(697) Feasibility of a Nurse-Led Chronotherapeutic Bundle in the PICU: RESTORE Resilience (R2)

Introduction: Optimizing circadian rhythms (CR) in adult ICUs is feasible, safe, and improves outcomes. However, PICUs do not use CR-restoring protocols. We hypothesized that implementation of an individualized, nurse-led chronotherapeutic bundle (R2) in the PICU would be feasible and safe.

Methods: Two-phase prospective cohort study in 2 PICUs. Baseline subjects (10/site) received usual care, then 40 intervention subjects (20/site) received R2 which included a) replication of pre-hospital daily routine, b) cycled day-night light/sound, c) nurse-implemented, goal-directed sedation, d) night fasting and bolus enteral day feeds, e) early, progressive mobility, f) nurse care continuity, and g) parent diaries. Subjects were enrolled within 48 hours of PICU admission and followed to PICU discharge. Eligible children were 0.5-17 years, intubated and mechanically ventilated (MV) for acute respiratory failure. Subjects had environment (light/sound) and patient (actigraphy, activity log, salivary melatonin, EEG) monitoring. Parents completed Family-Centered Care Scale (FCCS) at PICU discharge.

Feasibility included protocol adherence and acceptability (recruitment/retention, FCCS). Safety included adverse events, symptom-free days (pain, agitation, delirium, iatrogenic withdrawal syndrome), and time to physiologic stability (vasoactive medication, MV duration, length of stay).

Results: Over 4 years, 87 families were approached and 56 (20 baseline, 36 intervention) enrolled (64% consent rate). Refusal was higher in intervention group (40% vs. 26%). Recruitment ended early due to COVID-19 pandemic. Bundle elements were applied off protocol in 17% (IQR 14-23%) of baseline days. Mean daily bundle adherence during the intervention phase was 52% (IQR 43-60%). Protocol deviations were related to EEG (refusal, leads not intact, n=31), saliva sampling (inadequate, missed samples, n=27), and actigraph removal (n=10). Parent satisfaction (FCCS) was high and similar between groups. Few parents (n=16) used diaries. Adverse events (2 baseline, 1 intervention) were unrelated to R2. Symptom-free days and time to physiologic stability were similar between groups.

Conclusions: In the PICU, CR-restoring bundles are acceptable to parents; invasive monitoring and diaries are not. Bundle implementation is safe but requires nurse support.