A research definition and framework for acute paediatric critical illness across resource-variable settings: a modified Delphi consensus

Abstract

The true global burden of paediatric critical illness remains unknown. Studies on children with life-threatening conditions are hindered by the absence of a common definition for acute paediatric critical illness (DEFCRIT) that outlines components and attributes of critical illness and does not depend on local capacity to provide critical care. We present an evidence-informed consensus definition and framework for acute paediatric critical illness. DEFCRIT was developed following a scoping review of 29 studies and key concepts identified by an interdisciplinary, international core expert panel (n=24). A modified Delphi process was then done with a panel of multidisciplinary health-care global experts (n=109) until consensus was reached on eight essential attributes and 28 statements as the basis of DEFCRIT. Consensus was reached in two Delphi rounds with an expert retention rate of 89%. The final consensus definition for acute paediatric critical illness is: an infant, child, or adolescent with an illness, injury, or post-operative state that increases the risk for or results in acute physiological instability (abnormal physiological parameters or vital organ dysfunction or failure) or a clinical support requirement (such as frequent or continuous monitoring or time-sensitive interventions) to prevent further deterioration or death. The proposed definition and framework provide the conceptual clarity needed for a unified approach for global research across resource-variable settings. Future work will centre on validating DEFCRIT and determining high priority measures and guidelines for data collection and analysis that will promote its use in research.

Figure:. Possible illness trajectories over time

The y–axis represents the health or clinical status of a patient; high indicating good or towards baseline health, and a trend towards low indicating worsening clinical status. Acute critical illness can be identified at any point along this trajectory, depending on when the patient presents to medical care and the provider’s ability to recognise critical illness. The timecourse of acute critical illness progresses on the x–axis. For example, a previously healthy child presents with fever, tachycardia, tachypnoea, and respiratory distress and is diagnosed with pneumonia. The disease progresses to acute respiratory distress syndrome and the patient requires respiratory support. Monitoring and interventions reverse the trajectory and result in recovery, or the course of illness results in ventilatory dependence (chronicity or disability), or disease progression or complications result in death. *The need, frequency, or type of monitoring or interventions depend on the provider’s clinical judgement and the disease process. †Recovery can be variable, either returning to baseline or not. A patient’s trajectory can involve recurrent illness and multiple insults.