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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 165-173

The risk factors of the functional status, quality of life, and family psychological status in children with postintensive care syndrome: A cohort study


1 Department of Pediatrics, Division of Emergency and Intensive Care, Saiful Anwar General Hospital, Faculty of Medicine Brawijaya University, Malang, East Java, Indonesia
2 Department of Biomedical Sciences, Saiful Anwar General Hospital, Faculty of Medicine Brawijaya University, Malang, East Java, Indonesia

Date of Submission25-Jan-2022
Date of Acceptance11-Apr-2022
Date of Web Publication20-Sep-2022

Correspondence Address:
Dr. Saptadi Yuliarto
JA Suprapto Street Number 2, Malang, East Java 65111
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijciis.ijciis_7_22

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   Abstract 


Background: Intensive care treatment has a side effect of several impairments after hospital discharge, known as postintensive care syndrome (PICS). PICS in children must be well evaluated because PICS can affect their global development and quality of life. Our specific aims are to determine the impact of intensive care treatment and the risk factors which contribute to PICS.
Methods: In this observational cohort study, we identified critically ill children treated in intensive care units (ICUs) for more than 24 h and survived. We evaluated the internal and external risk factors of the patients in the intensive care. We interviewed their parents to define the functional status and quality of life of the patients in 7 days before ICU admission and the psychological status of the family at the time of intensive care admission. The interview was repeated in 3 months after the intensive care discharge.
Results: There was a significant decrease in functional status and quality of life after intensive care treatment (P < 0.001). However, none of the internal risk factors were significantly associated with PICS. Neurologic involvement in the disease was associated with the significantly reduced functional status of patients, while the severity of the disease was significantly associated with both functional status and quality of life. Our study also showed a significant psychological disorder of the family in the intensive care.
Conclusion: The occurrence of PICS in children was associated with the severity of the disease, decreased the functional status and quality of life, and contributed to psychological disorders for the family.

Keywords: Critical illness, functional status, pediatric intensive care, post-intensive care syndrome, quality of life, risk factors


How to cite this article:
Yuliarto S, Kadafi KT, Fauziah S, Khalasha T, Susanto WP. The risk factors of the functional status, quality of life, and family psychological status in children with postintensive care syndrome: A cohort study. Int J Crit Illn Inj Sci 2022;12:165-73

How to cite this URL:
Yuliarto S, Kadafi KT, Fauziah S, Khalasha T, Susanto WP. The risk factors of the functional status, quality of life, and family psychological status in children with postintensive care syndrome: A cohort study. Int J Crit Illn Inj Sci [serial online] 2022 [cited 2022 Nov 30];12:165-73. Available from: https://www.ijciis.org/text.asp?2022/12/3/165/356357




   Introduction Top


Improvement of pediatric intensive care technology and management recently has brought the increase of children's survival rate from various critical diseases.[1] However, this improvement is frequently followed by an increase in morbidity after the intensive care has finished.[2] This condition is also known as postintensive care syndrome (PICS) and has a varied spectrum of impairment. PICS is defined as the novel impairment of a patient who survived intensive care after suffering a critical condition.[3] These impairments are classified into three main groups, which are physical function, mental status, and cognitive function.[3] New disabilities in children following intensive care may have significant long-term effects and should be detected and managed comprehensively in a timely fashion. In children, PICS detection is complicated by differences in dependency and baseline functional status, organ maturation, and other factors. In addition, PICS may also negatively impact the patient's family, known as PICS-Family.[1],[4]

The main concern of PICS impairment in children is how this condition affects functional status and quality of life afterward. A study by Namachivayam et al. showed that there was a decrease in mobility in children after surviving from pediatric intensive care unit (PICU), and this limitation mostly lasts up to 1 year afterward.[5] This condition is also known as intensive care unit-acquired weakness (ICU-AW), which occurs by several mechanisms, including microvascular ischemia, catabolism-induced muscle wasting, and critical neuropathy.[6] Even more than mobility impairment, Colville and Pierce (2012) showed an overall decrease of quality of life (QoL) from children for up to 1-year post-ICU treatment.[7] The effects of PICS are also altering psychological and cognitive aspects of children, which are harder to deal with.

The treatment process of the ICU involves several invasive interventions which the patient must deal with, and this could be associated with morbidity in PICS. Other factors known to impact the occurrence of PICS include age, gender, type and severity of disease, amount of intervention performed, and length of intensive care.[5] These factors could influence the outcome of the patient, but the significance and the synergy of each factor remains unclear. This study aimed to show the effect of intensive care treatment on pediatric patients in terms of functional status and QoL and the impact on the family. Risk factors were analyzed to further clarify their level of contribution.


   Methods Top


This analytical observational prospective cohort study was designed to discover the impairment of functional status and QoL in children with PICS and the psychological impact on their family with identification of significant contributing internal or external factors. The sample of this study was defined as children aged 1 month–18 years who were treated in the PICU for more than 24 h and survived the critical disease. The patient and family then followed up 3 months after the intensive care. This study was conducted by the Pediatric Emergency Department of Saiful Anwar General Hospital from December 1, 2019, to May 31, 2020, at PICU of Saiful Anwar General Hospital. All the protocols in this study were approved by the Ethical Committee of Faculty of Medicine, Brawijaya University, Malang City, Indonesia.

Every parent of the patients who were eligible to be included in this study received and signed informed consent about this study. We classified many predicted risk factors into internal and external factors. The internal factors included gender, age, family composition, and socioeconomic status. The family composition was divided into intact (parents are married and live together in the same house with the children) and nonintact (any close family member who does live not in the same house). Based on monthly income category set by Indonesian Central Bureau of Statistic where socio-economic status was divided into: low (monthly income < Rp 1,500,000), middle (monthly income between Rp 1,500,000 to Rp 3,500,000), and high (monthly income > Rp 3,500,000).[8]

The external factors included surgical intervention, neurological disease involvement, pediatric index mortality (PIM), PICU length of stay, length of mechanical ventilation, and the number of interventions. The number of interventions was evaluated using Therapeutic Intervention Scoring System (TISS) score [Appendix 1].[9] The parents were also interviewed about Functional Status Scale (FSS) [Appendix 2],[10] Pediatric Quality of Life (PedsQL) [Appendix 3] [11] of their children <7 days before admission, and the psychological condition of the family by Depression, Anxiety, and Stress Score (DASS) [Appendix 4] [12] on the time of intensive care admission. The interview was then repeated after 3 months after completion of the intensive care.



The baseline characteristic data were descriptively analyzed and then reported in median and interquartile range. Normality test was performed to all of the parameters with Shapiro–Wilk test, followed by homogeneity test (by Levene's test). The comparison of the results of FSS, PedsQL, and DASS between pre-intensive care and 3 months after intensive care was performed by dependent t-test or Wilcoxon Signed Rank test. The bivariate association between each of the factors with FSS, PedsQL, and DASS after intensive care is also being analyzed by Mann–Whitney Test, Kruskall–Wallis Test, or Spearman's correlation test, based on the type of the data. Every factor which elicits significant differences in bivariate analysis is then collected, and the multivariate analysis is performed (by multiple logistic regression) to gain the contributing factor. Each statistical analysis is considered to be statistically significant if the P < 0.05.


   Results Top


Subject characteristics

There are 45 children and their parents included in this study who survived the intensive care and could be followed up 3 months later. The baseline characteristics, as shown in [Table 1], are already classified into every factor tested in this study. From the internal factors, most of the family was intact and classified into middle social-economic status. From the external factor, more children had a critical disease that required surgical intervention. The severity of the disease by PIM score means reported 8.86% predicted death rate of the patient in this study. TISS score median was 24, which indicated the various interventions given and potentially induced morbidity of the patient afterward.
Table 1: Baseline subjects characteristics

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Comparison between pre- and post-intensive care

Functional Status Scale

There was a significant difference (P < 0.001) in children's functional status before intensive care and 3 months after intensive care. Twenty-two children with previous normal conditions gained mild-to-severe dysfunction 3 months after intensive care [Table 2].
Table 2: Functional Status Scale result

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Pediatric Quality of Life

There was a significant (P < 0.001) decrease in patients' QoL before intensive care and after 3 months after intensive care. As shown in [Figure 1], the mean of PedsQL before intensive care was 76.1 ± 2.6 and decreased to 61.1 ± 3.1 in 3 months after intensive care.
Figure 1: Mean differences of Pediatric Quality of Life score before and 3 months after intensive care

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Family Depression, Anxiety, and Stress Score

There was a significant improvement of family psychological condition between admission and 3 months after completing the intensive care. As shown in [Table 3], most of the family developed depression, anxiety, and stress with various severity; however, they got improvement after 3 months' postintensive care.
Table 3: Family Depression, Anxiety, and Stress Score

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Risk factor to functional status

From the bivariate analysis, there were several risk factors significantly associated with the functional status of the patient. As shown in [Table 4], none of the internal factors are associated, and all of the external factors but surgical interventions were associated with the functional status. From the multivariate analysis, PIM score and neurologic disease involvement were significantly associated with less functional status in children after intensive care, as shown in [Table 5].
Table 4: Bivariate analysis of risk factor to functional status

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Table 5: Multivariate analysis of risk factor to functional status

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Risk factor to quality of life

From the bivariate analysis, several external factors of the patient had an association with the decrease in QoL. Similar to the pattern shown in functional status, as shown in [Table 6], none of the internal factors and external factors elicited a significant decrease; however, surgical intervention was associated with the patients' QoL. From the multivariate analysis, as shown in [Table 7], only the PIM score showed a significant association with the decrease in QoL (P < 0.001).
Table 6: Bivariate analysis of risk factors to the quality of life

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Table 7: Multivariate analysis of risk factors to the quality of life

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Risk factor to family psychological condition

From the bivariate analysis, several external factors of the patient had a significant association with the deterioration of the family psychological condition, as shown in [Table 8]. All kinds of psychological disturbances evaluated by DASS elicited by similar external risk factors, such as PIM score, length of ventilator usage, and TISS score. From the multivariate analysis, as shown in [Table 9], none of the risk factors showed a significant association with family psychological condition differences.
Table 8: Bivariate analysis of risk factors to the family psychological condition

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Table 9: Multivariate analysis of risk factors to the family psychological condition

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   Discussion Top


There was a significant decrease in functional status and QoL in children after they had undergone intensive care and survived. Functional status evaluated by FSS showed the condition of 6 domains, which are mental status, sensory function, communication, motoric function, feeding ability, and respiration. Each FSS domain can deteriorate after intensive care and indicate several pathologic events described in PICS, such as muscle mass decrease, neuromuscular weakness, blunt sensory, nociceptive function, fatigue, and weight loss. This functional disruption furthermore causes a reduction of patients' QoL. These conditions may improve after a long time with follow-up therapy, as reported by Theofilou et al. that there was a significant improvement in the patient 12 months later. This study evaluated until 3 months after intensive care was fulfilled, thus evaluated patients over a longer time horizon, may identify continued recovery and restore children's QoL.[13]

None of the internal risk factors were significantly associated with the decrease in functional status and QoL of the patient. This result is different from a previous study by Als et al. that reported younger children and nonintact family composition had an association with fatigue postintensive care, one of the spectra of PICS.[14] The nonintact family was much less than the intact family in our study, which can explain the nonsignificant results. In addition, the composition of the family not always correlated with less care of the children, which also can reduce the disability of the children. The external factor more significantly induces morbidity in children postintensive care.

Neurologic disease involvement had a significant association with the decrease of functional status postintensive care but was nonsignificant to reduce the QoL. This result parallels with the previous study which reported neurologic critical disease that causes the patient to be hospitalized in intensive care produce neurologic dysfunction sequelae. This neurologic impairment reduces motor, sensory, and cognitive function which had a pivot role in long-term disability.[15] Impairment of each age phase of children inhibits the development process, which could produce less QoL. Nonsignificant decrease in QoL in this study might just be statistically, which required more patients to be included in this study.

The severity of the disease was significantly associated with the decrease of functional status and QoL postintensive care. Patients with higher PIM scores on PICU admission developed more functional status impairment and lower QoL afterward. These results are following the previous study from Pereira et al. which reported that functional impairment even lasted up to 2 years' postintensive care and was mainly affected by the severity of the disease and any organ dysfunction. Lower functional status in children postintensive care can lead to disturbance of normal development which causes higher and longer dependence on parents' care. This event reduces the ability of the children to learn and develop by themselves, thus lowering their QoL.[16]

From the impact of intensive care to family psychological conditions, admission of their children definitely caused a burden in psychological terms. Of the 45 parents included in this study, 18 developed depression syndromes, 32 with anxiety, and even 10 parents developed stress conditions in the time of their children admission to PICU. These results are similar to a study from Davidson and Harvey who reported anxiety found in 10%–75% family and 8%–42% develop symptoms of Post-Traumatic Stress Disorder.[17] This condition can be hard enough to disturb the daily activity of the family and require taking some medication to relieve them. A study from Lemiale et al. reported 36% of the family took antidepressant medication, and 8% took psychotropic drugs.[18] The psychological condition of the family was much better after 3 months in this study. The ability to adapt to the patient's problem or disability would reduce the incidence of depression, anxiety, or stress to the family. The complete comprehension of the family about the patient's condition was also crucial to prevent the psychological problem, which could be achieved by involvement of the close family in their children nursing and good communication between health professionals and the family throughout and after the intensive care.[19] None of the internal and external risk factors evaluated in this study had a significant impact on the family psychological condition. It showed that clear continuous communication and the involvement of the family, as not evaluated in this study, were the key aspects to maintain the good psychological condition of the family.

There are some limitations to this study, considering this study was single-centered research. The social and cultural background was similar between the patient and family included in this study, so the demography characteristics were homogeneous, and this can impact the outcome of the study. Another factor that could influence the patients' outcomes, such as intervention postintensive care also not evaluated in this study. Longer study and the impact of the intervention postintensive care required to comprehend the occurrence of PICS and how can we deal with it.


   Conclusion Top


From this study, we found that the occurrence of PICS in children could decrease the functional status and QoL. The severity of the illness was the important factor affecting the deterioration of functional status and QoL. Neurologic disease involvement at the time of admission also had an impact on the patient's outcomes postintensive care. Intensive care to the children also had an impact on their family, especially their parents, and could induce psychological disturbances, such as depression, anxiety, and stress. These conditions were relieved as time goes on and better comprehension to adapt to the patient's condition.

Research quality and ethics statement

This study was approved by the Institutional Review Board/Ethics Committee of the Faculty of Medicine, Universitas Brawijaya, Malang City, Indonesia (Approval No.400/291/K.3/302/2019; Approval date December 13th, 2019). The authors followed the applicable EQUATOR Network guidelines, specifically the STROBE Guidelines, during the conduct of this research project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Manning JC, Pinto NP, Rennick JE, Colville G, Curley MA. Conceptualizing post intensive care syndrome in children The PICS-p framework. Pediatr Crit Care Med 2018;19:298-300.  Back to cited text no. 1
    
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Pollack MM, Holubkov R, Funai T, Clark A, Berger JT, Meert K, et al. Pediatric intensive care outcomes: Development of new morbidities during pediatric critical care. Pediatr Crit Care Med 2014;15:821-7.  Back to cited text no. 2
    
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Herrup EA, Wieczorek B, Kudchadkar SR. Characteristics of postintensive care syndrome in survivors of pediatric critical illness: A systematic review. World J Crit Care Med 2017;6:124-34.  Back to cited text no. 4
    
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Namachivayam P, Taylor A, Montague T, Moran K, Barrie J, Delzoppo C, et al. Long-stay children in intensive care: Long-term functional outcome and quality of life from a 20-yr institutional study. Pediatr Crit Care Med 2012;13:520-8.  Back to cited text no. 5
    
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Colville GA, Pierce CM. Children's self-reported quality of life after intensive care treatment. Pediatr Crit Care Med 2013;14:e85-92.  Back to cited text no. 7
    
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Badan Pusat Statistik Indonesia (Indonesian Central Bureau of Statistic). The Classification of the Population According to Income. BPS; 2016. Available from: https://www.bps.go.id. [Last accessed on 2022 Mar 31].  Back to cited text no. 8
    
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Rosa RG, Roehrig C, Oliveira RP, Maccari JG, Antônio AC, Castro Pde S, et al. Comparison of unplanned intensive care unit readmission scores: A prospective cohort study. PLoS One 2015;10:e0143127.  Back to cited text no. 9
    
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Pollack MM, Holubkov R, Glass P, Dean JM, Meert KL, Zimmerman J, et al. Functional Status Scale: New pediatric outcome measure. Pediatrics 2009;124:e18-28.  Back to cited text no. 10
    
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Varni JW, Burwinkle TM, Seid M, Skarr D. The PedsQL 4.0 as a pediatric population health measure: Feasibility, reliability, and validity. Ambul Pediatr 2003;3:329-41.  Back to cited text no. 11
    
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Antony M, Bieling P, Cox B, Enns M, Swinson R. Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychol Assess 1998;10:176-81.  Back to cited text no. 12
    
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Theofilou P. Quality of life: Definition and measurement. Eur J Psychol 2013;9:150-62.  Back to cited text no. 13
    
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Als LC, Picouto MD, Hau SM, Nadel S, Cooper M, Pierce CM, et al. Mental and physical well-being following admission to pediatric intensive care. Pediatr Crit Care Med 2015;16:e141-9.  Back to cited text no. 14
    
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Sculier C, Gaínza-Lein M, Sánchez Fernández I, Loddenkemper T. Long-term outcomes of status epilepticus: A critical assessment. Epilepsia 2018;59 Suppl 2:155-69.  Back to cited text no. 15
    
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Pereira GA, Schaan CW, Ferrari RS. Functional evaluation of pediatric patients after discharge from the intensive care unit using the Functional Status Scale. Rev Bras Ter Intensiva 2017;29:460-5.  Back to cited text no. 16
    
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Davidson JE, Harvey MA. Patient and family post-intensive care syndrome. AACN Adv Crit Care 2016;27:184-6.  Back to cited text no. 17
    
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Lemiale V, Kentish-Barnes N, Chaize M, Aboab J, Adrie C, Annane D, et al. Health-related quality of life in family members of intensive care unit patients. J Palliat Med 2010;13:1131-7.  Back to cited text no. 18
    
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de Beer J, Brysiewicz P. Developing a theory of family care during critical illness. South Afr J Crit Care (Online) 2019;35:19-24.  Back to cited text no. 19
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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