Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals

Recognition and Management of Delirium in the Neonatal Intensive Care Unit: Case Series From a Single-Center Level 4 Intensive Care Unit

Delirium often goes unrecognized in neonates and children because of lack of experience in evaluating behavior and cognition, insufficient awareness of the prevalence, and nondistinctive symptoms in this population. Although there are increasing reports of the presence of delirium in neonates, there are few data to guide the pharmacologic treatment in this population. In this retrospective single-center case series, we present our experience using quetiapine to treat delirium in 9 medically complex neonates. Based on an extensive literature review, expert opinion, and institutional experience, we propose an approach for monitoring and treating delirium in neonates and infants.

Age-specific vulnerability and high prevalence of delirium in pediatric intensive care based on a prospective cohort study

BACKGROUND

Delirium, a neuropsychiatric syndrome characterized by acute disruptions in attention and awareness, significantly impacts children in Pediatric Intensive Care Units (PICUs), leading to prolonged hospitalization, increased infection risk, and dependence on mechanical ventilation. Despite growing recognition, its true burden and risk factors in children remain poorly understood. This prospective cohort study investigated the prevalence, characteristics, and potential therapeutic targets for delirium in 890 children admitted to a tertiary PICU between January and December 2022. Delirium was screened every 12 hours using the validated Cornell Assessment of Pediatric Delirium (CAPD). We analyzed data on demographics, comorbidities, medications, interventions, and clinical outcomes to identify associations with the development of delirium. Our study revealed a high prevalence of delirium, affecting 69.4% (95% CI: 66.33-72.3) of admitted children. Notably, infants were disproportionately affected, accounting for 33.5% of delirium cases. Respiratory diagnoses were significantly associated with delirium (78.6%), while oncology cases had the lowest prevalence (29.4%). Opioid use was identified as a risk factor, increasing the risk of delirium by 45.2%. Furthermore, 97.6% of children with withdrawal syndrome also experienced delirium, highlighting a strong association between these conditions. Delirium was significantly associated with longer PICU stays, and all 20 mortalities during the study period occurred in delirious patients. The adjusted odds ratios from multi-level regression modeling further elucidated the risk factors associated with the development of delirium. This study demonstrates a high prevalence of delirium in PICUs, with infants and those with respiratory diagnoses being particularly vulnerable. Opioid use and withdrawal syndrome emerged as risk factors. Further research is needed to elucidate the mechanisms underlying these associations and develop targeted interventions to prevent, manage, and improve outcomes for children suffering from delirium in critical care settings.

Factors Influencing Analgesic Use During Transport of Intubated Pediatric Patients

OBJECTIVES

Critically ill children undergo painful procedures during resuscitation and stabilization before and during interfacility transport. The literature supporting pain management in this unique environment focuses predominantly on isolated traumatic injuries. Timely administration of analgesia can improve patient well-being by attenuating stress responses and reducing severe adverse events. To determine the prevalence of analgesia administration among pediatric patients undergoing mechanical ventilation during transport and to identify associated factors.

METHODS

We conducted a retrospective cohort study using electronic patient records from a large critical care transport system in North America, between 2014 and 2018. We included sequential pediatric patients who were intubated and mechanically ventilated. We examined analgesia administration (with opioids or ketamine) administered by paramedics. Adverse events were examined in relation to analgesia administration. Multivariable logistic regression identified factors associated with in-transport analgesia administration.

RESULTS

Of 903 patients (median age 9.1 years), 770 (85.3%) received analgesia during transport, with 83.3% receiving opioids or ketamine. Patients without opiate or ketamine analgesia during transport experienced higher rates of hypotension (38.4% vs. 26.9%) and hypoxemia (29.1% vs. 22.1%). Factors significantly associated with opiate or ketamine use included the reason for transport, transport duration, paralytic use, and pre-transport opiate or ketamine administration. Patients with comorbidities were less likely to receive analgesia during transport.

CONCLUSIONS

This study's findings highlight the need for improved pain evaluation in caring for mechanically ventilated pediatric patients during transport. Factors such as transport, duration, the reason for transport, pre-transport opiate or ketamine administration, and paralytics increase the likelihood of analgesia administration. At the same time, the presence of comorbidities decreases the likelihood. The study underscores the importance of improved documentation of pain to inform analgesic choices and administration with the ultimate goal of reducing adverse events.

Sedation - analgesia - muscle relaxant - withdrawal and delirium practices in pediatric intensive care units in Türkiye

BACKGROUND

Pain and sedation management is an integral part of pediatric intensive care practice. Sedoanalgesia management must be balanced in order to optimize comfort and avoid complications. In order to achieve this balance, sedoanalgesia management needs to be clarified in pediatric intensive care units (PICU). With this study, we aimed to investigate sedation, analgesia, withdrawal and delirium practices, pharmacologic agent preferences, and current experiences and practices in scoring systems in PICUs in Türkiye.

METHOD

A questionnaire consisting of 57 questions was sent via e-mail to the 'Pediatric Intensive Care and Emergency' group, which includes all intensive care specialists, subspecialty students and lecturers in Türkiye.

RESULTS

Our study involved 36 pediatric intensive care physicians working in PICUs in Türkiye. Among the PICU specialists who participated in the study, 83.3% stated that they performed routine assessments of sedation efficacy. While dexmedetomidine was the most commonly used sedative agent in patients undergoing noninvasive mechanical ventilation, benzodiazepines were the most preferred pharmacologic agent for sedation during mechanical ventilation. Of the pediatric intensivists who participated in the study, 94.4% stated that they performed routine pain assessments in their units. Of the PICU specialists who participated in the study, 69.4% stated that muscle relaxants were most commonly used to prevent patient-ventilator incompatibility during mechanical ventilation. Of the participants, 88.8% made withdrawal assessments when discontinuing sedo-analgesic agents. Delirium assessment was routinely performed by 58.3% of the participants.

CONCLUSIONS

This study showed that the practices in sedoanalgesia management in PICUs in Türkiye are in parallel with recommendations of the sedation guideline. Despite the increased sensitivity in sedoanalgesia management, awareness in the management of delirium and withdrawal syndrome is not at the desired level. Therefore, there is a need to develop guidelines, raise awareness and increase training on these issues in our Türkiye.

Implementing Screening for Neonatal Delirium in the Neonatal Intensive Care Unit: A Quality Improvement Initiative

Introduction

Delirium is not commonly diagnosed in neonatal intensive care units and can adversely impact patient outcomes in the ICU setting. Recognition of delirium in the NICU is a necessary first step to address the potential impact on neonatal outcomes.

Methods

We conducted a quality improvement initiative implementing screening for neonatal delirium. We aimed to increase screening in NICU patients from 0% to 85% by March 2022. Interdisciplinary meetings were held with key stakeholders to develop a clinical algorithm. We used standardized tools for delirium screening. Our process measures included weekly nursing compliance with Richmond Agitation Sedation Scale/Cornell Assessment of Pediatric Delirium/ scoring documentation (Fig. 1) and patients referred to psychiatry. Outcome measures included the percentage of patients screened for delirium before discharge. We conducted Plan-Do-Study Act cycles to optimize the screening process in the electronic medical record (EMR). This included creating an order set, documentation flowsheets, and prompts in the EMR for patients.

Results

After initial implementation, we achieved an average weekly screening compliance of 76% (Fig. 1). Inclusion criteria expansion resulted in a downward compliance shift to 59%. Subsequently, the addition of the EMR checklist resulted in a center-line shift to a sustained average weekly screening compliance of 77%. An average of 82% of all eligible NICU patients received delirium screening before discharge (Fig. 2).

Conclusions

Using quality improvement methodology, there was increased screening and recognition of delirium in our NICU. Future research efforts could focus on assessing preventive measures and the impact of neonatal delirium on patient outcomes.

The effects of maternal voice on pain during placement of peripherally inserted central catheter in neonates

Background

Peripherally inserted central catheter (PICC) are a necessary procedure for preterm newborns care. Despite the use of analgesic treatments, its insertion can be painful. Our objective was to study the effect of maternal voice on pain during PICC insertion.

Method

We conducted a pre post study for 2 years. Pain was compared between the two groups (with/without maternal presence) using a neonatal pain scale (FANS). Infection rate, procedure time, number of failures, mothers' anxiety and caregivers'anxiety were compared between the two groups.

Results

Ninety neonates were eligible. Finally, 63 neonates were included. Thirty-four placements were realized without maternal voice (first period) and 29 with maternal voice (second period). Mean FANS during PICC placement was lower in the maternal voice group than in the control group (1.15 ± 1.27 vs. 1.41 ± 1.49, p = 0.033). The FANS was also lower in the maternal voice group during the time of the first cutaneous effraction (p = 0.032). There was no significant difference between the two groups concerning the other outcomes.

Conclusion

Maternal voice added to conventional care decreased acute pain during PICC insertion without increasing infection rate, number of failures or procedure time.

Procedural sedation and analgesia in pediatric diagnostic and interventional radiology: An expert DELPHI consensus document developed by the ITALIAN scientific society of anesthesia, analgesia, resuscitation and intensive care (SIAARTI)

BACKGROUND

Children undergoing diagnostic and interventional radiology procedures often require sedation to achieve immobility and analgesia if the procedure is painful. In the past decades, leading scientific organizations have developed evidence-based guidelines for procedural sedation and analgesia in children outside of the operating room. Their recommendations are being applied to procedural sedation in radiology. However, some questions remain open regarding specific aspects contextualized to the radiology setting, such as elective prone sedation, the urgency of the procedure, when venous access or airway protection is required, and others.

AIMS

To address the unresolved issues of procedural sedation and analgesia in pediatric diagnostic and interventional radiology.

METHODS

An expert panel of pediatricians, pediatric anesthesiologists, intensivists, and neuroradiologists selected topics representative of current controversies and formulated research questions. Statements were developed by reviewing the literature for new evidence, comparing expertise and experience, and expressing opinions. Panelists' agreement with the statements was collected anonymously using the DELPHI method.

RESULTS

Twelve evidence-based or expert opinion incorporate are presented, considering risks, benefits, and applicability.

CONCLUSIONS

This consensus document, developed by a multidisciplinary panel of experts involved in the field, provides statements to improve the quality of decision-making practice in procedural sedation and analgesia in pediatric radiology.

Practices of assessment of pain, sedation, iatrogenic withdrawal syndrome, and delirium in European paediatric intensive care units: A secondary analysis of the European Prevalence of Acute Rehab for Kids in the paediatric intensive care unit study

BACKGROUND

Analgosedation is standard practice to ensure comfort and safety of critically ill children in paediatric intensive care units (PICUs). However, a significant number of children develop iatrogenic withdrawal syndrome or delirium with these drugs. The European Society of Paediatric and Neonatal Intensive Care published a position statement in 2016, but how successfully its recommendations have been implemented is unknown.

OBJECTIVES

Following were the objectives of this study: (i) to describe assessment practices (prevalence, measurement instruments, and frequency) for pain, sedation, iatrogenic withdrawal syndrome and delirium; (ii) to assess how practices meet the position statement; and (iii) to identify organisational factors associated with the use of recommendations for pain and sedation assessment.

METHOD

A secondary analysis of prospectively collected data from the multicentre prevalence study (European Prevalence of Acute Rehab for Kids in the PICU) conducted in 38 PICUs, across 15 European countries in 2018. Data from 453 children were analysed.

RESULTS

Of the 38 PICUs, 97% assessed pain, 89% sedation, 82% withdrawal, and 42% delirium. These four symptoms were mainly assessed and documented by the Face, Legs, Activity, Cry, Consolability scale (39%) and Numerical Rating Scale (24%) every 8, 4, or 2 h for pain; the COMFORT-B (45%) and COMFORT (24%) scales every 8 or 2 h for sedation; the Sophia Observation withdrawal Scale (37%) and Withdrawal Assessment Tool-1 (32%) scales every 8 or 4 h for withdrawal and the Cornell Assessment Pediatric-Delirium (18%) and Sophia Observation Withdrawal Symptoms-Pediatric Delirium (16%) scales every 12 or 8 h for delirium. Concordance with the position statement recommendations was low to moderate (13-69%). Adherence to recommendations were influenced by the variables of nurse-to-patient ratio, type of hospital, and the number of PICU beds.

CONCLUSION

Based on prospectively collected data, there was variability in pain and sedation assessment practices and a lack of adherence with recommendations in the EU, particularly for delirium. These findings highlight the need for more proactive dissemination, and investigation of barriers and implementation strategies to improve evidence-based assessment practices.

Impact of Prolonged Continuous Ketamine Infusions in Critically Ill Children: A Prospective Cohort Study

BACKGROUND

Ketamine has been considered as an adjunct for children who do not reach their predefined target sedation depth. However, there is limited evidence regarding the use of ketamine as a prolonged infusion (i.e., >24 hours) in the pediatric intensive care unit (PICU).

OBJECTIVE

We sought to evaluate the safety and effectiveness of continuous ketamine infusion for >24 hours in mechanically ventilated children.

METHODS

We conducted a prospective cohort study in a tertiary PICU from January 2020 to December 2022. The primary outcome was the incidence of adverse events (AEs) after ketamine initiation. The secondary outcome included assessing the median proportion of time the patient spent on the Richmond Agitation-Sedation Scale (RASS) goal after ketamine infusion. Patients were also divided into two groups based on the sedative regimen, ketamine-based or non-ketamine-based, to assess the incidence of delirium.

RESULTS

A total of 269 patients were enrolled: 73 in the ketamine group and 196 in the non-ketamine group. The median infusion rate of ketamine was 1.4 mg/kg/h. Delirium occurred in 16 (22%) patients with ketamine and 15 (7.6%) patients without ketamine (p = 0.006). After adjusting for covariates, logistic regression showed that delirium was associated with comorbidities (odds ratio [OR] 4.2), neurodevelopmental delay (OR 0.23), fentanyl use (OR 7.35), and ketamine use (OR 4.17). Thirty-one (42%) of the patients experienced at least one AE following ketamine infusion. Other AEs likely related to ketamine were hypertension (n = 4), hypersecretion (n = 14), tachycardia (n = 6), and nystagmus (n = 2). There were no significant changes in hemodynamic variables 24 h after the initiation of ketamine. Regarding the secondary outcomes, patients were at their goal RASS level for a median of 76% (range 68-80.5%) of the time in the 24 hours before ketamine initiation, compared with 84% (range 74.5-90%) of the time during the 24 h after ketamine initiation (p < 0.001). The infusion rate of ketamine did not significantly affect concomitant analgesic and sedative infusions. The ketamine group experienced a longer duration of mechanical ventilation and a longer length of stay in the PICU and hospital than the non-ketamine group.

CONCLUSION

The use of ketamine infusion in PICU patients may be associated with an increased rate of adverse events, especially delirium. High-quality studies are needed before ketamine can be broadly recommended or adopted earlier in the sedation protocol.

Nurses' Assessment of Pain in Saudi Neonatal Intensive Care Units

BACKGROUND

Research reveals that neonatal pain management in Neonatal Intensive Care Units (NICUs) is suboptimal. There is limited research that assessed NICU nurses' pain assessment practices in Saudi Arabia.

AIM

To assess the nurses' pain assessment practices in the NICU in Saudi Arabia.

DESIGN

This study used a descriptive cross-sectional design.

SETTINGS

Research was conducted using an online survey.

PARTICIPANTS/SUBJECTS

This study was carried out on 65 NICU nurses. The participants were recruited from one governmental and one private hospital in Saudi Arabia.

METHODS

Data on pain assessment practices were collected, including the frequency of pain assessment, pain assessment scales used for preterm and term neonates, and pain assessment documentation. Data were analyzed using frequencies and percentages.

RESULTS

The majority of the participants (94%) routinely assessed pain and documented pain assessment (97%). One-third of the participants assessed pain regularly every hour (32%). The most used pain assessment scales for term neonates were the neonatal infant pain scale (40%) and the cry, required oxygen, increased vital signs, expression, and sleeplessness scale (23%). The most used pain assessment scales for preterm neonates were the neonatal infant pain scale (31%), the cry, required oxygen, increased vital signs, expression, sleeplessness scale (19%), and the premature infant pain profile (17%).

CONCLUSIONS

NICU nurses in Saudi Arabia consistently assessed for and documented pain; however, the tools chosen were sometimes suboptimal. A substantial number of NICU nurses used invalid tools to assess pain in term and preterm neonates. An interventional program is needed to enhance the use of evidence-based practice recommendations regarding neonatal pain assessment by nurses in the Neonatal Intensive Care Units in Saudi Arabia.

A nomogram for predicting postoperative delirium in pediatric patients following cardiopulmonary bypass: A prospective observational study

OBJECTIVES

To create a nomogram for early delirium detection in pediatric patients following cardiopulmonary bypass.

RESEARCH METHODOLOGY/DESIGN

This prospective, observational study was conducted in the Cardiac Intensive Care Unit at a Children's Hospital, enrolling 501 pediatric patients from February 2022 to January 2023. Perioperative data were systematically collected through the hospital information system. Postoperative delirium was assessed using the Cornell Assessment of Pediatric Delirium (CAPD). For model development, Least Absolute Shrinkage and Selection Operator (LASSO) regression was employed to identify the most relevant predictors. These selected predictors were then incorporated into a multivariable logistic regression model to construct the predictive nomogram. The performance of the model was evaluated by Harrell's concordance index, receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis. External validity of the model was confirmed through the C-index and calibration plots.

RESULTS

Five independent predictors were identified: age, SpO2 levels, lymphocyte count, diuretic use, and midazolam administration, integrated into a predictive nomogram. This nomogram demonstrated strong predictive capacity (AUC 0.816, concordance index 0.815) with good model fit (Hosmer-Lemeshow test p = 0.826) and high accuracy. Decision curve analysis showed a significant net benefit, and external validation confirmed the nomogram's reliability.

CONCLUSIONS

The study successfully developed a precise and effective nomogram for identifying pediatric patients at high risk of post-cardiopulmonary bypass delirium, incorporating age, SpO2 levels, lymphocyte counts, diuretic use, and midazolam medication.

IMPLICATIONS FOR CLINICAL PRACTICE

This nomogram aids early delirium detection and prevention in critically ill children, improving clinical decisions and treatment optimization. It enables precise monitoring and tailored medication strategies, significantly contributes to reducing the incidence of delirium, thereby enhancing the overall quality of patient care.

Delirium: Where Are We Now?

Delirium has long been recognized within the adult intensive care world, but it is only within the past decade that its presence and prevalence in the context of pediatric intensive care has been studied. There is now a greater understanding of risk factors for delirium, a better selection of methods to recognize it, and treatment specifically directed to pediatric patients. An understanding of delirium is also relevant to pediatricians practicing outside of the intensive care unit, as delirium can present in other care environments, where it remains under-recognized. The purpose of this article is to review pediatric delirium by discussing its pathophysiology, the tools available to screen patients, and current prevention and management approaches. [Pediatr Ann. 2024;53(8):e288-e292.].

Antibiotics, Analgesic Sedatives, and Antiseizure Medications Frequently Used in Critically Ill Neonates: A Narrative Review

Antibiotic, analgesic sedative, and antiseizure medications are among the most commonly used medications in preterm/sick neonates, who are at high risk of nosocomial infections, central nervous system complications, and are exposed to numerous painful/stressful procedures. These severe and potentially life-threatening complications may have serious short- and long-term consequences and should be prevented and/or promptly treated. The reported variability in the medications used in neonates indicates the lack of adequate neonatal studies regarding their effectiveness and safety. Important obstacles contributing to inadequate studies in preterm/sick infants include difficulties in obtaining parental consent, physicians' unwillingness to recruit preterm infants, the off-label use of many medications in neonates, and other scientific and ethical concerns. This review is an update on the use of antimicrobials (antifungals), analgesics (sedatives), and antiseizure medications in neonates, focusing on current evidence or knowledge gaps regarding their pharmacokinetics, indications, safety, dosage, and evidence-based guidelines for their optimal use in neonates. We also address the effects of early antibiotic use on the intestinal microbiome and its association with long-term immune-related diseases, obesity, and neurodevelopment (ND). Recommendations for empirical treatment and the emergence of pathogen resistance to antimicrobials and antifungals are also presented. Finally, future perspectives on the prevention, modification, or reversal of antibiotic resistance are discussed.

Adapting the Cornell assessment of pediatric delirium for Swedish context: translation, cultural validation and inter-rater reliability

BACKGROUND

Pediatric delirium causes prolonged hospital stays, increased costs, and distress for children and caregivers. Currently, there is no delirium screening tool available in Sweden that has been translated, culturally validated, and tested for reliability. This study aimed to translate, culturally adapt, and assess the suitability of the Cornell Assessment of Pediatric Delirium (CAPD) for implementation in Swedish healthcare settings.

METHODS

The CAPD was translated and culturally adapted to Swedish context following the ten-step process recommended by the International Society for Pharmacoeconomics and Outcomes Task Force for Translation and Cultural Adaptation. The Swedish CAPD was tested in the pediatric intensive care unit of Uppsala University Hospital, a tertiary hospital in Sweden. Inter-rater reliability was tested using intraclass correlation coefficient (ICC), with both Registered Nurses (RNs) and Assistant Nurses (ANs) conducting parallel measurements using the Swedish CAPD. A reliability score of ICC > 0.75 was considered indicative of good reliability.

RESULTS

After translation of the CAPD into Swedish, 10 RNs participated in the cultural adaptation process. Issues related to word choice, education, and instructions were addressed. Wording improvements were made to ensure accurate interpretation. Supplementary training sessions were organized to strengthen users' proficiency with the Swedish CAPD. Additional instructions were provided to enhance clarity and usability. Inter-rater reliability testing resulted in an ICC of 0.857 (95% CI: 0.708-0.930), indicating good reliability.

CONCLUSION

This study successfully translated and culturally adapted the CAPD to align with Swedish contextual parameters. The resulting Swedish CAPD demonstrated good inter-rater reliability, establishing its viability as a tool for measuring delirium among pediatric patients in Swedish pediatric intensive care units.

TRAIL REGISTRATION

Not applicable.

What's new in pediatric critical care?

Pediatric intensive care medicine is a rapidly evolving field of medicine, with recent publication of landmark papers specific for the pediatric population. Progress has been made in modes of mechanical ventilation, including noninvasive ventilation in pediatric ARDS and after extubation failure, with updated guidelines on ventilator liberation. Improved technology and advancements in hemodynamic support allow for better care of our patients with heart disease. Sepsis burden in children remains high and continued efforts are made to improve survival. A nutritional plan with a tailored approach, focusing on individualized needs, could offer benefits for our patients. Sedation practices and guidelines have been updated, focusing on minimizing delirium and facilitating early mobility. This manuscript highlights some of the most recent advances and updates.

Recognition and Management of Delirium in the Neonatal Intensive Care Unit: Case Series From a Single-Center Level IV Intensive Care Unit

Delirium often goes unrecognized in neonates and children because of lack of experience in evaluating behavior and cognition, insufficient awareness of the prevalence, and nondistinctive symptoms in this population. Although there are increasing reports of the presence of delirium in neonates, there are little data to guide the pharmacologic treatment in this population. In this retrospective single-center case series, we present our experience using quetiapine to treat delirium in 9 medically complex neonates. Based on an extensive literature review, expert opinion, and institutional experience, we propose an approach for monitoring and treating delirium in neonates and infants.

Prospective validation of Sophia observation withdrawal symptoms: A paediatric delirium scale in critically ill children in Denmark

BACKGROUND

Paediatric delirium (PD) is increasingly recognised as a common disorder in critically ill children with a reported prevalence ranging from 9% to 66%. We validated the PD component of the Sophia Observation withdrawal Symptoms-Paediatric Delirium (SOS-PD) scale in a Danish setting to provide increased awareness and reliable identification of this critical condition, thereby paving the way for improved pathways to targeted delirium care.

OBJECTIVE

The objectives of this study were to criterion validate the PD component of the SOS-PD screening tool by comparing blinded psychiatric and nurse assessments and to estimate the prevalence of delirium in critically ill children in a Danish context.

METHODS

A prospective observational study was performed on critically ill children aged between 3 m and 18 y, admitted to an intensive care unit, with a hospital stay of 48 h or more. Assessments took place on a fixed weekday over an 18-month period. To test accuracy and criterion validity, bedside nurses' SOS-PD assessments were compared to the reference standard, a diagnostic assessment performed by a child psychiatrist according to the Diagnostic and Statistical Manual-V criteria by use of the Vanderbilt Assessment of Delirium in Infants and Children.

RESULTS

We included 141 children in the study, 30 (21%) of whom were diagnosed with delirium by the child psychiatrist. The accuracy of the delirium diagnosis was 93.6% (95% confidence interval [CI]: 88.3-97.1) among the nurses' SOS-PD assessments compared to the reference standard. The SOS-PD demonstrated a high sensitivity of 83.3% (95% CI: 65.3-94.4) and a high specificity of 96.4% (95% CI: 91.0-99.0) with five false-negative and four false-positive cases.

CONCLUSION

The PD component of the SOS-PD tool has good accuracy and validity for assessments performed by nurses compared to a child psychiatrist's diagnosis in critically ill children in a Danish setting. We recommend the use of the SOS-PD instrument in clinical practice.

Intermittent intravenous paracetamol versus continuous morphine in infants undergoing cardiothoracic surgery: a multi-center randomized controlled trial

BACKGROUND

To determine whether intermittent intravenous (IV) paracetamol as primary analgesic would significantly reduce morphine consumption in children aged 0-3 years after cardiac surgery with cardiopulmonary bypass.

METHODS

Multi-center, randomized, double-blinded, controlled trial in four level-3 Pediatric Intensive Care Units (PICU) in the Netherlands and Belgium. Inclusion period; March 2016-July 2020. Children aged 0-3 years, undergoing cardiac surgery with cardiopulmonary bypass were eligible. Patients were randomized to continuous morphine or intermittent IV paracetamol as primary analgesic after a loading dose of 100 mcg/kg morphine was administered at the end of surgery. Rescue morphine was given if numeric rating scale (NRS) pain scores exceeded predetermined cutoff values. Primary outcome was median weight-adjusted cumulative morphine dose in mcg/kg in the first 48 h postoperative. For the comparison of the primary outcome between groups, the nonparametric Van Elteren test with stratification by center was used. For comparison of the proportion of patients with one or more NRS pain scores of 4 and higher between the two groups, a non-inferiority analysis was performed using a non-inferiority margin of 20%.

RESULTS

In total, 828 were screened and finally 208 patients were included; parents of 315 patients did not give consent and 305 were excluded for various reasons. Fourteen of the enrolled 208 children were withdrawn from the study before start of study medication leaving 194 patients for final analysis. One hundred and two patients received intermittent IV paracetamol, 106 received continuous morphine. The median weight-adjusted cumulative morphine consumption in the first 48 h postoperative in the IV paracetamol group was 5 times lower (79%) than that in the morphine group (median, 145.0 (IQR, 115.0-432.5) mcg/kg vs 692.6 (IQR, 532.7-856.1) mcg/kg; P < 0.001). The rescue morphine consumption was similar between the groups (p = 0.38). Non-inferiority of IV paracetamol administration in terms of NRS pain scores was proven; difference in proportion - 3.1% (95% CI - 16.6-10.3%).

CONCLUSIONS

In children aged 0-3 years undergoing cardiac surgery, use of intermittent IV paracetamol reduces the median weight-adjusted cumulative morphine consumption in the first 48 h after surgery by 79% with equal pain relief showing equipoise for IV paracetamol as primary analgesic. Trial Registration Clinicaltrials.gov, Identifier: NCT05853263; EudraCT Number: 2015-001835-20.

Study on Risk Factors and Receiver Operator Characteristic Curve of Iatrogenic Withdrawal Syndrome in Pediatric Intensive Care Units: A Retrospective Study

INTRODUCTION

The aims of this study were to investigate the independent risk factors associated with iatrogenic withdrawal syndrome in pediatric intensive care units (PICUs) and to establish receiver operator characteristic (ROC) curve to facilitate the diagnosis of iatrogenic withdrawal syndrome in clinical settings.

METHODS

Pediatric patients who received analgesic and sedative medication at a tertiary hospital in the southern Zhejiang region of China between January 2016 and December 2022 were selected for the study. Clinical case data were retrospectively analyzed to gather information including age, gender, weight, total dose of analgesic and sedative medication, total treatment duration, average maintenance dose, and other relevant parameters. Medically induced withdrawal symptom scores were assessed using the Sophia Observation Scale for Withdrawal Symptoms (SOS). Univariate and multivariate logistic regression analyses were conducted on the above indicators to identify the risk factors for iatrogenic withdrawal, and an ROC curve was constructed.

RESULTS

The study encompassed a total of 104 pediatric patients, comprising 47 patients in the SOS score ≥4 group and 57 patients in the SOS score ≤3 group. The incidence of iatrogenic withdrawal was 45.19%. Univariate analysis identified cumulative total dose of fentanyl, average daily dose of fentanyl, average daily dose of midazolam, and patient weight (p < 0.05) as factors associated with iatrogenic withdrawal syndrome. The logistic multiple regression analysis revealed that the average daily dose of fentanyl was an independent risk factor for the occurrence of iatrogenic withdrawal syndrome in critically ill children (p < 0.05). ROC curve analysis indicated an area under the curve of 0.711 (95% CI: 0.610-0.811) with sensitivity and specificity of 73.7% and 61.7%, respectively.

CONCLUSION

The average daily maintenance dose of fentanyl holds significant clinical value in diagnosing and evaluating the prognosis of iatrogenic withdrawal syndrome and can provide a scientific foundation for enhancing sedative and analgesic management in clinical practice.

Early Rehabilitation in Critically ill Children: A Two Center Implementation Study

OBJECTIVES

To implement an early rehabilitation bundle in two Canadian PICUs.

DESIGN AND SETTING

Implementation study in the PICUs at McMaster Children's Hospital (site 1) and London Health Sciences (site 2).

PATIENTS

All children under 18 years old admitted to the PICU were eligible for the intervention.

INTERVENTIONS

A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were the duration of implementation, bundle compliance, process of care, safety, and the factors influencing implementation. Secondary endpoints were the impact of the bundle on clinical outcomes such as pain, delirium, iatrogenic withdrawal, ventilator-free days, length of stay, and mortality. Implementation occurred over 26 months (August 2018 to October 2020). Data were collected on 1,036 patients representing 4,065 patient days. Bundle compliance was optimized within 6 months of roll-out. Goal setting for mobilization and level of arousal improved significantly (p < 0.01). Benzodiazepine, opioid, and dexmedetomidine use decreased in site 1 by 23.2% (95% CI, 30.8-15.5%), 26.1% (95% CI, 34.8-17.4%), and 9.2% (95% CI, 18.2-0.2%) patient exposure days, respectively, while at site 2, only dexmedetomidine exposure decreased significantly by 10.5% patient days (95% CI, 19.8-1.1%). Patient comfort, safety, and nursing workload were not adversely affected. There was no significant impact of the bundle on the rate of delirium, ventilator-free days, length of PICU stay, or mortality. Key facilitators to implementation included institutional support, unit-wide practice guidelines, dedicated PICU educators, easily accessible resources, and family engagement.

CONCLUSIONS

A rehabilitation bundle can improve processes of care and reduce patient sedative exposure without increasing patient discomfort, nursing workload, or harm. We did not observe an impact on short-term clinical outcomes. The efficacy of a PICU-rehabilitation bundle requires ongoing study. Lessons learned in this study provide evidence to inform rehabilitation implementation in the PICU setting.

Neonatal Intensive Care Nurses' Knowledge of Neonatal Pain Assessment in Private and Public Hospitals in Jeddah, Saudi Arabia: A Cross-Sectional Study

BACKGROUND

Neonatal Intensive Care Unit (NICU) nurses with adequate neonatal pain assessment knowledge are crucial in effective neonatal pain management. There is limited research that assessed the knowledge of NICU nurses in Saudi Arabia regarding neonatal pain assessment.

OBJECTIVE

To assess the knowledge of NICU nurses in Saudi Arabia regarding neonatal pain assessment.

DESIGN AND METHODS

 A cross-sectional design using an online survey was conducted to capture information regarding neonatal pain assessment knowledge from 125 NICU nurses in Saudi Arabia. Knowledge of pain assessment was assessed using a modified version of the knowledge, attitudes, and practice scale. Knowledge scores were classified as high, average, and low.

RESULTS

Participants' knowledge regarding neonatal pain assessment was inadequate (Mean = 63/100). The majority of the participants had a low to average level of knowledge (n= 97, 78%).

CONCLUSION

A significant proportion of NICU nurses had inadequate knowledge regarding neonatal pain assessment, which can be improved. Educational interventions are needed to boost these nurses' knowledge regarding neonatal pain assessment.

Providing holistic care to children with cerebral palsy treated with transnasal neural stem cell transplantation

Objective

Holistic care is a key element in nursing care. Aiming at the heterogeneous disease of cerebral palsy, researchers focused on children with cerebral palsy who received transnasal transplantation of neural stem cells as a specific group. Based on establishing a multidisciplinary team, comprehensive care is carried out for this type of patient during the perioperative period to improve the effectiveness and safety of clinical research and increase the comfort of children.

Methods

Between January 2018 and June 2023, 22 children with cerebral palsy underwent three transnasal transplants of neural stem cells.

Results

No adverse reactions related to immune rejection were observed in the 22 children during hospitalization and follow-up. All children tolerated the treatment well, and the treatment was superior. One child developed nausea and vomiting after sedation; three had a small amount of bleeding of nasal mucosa after transplantation. Two children had a low fever (≤38.5°C), and one had a change in the type and frequency of complex partial seizures. Moreover, 3 children experienced patch shedding within 4 h of patch implantation into the nasal cavity.

Conclusion

The project team adopted nasal stem cell transplantation technology. Based on the characteristics of transnasal transplantation of neural stem cells in the treatment of neurological diseases in children, a comprehensive and novel holistic care plan is proposed. It is of great significance to guide caregivers of children to complete proper care, further improve the safety and effectiveness of treatment, and reduce the occurrence of complications.

Music Therapy During Basic Daily Care in Critically Ill Children: A Randomized Crossover Clinical Trial

OBJECTIVE

To assess whether music therapy (MT) is effective to reduce pain during daily personal hygiene care (DPHC), a procedure performed in all patients in a pediatric intensive care unit.

METHODS

Fifty critically ill children were enrolled in a crossover controlled clinical trial with random ordering of the intervention, that is, passive MT, and standard conditions, and blind assessment of pain on film recordings. The primary outcome was variation of the Face Legs Activity Cry Consolability (FLACC) score (range, 0-10) comparing before and during DPHC. Secondary outcomes were changes in heart rate, respiratory rate, and mean arterial blood pressure, and administration of analgesic or sedative drugs during DPHC. Mixed-effects linear model analysis was used to assess effect size (95% CI).

RESULTS

The median (Q25-Q75) age and weight of the patients were 3.5 years (1.0-7.6 years) and 15.0 kg (10.0-26.8 kg). Consecutive DPHC were assessed on days 3 (2-5) and 4 (3-7) of hospitalization. In standard conditions, FLACC score was 0.0 (0.0-3.0) at baseline and 3.0 (1.0-5.5) during DPHC. With MT, these values were, respectively, 0.0 (0.0-1.0) and 2.0 (0.5-4.0). Rates of FLACC scores of >4 during DPHC, which indicates severe pain, were 42% in standard conditions and 17% with MT (P = .013). Mixed-effects model analysis found smaller increases in FLACC scores (-0.54 [-1.08 to -0.01]; P = .04) and heart rate (-9.00; [-14.53; -3.40]; P = .001) with MT.

CONCLUSIONS

MT is effective to improve analgesia in critically ill children exposed to DPHC.

TRIAL REGISTRATION

This study was recorded (April 16, 2019) before patient recruitment on the National Library of Medicine registry (NCT03916835; https://clinicaltrials.gov/ct2/show/NCT03916835).

A Delirium Prevention and Management Initiative: Implementing a Best Practice Recommendation for the NICU

Medically complex infants experiencing NICU stays can be difficult to manage, exhibiting refractory agitation, disengagement, or both-all signs of delirium, which can present in a hypoactive, hyperactive, or mixed form. Though documented in other settings, delirium is under-recognized in NICUs. Pediatric studies show that a high percentage of patients with delirium are under the age of 12 months. Delirium is associated with increased ventilation days, hospital days, and costs. It negatively affects neurodevelopment and social interaction. Studies show that pediatric nurses are unprepared to recognize delirium. Our nurse-led multidisciplinary group created a best practice recommendation (BPR) focused on detecting delirium and minimizing risk through thoughtful sedation management, promotion of sleep hygiene and mobility, and facilitation of meaningful caregiver presence. Occasionally, medications, including melatonin and risperidone, are helpful. In 2019, we introduced this BPR to reduce delirium risk in our NICU. Practice changes tied to this initiative correlate with a significant reduction in delirium scores and risk including exposure to deliriogenic medications. A multidisciplinary care bundle correlates with decreased delirium screening scores in NICU patients.

Translation and cross-cultural adaptation of the anchor points of the Cornell Assessment of Pediatric Delirium scale into Portuguese

OBJECTIVE

To translate and cross-culturally adapt the Cornell Assessment of Pediatric Delirium anchor points from English to Brazilian Portuguese.

METHODS

For the translation and cross-cultural adaptation of the anchor points, all steps recommended internationally were followed after authorization for use by the lead author. The stages were as follows: translation of the original version into Portuguese by two bilingual translators who were native speakers of the target language, synthesis of the versions, reverse translation by two translators who were native speakers of the source language, review and synthesis of the back-translation, review by a committee of experts and preparation of the final version.

RESULTS

The translation and cross-cultural adaptation of the anchor points was conducted in accordance with recommendations. The linguistic and semantic issues that arose were discussed by a committee of judges, with 91.8% agreement, as determined using a Likert scale, after changes by consensus. After reanalysis by the authors, there were no changes, resulting in the final version, which was easy to understand and administer.

CONCLUSION

The translation and cross-cultural adaptation of the anchor points of the Cornell Assessment of Pediatric Delirium scale into Portuguese spoken in Brazil were successful, maintaining the linguistic and semantic properties of the original instrument. The table of anchor points is easy to understand and will be helpful during the assessment of children younger than 24 months using the Cornell Assessment of Pediatric Delirium scale.

Incidence, associated factors, and outcomes of delirium in critically ill children in china: a prospective cohort study

BACKGROUND

Delirium occurs frequently in critically ill children and has been reported in many countries, but delirium is not well-characterized in China. The aim of this study was to represent the incidence of delirium in critically ill children in China, its associated factors, and the influence of delirium on in-hospital outcomes.

METHODS

This observational prospective cohort study was set up in a large academic medical center with a 57-bed PICU in southwestern China. Critically ill children who required PICU stays over 24 h and were admitted between November 2019 and February 2022 were included in this study. The Cornell Assessment of Pediatric Delirium was used twice daily for delirium evaluation by bedside nurses, and twenty-four clinical features were collected from medical and nursing records during hospitalization.

RESULTS

The incidence of delirium was 26.0% (n = 410/1576). Multivariate analysis revealed that seven independent risk factors including days of mechanical ventilation and physical restraints, admission diagnosis (neurologic disorder), sleep deprivation, use of benzodiazepines and dexmedetomidine, liver failure/liver dysfunction associated with delirium in critically ill children. One potentially protective factor was the watching television /listening to music/playing with toys. Children with delirium had longer lengths of stay in the PICU (median 11 vs. 10 days, p < 0.001) and hospital (median 18 vs. 15 days, p < 0.001) compared to those without delirium. Additionally, the in-hospital mortality rates were 4.63% and 0.77% in patients with and without delirium (p < 0.05).

CONCLUSIONS

Delirium is common in critically ill children in China and related to poor outcomes. Interventional studies are warranted to determine the best practices to reduce delirium exposure in at-risk children.

Variation in Early Pediatric Intensive Care Management Strategies and Duration of Invasive Mechanical Ventilation for Acute Viral Bronchiolitis in the United Kingdom: A Retrospective Multicenter Cohort Study

OBJECTIVES

Management of mechanically ventilated patients with bronchiolitis is not standardized and duration of mechanical ventilation has been shown to vary widely between centers. The aim of this study was to examine practice in a large number of U.K. PICUs with a view to identify if early management choices relating to fluid prescription, sedative agent use, and endotracheal tube (ETT) placement were associated with differences in duration of invasive mechanical ventilation (IMV).

DESIGN

Retrospective multicenter cohort study. Primary outcome was duration of IMV. A hierarchical gamma generalized linear model was used to test for associations between practice variables (sedative and neuromuscular blocking agents, route of endotracheal intubation at 24 hr and fluid balance at 48 hr) and duration of IMV after adjustment for known confounders.

SETTING

Thirteen U.K. PICUs. Duration of 2 months between November and December 2019.

PATIENTS

Three hundred fifty infants receiving IMV for bronchiolitis. Excluded were patients receiving long-term ventilation, extracorporeal life support, or who died before separation from IMV.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

After adjustment for confounders, several variables were associated with an increase in the geometric mean duration of IMV (expressed as a percentage) including: nasal ETT use, 16% (95% CI, 1-32%); neuromuscular blockade use, 39% (95% CI, 21-61%); and fluid balance at 48 hr, 13% per 100 mL/kg positive fluid balance (95% CI, -1% to 28%). The association of sedative use varied with class of agent. The use of an alpha-2 agonist alone was associated with a reduction in duration of IMV by 19% in relation to no sedative agent (95% CI, -31 to -5%), whereas benzodiazepine uses alone or with alpha-2 agonist in combination were similar to using neither agent.

CONCLUSIONS

Early management strategies for bronchiolitis were associated with the duration of IMV across U.K. centers after adjustment for confounders. Future work should prospectively assess the impact of fluid restriction, route of endotracheal intubation, and alpha-2 agonist use on duration of IMV in infants with bronchiolitis, with the aim of reducing seasonal bed pressure.

Pain assessment & management decision-making in pediatric critical care

PURPOSE

The aim of this study was to explore how nurses in the Pediatric Intensive Care Unit (PICU) reach their pain management decisions in children who are mechanically ventilated and chemically paralyzed.

DESIGN AND METHODS

A qualitative descriptive design was used following a quantitative phase of a multi-method study. Eighteen PICU nurses participated in semi-structured interviews aiming at understanding how they assess pain and make management decisions. Content analysis was used to guide coding and generate themes.

RESULTS

Three major themes were identified: 1) Assessment or cues that nurses use to trigger a pain assessment; 2) Mental models or patterns that nurses create to interpret cues to guide decision-making; 3) External factors that inhibit or facilitate decision-making. Overall, nurses rely on physiological cues to assess pain. From there, a large amount of variation exists on how nurses interpret those cues to make their pain management decision. External factors such as unit culture, perceived barriers and facilitators, and the nurse's experiences impacted how decisions are made.

CONCLUSIONS

Variation exists in the mental models' nurses create to make their pain management decision in this population. Nurses reported confusion on pain and sedation scale selection and various documentation practices for pain assessment. "Assume pain present" was identified as a concept and documentation practice that may guide decisions; further research is needed.

PRACTICE IMPLICATIONS

Development of clinician decision support tools that not only aid their understanding of reliable pain cues but also help create clear documentation practices may help nurses make pain management decisions.

Adverse cardiovascular events are common during dexmedetomidine administration in neonates and infants during intensive care

AIM

This study aimed to assess the safety of a commonly used sedative, dexmedetomidine in neonates and infants during intensive care.

METHODS

A retrospective cohort study was conducted in the paediatric intensive care unit at Oulu University Hospital. The study population consisted of all children from birth up to 6 months of age who received dexmedetomidine during 2010-2016. Adverse cardiovascular outcomes were defined as abnormal heart rates or blood pressure values according to the Paediatric Early Warning Score.

RESULTS

Of the 172 infants, 56% had congenital malformation, and 48% had undergone surgery. Neonates and 1-3-month-olds experienced bradycardia (86% vs. 73% in 1-3-month-olds and 50% in 3-6-month-olds, p = 0.001) and severe bradycardia (17% vs. 14% in 1-3-month-olds and 0% in 3-6-month-olds, p = 0.005) more often than older patients. The median maximum rate of dexmedetomidine infusion was 0.86 μg/kg/h (IQR = 0.60-1.71 μg/kg/h). A dose-dependent increase in bradycardia and severe hypotension was found. Adverse cardiovascular events were managed with additional fluid boluses and discontinuation of the infusion.

CONCLUSION

Adverse cardiovascular events were common during dexmedetomidine administration in neonates and infants. Lower dexmedetomidine doses may be required in sedating neonates.

A survey of current practices in sedation, analgesia, withdrawal, and delirium management in paediatric cardiac ICUs

OBJECTIVE

To characterise the current approach to sedation, analgesia, iatrogenic withdrawal syndrome and delirium in paediatric cardiac ICUs.

DESIGN

A convenience sample survey of practitioners at institutions participating in the Pediatric Cardiac Critical Care Consortium conducted from September to December 2020.

SETTING

Paediatric cardiac ICUs.

MEASUREMENTS AND MAIN RESULTS

Survey responses were received from 33 of 42 institutions contacted. Screening for pain and agitation occurs commonly and frequently. A minority of responding centres (39%) have a written analgesia management protocol/guideline. A minority (42%) of centres have a written protocol for sedation. Screening for withdrawal occurs commonly, although triggers for withdrawal screening vary. Only 42% of respondents have written protocols for withdrawal management. Screening for delirium occurs "always" in 46% of responding centres, "sometimes" in 36% of centres and "never" 18%. Nine participating centres (27%) have written protocols for delirium management.

CONCLUSIONS

Our survey identified that most responding paediatric cardiac ICUs lack a standardised approach to the management of analgesia, sedation, iatrogenic withdrawal, and delirium. Screening for pain and agitation occurs regularly, while screening for withdrawal occurs fairly frequently, and screening for delirium is notably less consistent. Only a minority of centres use written protocols or guidelines for the management of these problems. We believe that this represents an opportunity to significantly improve patient care within the paediatric cardiac ICU.

Delirium Assessment Treatment Strategies in Critically Ill Pediatric Patients: A Pediatric Pharmacy Association Practice-Based Research Network Survey Study

OBJECTIVES

The purpose of this study was to describe overall screening, prevention, and treatments for pediatric delirium at various neonatal intensive care units (NICUs), cardiac intensive care units (CICUs), and pediatric intensive care units (PICUs) from the Pediatric Pharmacy Association (PPA) membership. The primary objective was to identify the number of respondents that had a defined delirium-based protocol. The secondary objectives included identification of delirium assessment tools used, first- and second-line delirium treatment options, and monitoring practices for antipsychotics for delirium management.

METHODS

A cross-sectional questionnaire was distributed to PPA members from February 8, 2022, to March, 25, 2022. Comparisons between the NICUs, PICUs, and CICUs were conducted by using chi-square tests, with a priori p value of <0.05.

RESULTS

The questionnaire was completed by 84 respondents at 62 institutions; respondents practiced in the PICU or mixed PICU (n = 48; 57.1%), CICU (n = 13; 15.5%), and NICU (n = 23; 27.4%). Sixty-one respondents (72.6%) noted their units routinely screen for delirium, and there was a significant difference between the respondents of different units that use a delirium scoring tool (p < 0.01). Only 33 respondents (39.3%) had a defined delirium protocol, and there was no difference between units (p = 0.31). The most common agents used for delirium treatment were quetiapine and risperidone. There was variability in the monitoring used between respondents, but the majority (n = 74; 88%) monitor electrocardiograms to assess the corrected QT interval, but practice variability existed.

CONCLUSIONS

Most respondents did not have a defined delirium protocol. Variations were noted in the treatment options and monitoring for critically ill pediatric patients with delirium.

A systematic review of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal syndrome in pediatric intensive care

Introduction

This systematic review aimed to evaluate the quality of clinical practice guidelines (CPGs) and recommendations for managing pain, sedation, delirium, and iatrogenic withdrawal syndrome in pediatric intensive care (PICU). The objectives included evaluating the quality of recommendations, synthesizing recommendations, harmonizing the strength of the recommendation (SoR) and the certainty of evidence (CoE), and assessing the relevance of supporting evidence.

Methods

A comprehensive search in four electronic databases (Medline, Embase.com, CINAHL and JBI EBP Database), 9 guideline repositories, and 13 professional societies was conducted to identify CPGs published from January 2010 to the end of May 2023 in any language. The quality of CPGs and recommendations was assessed using the AGREE II and AGREE-REX instruments. Thematic analysis was used to synthesize recommendations, and the GRADE SoR and CoE harmonization method was used to interpret the credibility of summary recommendations.

Results

A total of 18 CPGs and 170 recommendations were identified. Most CPGs were of medium-quality, and three were classified as high. A total of 30 summary recommendations were synthesized across each condition, focused on common management approaches. There was inconsistency in the SoRs and CoE for summary recommendations, those for assessment showed the highest consistency, the remaining were conditional, inconsistent, inconclusive, and lacked support from evidence.

Conclusion

This systematic review provides an overview of the quality of CPGs for these four conditions in the PICU. While three CPGs achieved high-quality ratings, the overall findings reveal gaps in the evidence base of recommendations, patient and family involvement, and resources for implementation. The findings highlight the need for more rigorous and evidence-based approaches in the development and reporting of CPGs to enhance their trustworthiness. Further research is necessary to enhance the quality of recommendations for this setting. The results of this review can provide a valuable foundation for future CPG development.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=274364, PROSPERO (CRD42021274364).

Implementation of an algorithm for tapering analgosedation reduces iatrogenic withdrawal syndrome in pediatric intensive care

BACKGROUND

Proper analgosedation is a cornerstone in the treatment of critically ill patients in Pediatric Intensive Care Units (PICUs). Medications, such as fentanyl, morphine, and midazolam, are essential to safe and respectful care. The use of these medications over time may lead to side effects such as iatrogenic withdrawal syndrome (IWS) in the tapering phase. The aim of the study was to test an algorithm for tapering analgosedation to reduce the prevalence of IWS in two Norwegian PICUs at Oslo University Hospital.

METHODS

A cohort of mechanically ventilated patients from newborn to 18 years with continuous infusions of opioids and benzodiazepines for 5 days or more were included consecutively from May 2016 to December 2021. A pre- and posttest design, with an intervention phase using an algorithm for tapering analgosedation after the pretest, was used. The ICU staffs were trained in using the algorithm after the pretest. The primary outcome was a reduction in IWS. The Withdrawal Assessment Tool-1 (WAT-1) was used to identify IWS. A WAT-1 score ≥3 indicates IWS.

RESULTS

We included 80 children, 40 in the baseline group, and 40 in the intervention group. Age and diagnosis did not differ between the groups. The prevalence of IWS was 95% versus 52.5% in the baseline group versus the intervention group, and the peak WAT-1 median was 5.0 (IQR 4-6.8) versus 3.0 (IQR 2.0-6.0) (p = .012). Based on SUM WAT-1 ≥ 3, which describes the burden over time better, we demonstrated a reduction of IWS, from a median of 15.5 (IQR 8.25-39) to a median of 3 (IQR 0-20) (p = <.001).

CONCLUSION

We suggest using an algorithm for tapering analgosedation in PICUs since the prevalence of IWS was significantly lower in the intervention group in our study.

Machine learning-based prediction of delirium 24 h after pediatric intensive care unit admission in critically ill children: A prospective cohort study

BACKGROUND

Accurately identifying patients at high risk of delirium is vital for timely preventive intervention measures. Approaches for identifying the risk of developing delirium among critically ill children are not well researched.

OBJECTIVE

To develop and validate machine learning-based models for predicting delirium among critically ill children 24 h after pediatric intensive care unit (PICU) admission.

DESIGN

A prospective cohort study.

SETTING

A large academic medical center with a 57-bed PICU in southwestern China from November 2019 to February 2022.

PARTICIPANTS

One thousand five hundred and seventy-six critically ill children requiring PICU stay over 24 h.

METHODS

Five machine learning algorithms were employed. Delirium was screened by bedside nurses twice a day using the Cornell Assessment of Pediatric Delirium. Twenty-four clinical features from medical and nursing records during hospitalization were used to inform the models. Model performance was assessed according to numerous learning metrics, including the area under the receiver operating characteristic curve (AUC).

RESULTS

Of the 1576 enrolled patients, 929 (58.9 %) were boys, and the age ranged from 28 days to 15 years with a median age of 12 months (IQR 3 to 60 months). Among them, 1126 patients were assigned to the training cohort, and 450 were assigned to the validation cohort. The AUCs ranged from 0.763 to 0.805 for the five models, among which the eXtreme Gradient Boosting (XGB) model performed best, achieving an AUC of 0.805 (95 % CI, 0.759-0.851), with 0.798 (95 % CI, 0.758-0.834) accuracy, 0.902 sensitivity, 0.839 positive predictive value, 0.640 F1-score and a Brier score of 0.144. Almost all models showed lower predictive performance in children younger than 24 months than in older children. The logistic regression model also performed well, with an AUC of 0.789 (95 % CI, 0.739, 0.838), just under that of the XGB model, and was subsequently transformed into a nomogram.

CONCLUSIONS

Machine learning-based models can be established and potentially help identify critically ill children who are at high risk of delirium 24 h after PICU admission. The nomogram may be a beneficial management tool for delirium for PICU practitioners at present.

Risk factors for hyperactive delirium after laparoscopic radical gastrectomy under general anesthesia in patients with gastric cancer

OBJECTIVE

This study aimed to analyze the risk factors for the occurrence of postoperative hyperactive delirium after laparoscopic radical gastrectomy under general anesthesia in patients with gastric cancer.

METHODS

The clinical data of 280 gastric cancer patients who underwent laparoscopic radical gastrectomy under general anesthesia in First Affiliated Hospital of Gannan Medical University from January 2020 to June 2023 were retrospectively analyzed, and the types and incidence of postoperative delirium were recorded. The factors influencing the occurrence of postoperative hyperactive delirium were analyzed.

RESULTS

Multi-factor logistic regression analysis showed that older age, high dosage of anesthetic drug consumption, high American Society of Anesthesiologists (ASA) classification (or ASA grade 3-4), long Post-anesthesia Care Unit (PACU) stay, and long extubation time were independent risk factors for the occurrence of hyperactive delirium after laparoscopic radical gastrectomy (OR > 1, P < 0.05). The area under the curve of the nomogram was used to predict the occurrence of hyperactive delirium after laparoscopic radical gastrectomy under general anesthesia was 0.903 (95% CI: 0.846-0.978).

CONCLUSION

Older age, high dosage of anesthetic drug consumption, high ASA classification (or ASA grade 3-4), long PACU stay, and long extubation time were independent risk factors affecting the occurrence of hyperactive delirium after laparoscopic radical gastrectomy under general anesthesia.

Improving Documentation of Pain Reassessment after Pain Management Interventions in the NICU

Background

Neonates exposed to painful procedures require pain assessment and reassessment using nonverbal scales. Nurses perform initial assessments routinely, but reassessment is variable. The goal was to increase pain reassessments in neonates with a previous score of 4 or higher within 60 minutes from 50% to 75% within 12 months.

Methods

After identifying key drivers, we tested several interventions using the IHI's Model for Improvement. The outcome measure was the rate of reassessments within 1 hour after scoring ≥4 on the Neonatal Pain Agitation and Sedation Scale (N-PASS). Duration of time between scoring and intervention was documented. Interventions included electronic health record (EHR) changes, direct communication with bedside nurses through text messages and emails, in-person education, and a yearly competency module. The process measure was the number of messages/emails to staff. Sedation scores were the balancing measure.

Results

Baseline compliance was 50% with significant variability. A centerline shift occurred after the first intervention. After the first four interventions in the following 3 months, a 29% total increase occurred. Overall time-lapse between reassessments decreased from 102 to 90 minutes. Overall sedation scores decreased from -2.5 during the baseline to -1.7 during the sustain period. The goal of 75% pain reassessments was achieved and sustained for two years.

Conclusions

Automated tools such as the trigger report provided data that increased noncompliance visibility. Real-time and personalized reminders and education improved awareness and set the tone for culture change. Electronic health record reminders for reassessments and standardized annual education helped in sustaining change.

Pain Assessment and Management for a Chemically Paralyzed Child Receiving Mechanical Ventilation

BACKGROUND

Pain assessment in the pediatric intensive care unit (PICU) is complex, specifically for children receiving mechanical ventilation who require neuromuscular blockade (NMB). No valid pain assessment method exists for this population. Guidelines are limited to using physiologic variables; it remains unknown how nurses are assessing and managing pain for this population in practice.

OBJECTIVES

To describe how PICU nurses are assessing and managing pain for children who require NMB.

METHODS

A cross-sectional quantitative design was used with an electronic survey. Nurses were asked to respond to 4 written vignettes depicting a child who required NMB and had a painful procedure, physiologic cues, both, or neither.

RESULTS

A total of 107 PICU nurses answered the survey. Nurses primarily used behavioral assessment scales (61.0%) to assess the child's pain. All nurses reported that physiologic variables are either moderately or extremely important, and 27.3% of nurses used the phrase "assume pain present" formally at their organization. When physiologic cues were present, the odds of a nurse intervening with a pain intervention were 23.3 times (95% CI, 11.39-53.92; P < .001) higher than when such cues were absent.

CONCLUSIONS

These results demonstrate variation in how nurses assess pain for a child who requires NMB. The focus remains on behavioral assessment scales, which are not valid for this population. When intervening with a pain intervention, nurses relied on physiologic variables. Decision support tools to aid nurses in conducting an effective pain assessment and subsequent management need to be created.

Updates and Clinical Implications of Pediatric Delirium

Delirium is a fluctuating level of awareness based on a physiologic disease process. Within pediatrics, delirium affects approximately 30% of patients admitted to critical care units and is associated with increased mortality, morbidity, length of stay, and care costs. Multiple pediatric critical care societies recommend the implementation of screening practices using validated delirium tools. Delirium remains underrecognized because of suboptimal screening and protocol implementation in pediatric critical care units nationally and internationally. The mainstay of delirium prevention and management is nonpharmacologic, focusing on normalizing a patient's environment, sleep/wake cycles, nutritional status, and activity levels.

Assessment and management of iatrogenic withdrawal syndrome and delirium in pediatric intensive care units across Europe: An ESPNIC survey

INTRODUCTION

Analgesia and sedation are essential for the care of children in the pediatric intensive care unit (PICU); however, when prolonged, they may be associated with iatrogenic withdrawal syndrome (IWS) and delirium. We sought to evaluate current practices on IWS and delirium assessment and management (including non-pharmacologic strategies as early mobilization) and to investigate associations between the presence of an analgosedation protocol and IWS and delirium monitoring, analgosedation weaning, and early mobilization.

METHODS

We conducted a multicenter cross-sectional survey-based study collecting data from one experienced physician or nurse per PICU in Europe from January to April 2021. We then investigated differences among PICUs that did or did not follow an analgosedation protocol.

RESULTS

Among 357 PICUs, 215 (60%) responded across 27 countries. IWS was systematically monitored with a validated scale in 62% of PICUs, mostly using the Withdrawal Assessment Tool-1 (53%). The main first-line treatment for IWS was a rescue bolus with interruption of weaning (41%). Delirium was systematically monitored in 58% of PICUs, mostly with the Cornell Assessment of Pediatric Delirium scale (48%) and the Sophia Observation Scale for Pediatric Delirium (34%). The main reported first-line treatment for delirium was dexmedetomidine (45%) or antipsychotic drugs (40%). Seventy-one percent of PICUs reported to follow an analgosedation protocol. Multivariate analyses adjusted for PICU characteristics showed that PICUs using a protocol were significantly more likely to systematically monitor IWS (odds ratio [OR] 1.92, 95% confidence interval [CI] 1.01-3.67) and delirium (OR 2.00, 95% CI 1.07-3.72), use a protocol for analgosedation weaning (OR 6.38, 95% CI 3.20-12.71) and promote mobilization (OR 3.38, 95% CI 1.63-7.03).

CONCLUSIONS

Monitoring and management of IWS and delirium are highly variable among European PICUs. The use of an analgosedation protocol was associated with an increased likelihood of monitoring IWS and delirium, performing a structured analgosedation weaning and promoting mobilization. Education on this topic and interprofessional collaborations are highly needed to help reduce the burden of analgosedation-associated adverse outcomes.

Ketamine Clinical Use on the Pediatric Critically Ill Infant: A Global Bibliometric and Critical Review of Literature

The developing central nervous system is vulnerable to several stimuli, especially psychotropic drugs. Sedation procedures during the developmental period are frequent in pediatric intensive care units (PICUs), in which the use of the sedative agent is still a challenge for the PICU team. Ketamine has been indicated for sedation in critically ill children with hemodynamic and ventilatory instabilities, but the possible neurobehavioral consequences related to this use are still uncertain. Here, we performed a bibliometric analysis with conventional metrics and a critical review of clinical findings to reveal a gap in the literature that deserves further investigation. We revealed that only 56 articles corresponded to the inclusion criteria of the study. The United States of America emerges as the main country within the scope of this review. In addition, professional clinical societies play a key role in the publications of scientific clinical findings through the specialist journals, which encourages the sharing of research work. The co-occurrence of keywords evidenced that the terms "sedation", "ketamine", and "pediatric" were the most frequent. Case series and review articles were the most prevalent study design. In the critical evaluation, the scarce studies highlight the need of use and post-use monitoring, which reinforces the importance of additional robust clinical studies to characterize the possible adverse effects resulting from ketamine anesthetic protocol in critically ill children.

Effectiveness, quality and implementation of pain, sedation, delirium, and iatrogenic withdrawal syndrome algorithms in pediatric intensive care: a systematic review and meta-analysis

Background

Pain, sedation, delirium, and iatrogenic withdrawal syndrome are conditions that often coexist, algorithms can be used to assist healthcare professionals in decision making. However, a comprehensive review is lacking. This systematic review aimed to assess the effectiveness, quality, and implementation of algorithms for the management of pain, sedation, delirium, and iatrogenic withdrawal syndrome in all pediatric intensive care settings.

Methods

A literature search was conducted on November 29, 2022, in PubMed, Embase, CINAHL and Cochrane Library, ProQuest Dissertations & Theses, and Google Scholar to identify algorithms implemented in pediatric intensive care and published since 2005. Three reviewers independently screened the records for inclusion, verified and extracted data. Included studies were assessed for risk of bias using the JBI checklists, and algorithm quality was assessed using the PROFILE tool (higher % = higher quality). Meta-analyses were performed to compare algorithms to usual care on various outcomes (length of stay, duration and cumulative dose of analgesics and sedatives, length of mechanical ventilation, and incidence of withdrawal).

Results

From 6,779 records, 32 studies, including 28 algorithms, were included. The majority of algorithms (68%) focused on sedation in combination with other conditions. Risk of bias was low in 28 studies. The average overall quality score of the algorithm was 54%, with 11 (39%) scoring as high quality. Four algorithms used clinical practice guidelines during development. The use of algorithms was found to be effective in reducing length of stay (intensive care and hospital), length of mechanical ventilation, duration of analgesic and sedative medications, cumulative dose of analgesics and sedatives, and incidence of withdrawal. Implementation strategies included education and distribution of materials (95%). Supportive determinants of algorithm implementation included leadership support and buy-in, staff training, and integration into electronic health records. The fidelity to algorithm varied from 8.2% to 100%.

Conclusions

The review suggests that algorithm-based management of pain, sedation and withdrawal is more effective than usual care in pediatric intensive care settings. There is a need for more rigorous use of evidence in the development of algorithms and the provision of details on the implementation process.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021276053, PROSPERO [CRD42021276053].

Improving Daily Patient Goal-Setting and Team Communication: The Liber8 Glass Door Project

OBJECTIVES

To develop and implement a tool to improve daily patient goal setting, team collaboration and communication.

DESIGN

Quality improvement implementation project.

SETTING

Tertiary-level PICU.

PATIENTS

Inpatient children less than 18 years old requiring ICU level care.

INTERVENTION

A "Glass Door" daily goals communication tool located in the door front of each patient room.

MEASUREMENTS AND MAIN RESULTS

We used Pronovost's 4 E's model to implement the Glass Door. Primary outcomes were uptake of goal setting, healthcare team discussion rate around goals, rounding efficiency, acceptability and sustainability of the Glass Door. The total implementation duration from engagement to evaluation of sustainability was 24 months. Goal setting increased significantly from 22.9% to 90.7% ( p < 0.01) patient-days using the Glass Door compared to a paper-based daily goals checklist (DGC). One-year post implementation, the uptake was sustained at 93.1% ( p = 0.04). Rounding time decreased from a median of 11.7 minutes (95% CI, 10.9-12.4 min) to 7.5 minutes (95% CI, 6.9-7.9 min) per patient post-implementation ( p < 0.01). Goal discussions on ward rounds increased overall from 40.1% to 58.5% ( p < 0.01). Ninety-one percent of team members perceive that the Glass Door improves communication for patient care, and 80% preferred the Glass Door to the DGC for communicating patient goals with other team members. Sixty-six percent of family members found the Glass Door helpful in understanding the daily plan and 83% found it helpful in ensuring thorough discussion among the PICU team.

CONCLUSIONS

The Glass Door is a highly visible tool that can improve patient goal setting and collaborative team discussion with good uptake and acceptability among healthcare team members and patient families.

Severe irritability in a critically ill preterm infant: a case of delirium at the neonatal intensive care unit

Delirium is a common disorder in intensive care units, being associated with greater morbidity and mortality. However, in neonatal intensive care units, delirium is rarely diagnosed, due to the low familiarity of the neonatologist with the subject and the difficulties in the applicability of diagnostic questionnaires. This case report aimed to assess the presence of this disorder in this group of patients and identify the difficulties encountered in the diagnosis and treatment. We report the case of a premature newborn with necrotizing enterocolitis during hospitalization and underwent three surgical approaches. The newborn exhibited intense irritability, having received high doses of fentanyl, dexmedetomidine, clonidine, ketamine, phenytoin, and methadone, without the control of the symptoms. A diagnosis of delirium was then made and treatment with quetiapine was started, with a complete reversal of the symptoms. This is the first case reported in Brazil and the first describing the withdrawal of the quetiapine.

Prospective observational study on the use of continuous intravenous ketamine and propofol infusion for prolonged sedation in critical care

INTRODUCTION

Analgesia and sedation are a priority in paediatric intensive care. The combination of ketamine and propofol is a possible option in patients requiring prolonged or difficult sedation and to reduce the use of benzodiazepines and opiates. The aim of this study was to assess the efficacy and safety of combination ketamine and propofol in continuous infusion for prolonged analgesia/sedation in the paediatric intensive care setting.

PATIENTS AND METHODS

Prospective, observational single-group cohort study in patients aged 1 month to 16 years admitted to the paediatric intensive care unit in 2016-2018 that received ketamine and propofol in continuous infusion for analgesia and sedation. We collected data on demographic and clinical characteristics, analgesia and sedation scores (MAPS, COMFORT-B and SOPHIA), haemodynamic parameters and adverse events.

RESULTS

The study included 32 patients. The maximum dose of ketamine was 1.5 mg/kg/h (interquartile range [IQR], 1-2 mg/kg/h) and the infusion duration was 5 days (IQR, 3-5 days). The maximum dose of propofol was 3.2 mg/kg/h (IQR, 2.5-3.6 mg/kg/h) and the infusion duration, 5 days (IQR, 3-5 days). Thirty (93.7%) patients had previously received midazolam and 29 (90.6%) fentanyl. Analgesia scores did not change after initiation of the ketamine and propofol infusion. There was a statistically significant increase in the COMFORT-B score, but the score remained in the adequate sedation range (12-17). There were small but statistically significant decreases in the mean arterial pressure (from 64 mmHg to 60 mmHg; P = .006) and the diastolic blood pressure (from 50.5 to 48 mmHg; P = .023) 1 h after the initiation of the ketamine and propofol infusion, but this difference was not observed 12 h later and did not require administration of vasoactive drugs. No other major adverse events were detected during the infusion.

CONCLUSIONS

The combination of ketamine and propofol in continuous infusion is a safe treatment in critically ill children that makes it possible to achieve an appropriate level of analgesia and sedation without relevant haemodynamic repercussions.

Analgesia and sedation in critically ill pediatric patients: an update from the recent guidelines and point of view

In the last decades, the advancement of knowledge in analgesia and sedation for critically ill pediatric patients has been conspicuous and relevant. Many recommendations have changed to ensure patients' comfort during their intensive care unit (ICU) stay and prevent and treat sedation-related complications, as well as improve functional recovery and clinical outcomes. The key aspects of the analgosedation management in pediatrics have been recently reviewed in two consensus-based documents. However, there remains a lot to be researched and understood. With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field.    Conclusion: With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field. What is Known: • Critically ill pediatric patients receiving intensive care required analgesia and sedation to attenuate painful and stressful stimuli. •Optimal management of analgosedation is a challenge often burdened with complications such as tolerance, iatrogenic withdrawal syndrome, delirium, and possible adverse outcomes. What is New: •The new insights on the analgosedation treatment for critically ill pediatric patients delineated in the recent guidelines are summarized to identify strategies for changes in clinical practice. •Research gaps and potential for quality improvement projects are also highlighted.

Validation of the withdrawal assessment tool-1 (WAT-1) in pediatric cardiovascular patients on an inpatient unit

PURPOSE

Sedation and analgesia are administered to critically ill patients, which may result in physical dependence and subsequent iatrogenic withdrawal. The Withdrawal Assessment Tool-1 (WAT-1) was developed and validated as an objective measurement of pediatric iatrogenic withdrawal in intensive care units (ICUs), with a WAT-1 score ≥ 3 indicative of withdrawal. This study's objectives were to test interrater reliability and validity of the WAT-1 in pediatric cardiovascular patients in a non-ICU setting.

DESIGN AND METHODS

This prospective observational cohort study was conducted on a pediatric cardiac inpatient unit. WAT-1 assessments were performed by the patient's nurse and a blinded expert nurse rater. Intra-class correlation coefficients were calculated, and Kappa statistics were estimated. A two-sample, one-sided test of proportions of weaning (n = 30) and nonweaning (n = 30) patients with a WAT-1 ≥3 were compared.

RESULTS

Interrater reliability was low (K = 0.132). The WAT-1 area under the receiver operating curve was 0.764 (95% confidence interval; ± 0.123). There was a significantly higher proportion (50%, p = 0.009) of weaning patients with WAT-1 scores ≥3 compared to the nonweaning patients (10%). The WAT-1 elements of moderate/severe uncoordinated/repetitive movement and loose, watery stools were significantly higher in the weaning population.

PRACTICE IMPLICATIONS

Methods to improve interrater reliability warrant further examination. The WAT-1 had good discrimination at identifying withdrawal in cardiovascular patients on an acute cardiac care unit. Frequent nurse re-education may increase accurate tool use. The WAT-1 tool may be used in the management of iatrogenic withdrawal in pediatric cardiovascular patients in a non-ICU setting.

Effect of S-ketamine administered at the end of anesthesia on emergence delirium in preschool children undergoing tonsillectomy and/or adenoidectomy

Background: S-ketamine (the S-isomer of ketamine) is twice as potent as the racemic mixture of this agent and carries fewer side effects when administered to humans. Information regarding the use of S-ketamine for the prevention of emergence delirium (ED) is limited. Thus, we evaluated the effect of S-ketamine administered at the end of anesthesia on ED in preschool children undergoing tonsillectomy and/or adenoidectomy. Methods: We investigated 108 children aged 3-7 years, who were scheduled for elective tonsillectomy and/or adenoidectomy under general anesthesia. They were randomly assigned to receive either S-ketamine 0.2 mg/kg or an equal volume of normal saline at the end of anesthesia. The primary outcome was the highest score on the pediatric anesthesia ED (PAED) scale during the first 30 min post-surgery. The secondary outcomes included the incidence of ED (defined as a score of ≥ 3 on Aono scale), pain score, time to extubation, and incidences of adverse events. Multivariate analyses were also performed using logistic regression to evaluate the independent factors predictive of ED. Results: The median (interquartile range) PAED score of the S-ketamine group (0 [0, 3]) was significantly lower than that in the control group (1 [0, 7]) (estimate median difference = 0, 95% confidence interval -2 to 0, p = 0.040). Significantly fewer patients in the S-ketamine group had an Aono scale score ≥ 3 (4 [7%] vs. 12 [22%], p = 0.030). Patients in the S-ketamine group also had a lower median pain score than did control subjects (4 [4, 6] vs. 6 [5, 8], p = 0.002). The time to extubation and incidences of adverse events were comparable between the two groups. However, multivariate analyses indicated that except S-ketamine use, pain scores, age and duration of anesthesia were independent factors predictive of ED. Conclusion: S-ketamine (0.2 mg/kg) administered at the end of anesthesia effectively reduced the incidence and severity of ED in preschool children undergoing tonsillectomy and/or adenoidectomy without prolonging the time to extubation or increasing adverse events. However, S-ketamine use was not an independent factor predictive of ED.

[Evidence-based guideline for neonatal pain management in China (2023)]

Pain disrupts neonatal vital signs and internal environment homeostasis and affects the recovery process, and recurrent pain stimulation is one of the important risk factors for neurodevelopmental disorders and some chronic diseases. In order to standardize pain management practice in neonatal wards in China and effectively prevent and reduce the adverse effects of pain on the physical and mental development of neonates, National Clinical Research Center for Child Health and Diseases (Children's Hospital of Chongqing Medical University) convened a multidisciplinary panel to formulate the evidence-based guideline for neonatal pain management in China (2023 edition) following the principles and methods for the guideline development issued by the World Health Organization. Based on the best evidence and expert consensus, this guideline gives 26 recommendations for nine clinical issues, i.e., the classification and definition of neonatal pain, common sources of pain, pain assessment principles, pain assessment methods, analgesic principle, non-pharmaceutical analgesic methods, pharmaceutical analgesic methods, parental participation in pain management, and recording methods for pain management, so as to provide medical staff with guidance and a decision-making basis for neonatal pain assessment and analgesia management.