Research Utilization Project: Early mobilization in pediatric cardiac surgical patients
Theodore R. Dage
University of Florida

Abstract

Prolonged sedation and mechanical ventilation in the ICU setting has the potential for negative effects in the pediatric post-surgical period. A systematic review of the literature reveals a lack of high-quality recent research into the feasibility and benefits of an early mobilization protocol in this population. A PICO question will be stated to guide research, and an examination of the existing research on the subject discussed. The author will demonstrate the justification for further research into such a protocol.

Research Utilization Project: Early mobilization in pediatric cardiac surgical patients
Mechanically ventilated patients in the adult ICU setting frequently experience prolonged periods of immobility and sedation (Schweickert et al., 2009); this is also the case in the pediatric post-surgical population. Prolonged pharmacologic sedation is associated with significant adverse sequelae (Wolf & Jackman, 2011). Early extubation and mobilization of cardiac surgical patients has been shown to reduce postoperative complications and shorten length of stay (Pande, Nader, Donias, D’Ancona, & Karamanoukian, 2003).
The research question generated to examine a justification for a clinical research project is stated in PICO format as follows: In pediatric patients aged 6-13 (P), does a protocol of early mobilization and extubation (I) reduce length of stay and postoperative complications (O) when compared to the standard protocol for this patient population (C). This question was utilized to guide preliminary and subsequent literature searches; upon a cursory review of the literature and finding no evidence-based guidelines for early mobilization of patients, this author determined that the PICO question was sufficiently relevant and narrow to justify guiding a research project without revision.
A PubMed search was performed using MeSH terms “cardiac surgery,” “early ambulation,” and “child.” This search resulted a single study regarding parental perceptions of fast-track cardiac surgery by Jawahar & Scarisbrick (2009). A revision of the PubMed search to include the term “fast-track” and delete “early ambulation” yielded 16 results, of which 7 were discarded for reasons including a focus on adult populations, a focus on parental perception, or a clinical focus on one specific intervention such as bispectral monitoring. The remaining articles range in date from 2000 to 2014, with the majority of studies conducted less than five years prior to this article.
A Cochrane database search was conducted utilizing the same MeSH terms as the PubMed search; there was no result returned. The search strategy was expanded to exclude the term “pediatric,” yielding a single meta-analysis by Zhu, Lee, & Chee (2012). While this review focuses on the adult cardiac patient, the fast-track strategies and discussion of adverse events associated with prolonged immobility and intubation may be generalizable to the pediatric population.
A comprehensive search of the AHRQ guideline database, guidelines.gov, in an effort to find evidence-based clinical practice guidelines for either early mobilization or fast track extubation; no such guidelines exist. A general database search in EBSCO provided a single UK guideline with tangential application to the research question. However, the majority of the guideline is dedicated to the discussion of sedation and analgesia in the critically ill child, and only indirectly discusses early extubation and mobilization (Playfor et al., 2006).
Given the articles found, there is reason to conclude that a knowledge gap exists in the discussion of mobilization of post-operative cardiac pediatric surgical patients. With the potential for negative outcomes and adverse events, as well as potential reduction in length of stay, it is reasonable to state that the benefits of answering the PICO question outweigh the expenditure of resources and time. It is the conclusion of this author that a research project is justified based upon the PICO question as stated.

References
Jawahar, K., & Scarisbrick, A. A. (2009, April). Parental perceptions in pediatric cardiac fast-track surgery. AORN Journal, 89, 725-731. http://dx.doi.org/10.1016/j.aorn.2008.11.029
Pande, R. U., Nader, N. D., Donias, H. W., D’Ancona, G., & Karamanoukian, H. L. (2003, April 24). Fast-tracking cardiac surgery. The Heart Surgery Forum, 6, 244-248. Retrieved from www.hsforum.com/vol6/issue4/2003-21309.html
Playfor, S., Jenkins, I., Boyles, C., Choonara, I., Davies, G., Haywood, T., ... Wolf, A. (2006, August). Consensus guidelines on sedation and analgesia in critically ill children. Intensive Care Medicine, 32, 1125-1136. http://dx.doi.org/10.1007/s00134-006-0191-9
Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., ... Kress, J. P. (2009, May 30). Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomized control trial. The Lancet, 373, 1874-1882. http://dx.doi.org/DOI:10.1016/S0140-6736(09)60658-9
Wolf, A. R., & Jackman, L. (2011, May 2011). Analgesia and sedation after pediatric cardiac surgery. Pediatric Anesthesia, 21, 567-576. http://dx.doi.org/10.1111/j.1460-9592.2010.03460.x
Zhu, F., Lee, A., & Chee, Y. E. (2012, October). Fast-track cardiac care for adult cardiac surgical patients. The Cochrane Database of Systematic Reviews, 1-73. http://dx.doi.org/10.1002/14651858.CD003587.pub2