons, we should not regret the improvements in lifesaving care we have achieved. So, what are we to do? One approach would be to shift the emphasis away from concerns about “saving too many” children, and instead, we should focus on making sure families are informed about the full range of options, including less-invasive comfort measures, for their children. Ideally, this discussion should occur before the onset of a critical illness, yet many times, the deterioration itself is the spur for the discussion. There is evidence that over time more parents of children with complex chronic conditions are choosing to take their children home with hospice (8). If we set up systems to make sure such services are available, then we can better assist families in making choices that meet the needs of their child. The findings in this manuscript also underscore the need for improved systems of follow-up after discharge from the PICU, so that we can come to a better understanding of the individual and societal impact of the lifesaving care we provide. The Melbourne group has a good start by simply including a follow-up phone call in their database. More rigorous long-term outcome data and PICU follow-up programs would go *See also p. 549.