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Maia MLF, Pantoja LVPS, Da Conceição BC, Machado-Ferraro KM, Gonçalves JKM, Dos Santos-Filho PM, Lima RR, Fontes-Junior EA, Maia CSF. Ketamine Clinical Use on the Pediatric Critically Ill Infant: A Global Bibliometric and Critical Review of Literature. J Clin Med 2023; 12:4643. [PMID: 37510758 PMCID: PMC10380297 DOI: 10.3390/jcm12144643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/14/2023] [Accepted: 05/29/2023] [Indexed: 07/30/2023] Open
Abstract
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.
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Affiliation(s)
- Mary Lucy Ferraz Maia
- Laboratory of Pharmacology of Inflammation and Behavior, Faculty of Pharmacy, Institute of Health Science, Federal University of Pará, Belém 66075-900, Pará, Brazil
| | - Lucas Villar Pedrosa Silva Pantoja
- Laboratory of Pharmacology of Inflammation and Behavior, Faculty of Pharmacy, Institute of Health Science, Federal University of Pará, Belém 66075-900, Pará, Brazil
| | - Brenda Costa Da Conceição
- Laboratory of Pharmacology of Inflammation and Behavior, Faculty of Pharmacy, Institute of Health Science, Federal University of Pará, Belém 66075-900, Pará, Brazil
| | - Kissila Márvia Machado-Ferraro
- Laboratory of Pharmacology of Inflammation and Behavior, Faculty of Pharmacy, Institute of Health Science, Federal University of Pará, Belém 66075-900, Pará, Brazil
| | - Jackeline Kerlice Mata Gonçalves
- Laboratory of Pharmacology of Inflammation and Behavior, Faculty of Pharmacy, Institute of Health Science, Federal University of Pará, Belém 66075-900, Pará, Brazil
| | - Paulo Monteiro Dos Santos-Filho
- Laboratory of Pharmacology of Inflammation and Behavior, Faculty of Pharmacy, Institute of Health Science, Federal University of Pará, Belém 66075-900, Pará, Brazil
| | - Rafael Rodrigues Lima
- Laboratory of Functional and Structural Biology, Biological Science Institute, Federal University of Pará, Belém 66075-110, Pará, Brazil
| | - Enéas Andrade Fontes-Junior
- Laboratory of Pharmacology of Inflammation and Behavior, Faculty of Pharmacy, Institute of Health Science, Federal University of Pará, Belém 66075-900, Pará, Brazil
| | - Cristiane Socorro Ferraz Maia
- Laboratory of Pharmacology of Inflammation and Behavior, Faculty of Pharmacy, Institute of Health Science, Federal University of Pará, Belém 66075-900, Pará, Brazil
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Balit CR, LaRosa JM, Ong JSM, Kudchadkar SR. Sedation protocols in the pediatric intensive care unit: fact or fiction? Transl Pediatr 2021; 10:2814-2824. [PMID: 34765503 PMCID: PMC8578750 DOI: 10.21037/tp-20-328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 03/03/2021] [Indexed: 11/06/2022] Open
Abstract
Comfort of the critically unwell pediatric patient is paramount to ensuring good outcomes. Analgesia-based, multimodal sedative approaches are the foundation for comfort, whereby pain is addressed first and then sedation titrated to a predefined target based on the goals of care. Given the heterogeneity of patients within the pediatric critical care population, the approach must be individualized based on the age and developmental stage of the child, physiologic status, and degree of invasive treatment required. In both the adult and pediatric intensive care unit (PICU), sedation titration is practiced as standard of care to meet therapeutic goals with a focus on facilitating early rehabilitation and extubation while avoiding under- and over-sedation. Sedation protocols have been developed as methods to reduce variability and optimize goal-directed therapy. Components of a sedation protocol include routine analgesia and sedation scoring with validated tools at specified intervals and a predefined algorithm that allows the titration of analgesia and sedation based on those assessments. Sedation protocols are designed to improve communication and documentation of sedation goals while also empowering the bedside team to respond rapidly to changes in a patient's clinical status. Previously it was thought that sedation protocols would consistently reduce duration of mechanical ventilation (MV) and length of stay (LOS) for patients in the PICU, however, this has not been the case. Nonetheless, introduction of sedation protocols has provided several benefits, including: (I) reduction in benzodiazepine usage; (II) improvements in interprofessional communication surrounding sedation goals and management of sedation goals; and (III) reductions in iatrogenic withdrawal symptoms. Successful implementation of sedation protocols requires passionate clinical champions and a robust implementation, education, and sustainability plan. Emerging evidence suggests that sedation protocols as part of a bundle of quality improvement initiatives will form the basis of future studies to improve short- and long-term outcomes after PICU discharge. In this review, we aim to define sedation protocols in the context of pediatric critical care and highlight important considerations for clinical practice and research.
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Affiliation(s)
- Corrine R Balit
- Paediatric Intensive Care Unit, John Hunter Hospital, Newcastle, Australia
| | - Jessica M LaRosa
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jacqueline S M Ong
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Pediatric Critical Care Nurses' Practices Related to Sedation and Analgesia. Dimens Crit Care Nurs 2021; 40:280-287. [PMID: 34398564 DOI: 10.1097/dcc.0000000000000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Pediatric intensive care unit (PICU) nurses may consider additional factors beyond validated tools when managing pain and sedation of children. However, these other factors and related beliefs, practices, and decision-making for analgesia and sedation have not been well described. OBJECTIVES This study describes nurses' beliefs, practices, and decision-making related to sedation and analgesia for mechanically ventilated children on a PICU and a pediatric cardiovascular ICU at a tertiary academic children's medical center in the United States. METHODS A 35-item web-based survey tool was developed to more fully identify nurses' pain, sedation, comfort, and analgesia beliefs, decisions, planning, and procedures for children who were mechanically ventilated in the ICU. It was distributed to 102 nurses in the PICU, pediatric cardiovascular ICU, and pediatric critical care float pool. RESULTS Twenty-six nurses (25%) responded; a majority worked the night shift and had 5 years or less of ICU experience. While participants believed intubated pediatric patients required moderate to deep sedation, approximately only half reported patients were adequately sedated. They reported that they were more likely to manage pain and sedation using specific behaviors and changes in vital signs than scores on a standardized scale. Nurses also reported routinely incorporating nonpharmacologic comfort measures. Premedication was more common for invasive procedures than for routine nursing care. DISCUSSION Pediatric ICU nurses in this study considered factors beyond standardized scales when evaluating and managing pain and sedation of ventilated children. Nurses prioritized children's specific behaviors, vital signs, and their own nursing judgment above standardized scales. Research is needed to describe nurses' practices beyond this small study and to define and validate additional assessment parameters to incorporate into decision-making to improve management and care outcomes.
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Andersen RD, Olsson E, Eriksson M. The evidence supporting the association between the use of pain scales and outcomes in hospitalized children: A systematic review. Int J Nurs Stud 2020; 115:103840. [PMID: 33360247 DOI: 10.1016/j.ijnurstu.2020.103840] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Systematic use of pain intensity scales is considered a prerequisite for treatment of pain in hospitalized children, but already a decade ago, attention was called to the lack of robust evidence supporting the presumed positive association between their use and desired outcomes. OBJECTIVES To re-evaluate the evidence supporting the association between the use of pain scales and patient and process outcomes in hospitalized children. DESIGN Systematic literature review. DATA SOURCES The online databases PubMed and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched from inception to April 15, 2020. REVIEW METHODS We performed single screening of all records followed by duplicate screening of full texts of interest with a disagreement procedure in place. Studies where the authors evaluated outcomes from the use of self-report or behavioral-based pain scales in children 0-18 years in a hospital setting were included. Emergency care settings were excluded. RESULTS In a majority of the 32 included studies, complex interventions that included one or more pain scales were evaluated. Process outcomes (e.g., documentation) were most frequently studied. Interventions were commonly associated with improved documentation of pain assessment, while the effect on pain management documentation was inconsistent. However, improvements in process outcomes did not necessarily result in better patient outcomes. In regard to patient outcomes (e.g., pain intensity, side effects, or satisfaction with treatment), some authors reported reduced pain intensity on group level, but the effect on other functional outcomes, child and parent satisfaction, and aspects of safety were inconsistent. Methodological issues, e.g., weak study designs and small samples, biased the results, and it was not possible to determine how pain scales contributed to the overall effects since they were studied as part of complex interventions. CONCLUSIONS Although both a theoretically founded understanding of pain and clinical experience suggest that the use of pain scales will make a difference for hospitalized children with pain, there is still limited evidence to support this notion. As pain scales have been almost exclusively studied as an aspect of complex interventions, research that determines the active ingredient(s) in a complex intervention and their joint and individual effects on outcomes that are meaningful for the child (for example reduced pain intensity or improved function) are urgently needed. Tweetable abstract: Limited #research supports association between use of pediatric #pain scales and patient outcomes @_randida @PainPearl.
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Affiliation(s)
- Randi Dovland Andersen
- Department of Child and Adolescent Health Services and Department of Research, Telemark Hospital Trust, P.O. Box 2900 Kjørbekk, Skien 3710, Norway; Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro 701 82, Sweden.
| | - Emma Olsson
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro 701 82, Sweden; Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro 701 82, Sweden
| | - Mats Eriksson
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro 701 82, Sweden; Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro 701 82, Sweden
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Michel J, Hofbeck M, Peper AK, Kumpf M, Neunhoeffer F. Evaluation of an updated sedation protocol to reduce benzodiazepines in a pediatric intensive care unit. Curr Med Res Opin 2020; 36:1-6. [PMID: 31526142 DOI: 10.1080/03007995.2019.1663689] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aim: Midazolam like other benzodiazepines is supposed to be neurotoxic in small children and to represent a risk factor for the development of delirium. The aim of this study was to evaluate whether a modified analgesia and sedation protocol is feasible and effective to reduce the requirement of midazolam in neonates and young infants after cardiac surgery.Methods: Patients aged 6 months or younger who underwent surgery for congenital heart disease with cardiopulmonary bypass were enrolled and divided into a pre-modification group (January-December 2016) and after adjusting our sedation protocol into a post-modification group (January-December 2018). We assessed the doses of midazolam, morphine and clonidine as well as sedation scores according to our nurse-driven sedation protocol every 8 h until 120 h after cardiac surgery. During weaning from analgesia and sedation, children were monitored regarding withdrawal symptoms and pediatric delirium.Results: Sixty-five patients were included (33 patients in the pre-modification group, 32 patients in the post-modification group). The number of patients receiving midazolam and the cumulative dose of midazolam could be successfully reduced. The sedation scores were still within the desired target range for adequate sedation without any negative side effects.Conclusions: It is feasible and safe to reduce the use of midazolam in infants after cardiac surgery maintaining sedation goals based on a modified nurse-driven analgesia and sedation protocol.
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Affiliation(s)
- Jörg Michel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Ann-Kathrin Peper
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
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Ismail A, Forgeron P, Polomeno V, Gharaibeh H, Dagg W, Harrison D. Pain management interventions in the Paediatric Intensive Care Unit: A scoping review. Intensive Crit Care Nurs 2019; 54:96-105. [DOI: 10.1016/j.iccn.2019.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/13/2019] [Accepted: 05/18/2019] [Indexed: 01/18/2023]
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Staveski SL, Wu M, Tesoro TM, Roth SJ, Cisco MJ. Interprofessional Team's Perception of Care Delivery After Implementation of a Pediatric Pain and Sedation Protocol. Crit Care Nurse 2018; 37:66-76. [PMID: 28572103 DOI: 10.4037/ccn2017538] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Pain and agitation are common experiences of patients in pediatric cardiac intensive care units. Variability in assessments by health care providers, communication, and treatment of pain and agitation creates challenges in management of pain and sedation. OBJECTIVES To develop guidelines for assessment and treatment of pain, agitation, and delirium in the pediatric cardiac intensive unit in an academic children's hospital and to document the effects of implementation of the guidelines on the interprofessional team's perception of care delivery and team function. METHODS Before and after implementation of the guidelines, interprofessional team members were surveyed about the members' perception of analgesia, sedation, and delirium management RESULTS: Members of the interprofessional team felt more comfortable with pain and sedation management after implementation of the guidelines. Team members reported improvements in team communication on patients' comfort. Members thought that important information was less likely to be lost during transfer of care. They also noted that the team carried out comfort management plans and used pharmacological and nonpharmacological therapies better after implementation of the guidelines than they did before implementation. CONCLUSIONS Guidelines for pain and sedation management were associated with perceived improvements in team function and patient care by members of the interprofessional team.
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Affiliation(s)
- Sandra L Staveski
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio. .,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California. .,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California. .,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford. .,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California.
| | - May Wu
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
| | - Tiffany M Tesoro
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
| | - Stephen J Roth
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
| | - Michael J Cisco
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
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Nurse titrated analgesia and sedation in intensive care increases the frequency of comfort assessment and reduces midazolam use in paediatric patients following cardiac surgery. Aust Crit Care 2018; 31:31-36. [DOI: 10.1016/j.aucc.2017.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 02/08/2017] [Accepted: 02/11/2017] [Indexed: 12/24/2022] Open
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Sedating Children on Extracorporeal Membrane Oxygenation: Achieving More With Less. Crit Care Med 2017; 45:1794-1796. [PMID: 28915181 DOI: 10.1097/ccm.0000000000002560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Motta E, Luglio M, Delgado AF, Carvalho WBD. Importance of the use of protocols for the management of analgesia and sedation in pediatric intensive care unit. Rev Assoc Med Bras (1992) 2016; 62:602-609. [DOI: 10.1590/1806-9282.62.06.602] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/26/2016] [Indexed: 02/03/2023] Open
Abstract
Summary Introduction: Analgesia and sedation are essential elements in patient care in the intensive care unit (ICU), in order to promote the control of pain, anxiety and agitation, prevent the loss of devices, accidental extubation, and improve the synchrony of the patient with mechanical ventilation. However, excess of these medications leads to rise in morbidity and mortality. The ideal management will depend on the adoption of clinical and pharmacological measures, guided by scales and protocols. Objective: Literature review on the main aspects of analgesia and sedation, abstinence syndrome, and delirium in the pediatric intensive care unit, in order to show the importance of the use of protocols on the management of critically ill patients. Method: Articles published in the past 16 years on PubMed, Lilacs, and the Cochrane Library, with the terms analgesia, sedation, abstinence syndrome, mild sedation, daily interruption, and intensive care unit. Results: Seventy-six articles considered relevant were selected to describe the importance of using a protocol of sedation and analgesia. They recommended mild sedation and the use of assessment scales, daily interruptions, and spontaneous breathing test. These measures shorten the time of mechanical ventilation, as well as length of hospital stay, and help to control abstinence and delirium, without increasing the risk of morbidity and morbidity. Conclusion: Despite the lack of controlled and randomized clinical trials in the pediatric setting, the use of protocols, optimizing mild sedation, leads to decreased morbidity.
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Abstract
BACKGROUND Despite the fact that almost all critically ill children experience some degree of pain or anxiety, there is a lack of high-quality evidence to inform preferred approaches to sedation, analgesia, and comfort measures in this environment. We conducted this survey to better understand current comfort and sedation practices among Canadian pediatric intensivists. METHODS The survey was conducted after a literature review and initial focus groups. The survey was then pretested and validated. The final survey was distributed by email to 134 intensivists from 17 PICUs across Canada using the Research Electronic Data Capture system. RESULTS The response rate was 73% (98/134). The most commonly used sedation scores are Face, Legs, Activity, Cry, and Consolability (42%) and COMFORT (41%). Withdrawal scores are commonly used (65%). In contrast, delirium scores are used by only 16% of the respondents. Only 36% of respondents have routinely used sedation protocols. The majority (66%) do not use noise reduction methods, whereas only 23% of respondents have a protocol to promote day/night cycles. Comfort measures including music, swaddling, soother, television, and sucrose solutions are frequently used. The drugs most commonly used to provide analgesia are morphine and acetaminophen. Midazolam and chloral hydrate were the most frequent sedatives. CONCLUSION Our survey demonstrates great variation in practice in the management of pain and anxiety in Canadian PICUs. Standardized strategies for sedation, delirium and withdrawal, and sleep promotion are lacking. There is a need for research in this field and the development of evidence-based, pediatric sedation and analgesia guidelines.
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How to Sustain Quality Improvements in Sedation Practice? Pediatr Crit Care Med 2016; 17:792-4. [PMID: 27500614 DOI: 10.1097/pcc.0000000000000886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVES This review will focus on the pharmacokinetics (with an emphasis on the context-sensitive half-time), pharmacodynamics, and hemodynamic characteristics of the most commonly used sedative/hypnotic, analgesic, and IV anesthetics used in cardiac intensive care. In addition, the assessment of pain and agitation and withdrawal will be reviewed. DATA SOURCE MEDLINE, PubMed. CONCLUSIONS Children in the cardiac ICU often require one or more components of general anesthesia: analgesia, amnesia (sedation and hypnosis), and muscle relaxation to facilitate mechanical ventilation, to manage postoperative pain, to perform necessary procedures, and to alleviate fear and anxiety. Furthermore, these same children are often vulnerable to hemodynamic instability due to unique underlying physiologic vulnerabilities. An assessment of hemodynamic goals, postoperative procedures to be performed, physiologic vulnerabilities, and the intended duration of mechanical ventilation should be made. Based on this assessment, the optimal selection of sedatives, analgesics, and if necessary, muscle relaxants can then be made.
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care: Sedation, Analgesia and Muscle Relaxant. Pediatr Crit Care Med 2016; 17:S3-S15. [PMID: 26945327 DOI: 10.1097/pcc.0000000000000619] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This article reviews pharmacotherapies currently available to manage sedation, analgesia, and neuromuscular blockade for pediatric cardiac critical patients. DATA SOURCES The knowledge base of an expert panel of pharmacists, cardiac anesthesiologists, and a cardiac critical care physician involved in the care of pediatric cardiac critical patients was combined with a comprehensive search of the medical literature to generate the data source. STUDY SELECTION The panel examined all studies relevant to management of sedation, analgesia, and neuromuscular blockade in pediatric cardiac critical patients. DATA EXTRACTION Each member of the panel was assigned a specific subset of the studies relevant to their particular area of expertise (pharmacokinetics, pharmacodynamics, and clinical care) to review and analyze. DATA SYNTHESIS The panel members each crafted a comprehensive summary of the literature relevant to their area of expertise. The panel, as a whole, then collaborated to cohesively summarize all the available, relevant literature. CONCLUSIONS In the cardiac ICU, management of the cardiac patient requires an individualized sedative and analgesic strategy that maintains hemodynamic stability. Multiple pharmacological therapies exist to achieve these goals and should be selected based on the patient's underlying physiology, hemodynamic vulnerabilities, desired level of sedation and analgesia, and the projected short- or long-term recovery trajectory.
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Abou Elella R, Adalaty H, Koay YN, Mokrusova P, Theresa M, Male B, Francis B, Jarrab C, Al Wadai A. The efficacy of the COMFORT score and pain management protocol in ventilated pediatric patients following cardiac surgery. Int J Pediatr Adolesc Med 2015; 2:123-127. [PMID: 31528681 PMCID: PMC6738520 DOI: 10.1016/j.ijpam.2015.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 10/30/2015] [Accepted: 11/02/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES An optimal scoring system for pain assessment in pediatric intensive care is necessary to determine the efficacy of analgesics. We assess the COMFORT scale in postoperative ventilated children and study the effect of pain and sedation protocols on their outcomes. PATIENTS AND METHODS We included postoperative ventilated patients. The unit-based pain management protocol was used. The assessment of the COMFORT and FLACC scales was performed by 2-nurses at 2-h intervals on the day of surgery and at 4-h intervals during the first 2-postoperative days or until the patient was ex-tubated. The patients' outcomes were compared with age-matched and RACHS score matched patients prior to the application of the pain protocol. RESULTS One-hundred-ten prospective patients were included. The mean age and weight was 24 months and 9.8 ± 8.4 kg, respectively. There was a weak, statistically significant correlation between the COMFORT and FLACC scales, with a range of (r = 0.01-0.7). The COMFORT scale demonstrated good internal consistency, with a Cronbach's alpha of 0.75. The mean ventilation days were 1.3 ± 3, with a mean ICU and hospital stay of 5 ± 5 and 10 ± 9 days, respectively. The 110 patients were compared to 50 retrospective matching patients. The prospective group demonstrated statistically less ventilation days, ICU stay time and hospital stay time, with P-values of 0.0004, 0.001 and 0.0003, respectively. CONCLUSION The COMFORT scale is a valuable and reliable pain assessment tool for use in postoperative ventilated pediatric patients. The implementation of a pain and sedation protocol decreased the incidence of withdrawal and the duration of mechanical ventilation as well as ICU and hospital stays.
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Affiliation(s)
- Raja Abou Elella
- Heart Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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Keogh SJ, Long DA, Horn DV. Practice guidelines for sedation and analgesia management of critically ill children: a pilot study evaluating guideline impact and feasibility in the PICU. BMJ Open 2015; 5:e006428. [PMID: 25823444 PMCID: PMC4386214 DOI: 10.1136/bmjopen-2014-006428] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIMS The aim of this study was to develop and implement guidelines for sedation and analgesia management in the paediatric intensive care unit (PICU) and evaluate the impact, feasibility and acceptability of these as part of a programme of research in this area and as a prelude to future trial work. METHOD This pilot study used a pre-post design using a historical control. SETTING Two PICUs at different hospitals in an Australian metropolitan city. PARTICIPANTS Patients admitted to the PICU and ventilated for ≥24 h, aged more than 1 month and not admitted for seizure management or terminal care. INTERVENTION Guidelines for sedation and analgesia management for critically ill children including algorithm and assessment tools. OUTCOME VARIABLES In addition to key outcome variables (ventilation time, medication dose and duration, length of stay), feasibility outcomes data (recruitment, data collection, safety) were evaluated. Guideline adherence was assessed through chart audit and staff were surveyed about merit and the use of guidelines. RESULTS The guidelines were trialled for a total of 12 months on 63 patients and variables compared with the historical control group (n=75). Analysis revealed differences in median Morphine infusion duration between groups (pretest 3.63 days (87 h) vs post-test 2.83 days (68 h), p=0.05) and maximum doses (pretest 120 μg/kg/h vs post-test 97.5 μg/kg/h) with no apparent change to ventilation duration. Chart audit revealed varied use of tools, but staff were positive about the guidelines and their use in practice. CONCLUSIONS The sedation guidelines impacted on the duration and dosage of agents without any apparent impact on ventilation duration or length of stay. Furthermore, the guidelines appeared to be feasible and acceptable in clinical practice. The results of the study have laid the foundation for follow-up studies in withdrawal from sedation, point prevalence and longitudinal studies of sedation practices as well as drug trial work.
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Affiliation(s)
- Samantha J Keogh
- Nursing Research Services, Royal Children's Hospital, Brisbane, Queensland, Australia
- NHMRC Centre of Research Excellence in Nursing (NCREN)—Centre for Health Practice Innovation—Griffith Health Institute, Griffith University, Nathan, Australia
| | - Debbie A Long
- Paediatric Intensive Care Unit, Royal Children's Hospital, Brisbane, Queensland, Australia
- NHMRC Centre of Research Excellence in Nursing (NCREN)—Centre for Health Practice Innovation—Griffith Health Institute, Griffith University, Nathan, Australia
| | - Desley V Horn
- Paediatric Intensive Care Unit, Royal Children's Hospital, Brisbane, Queensland, Australia
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Poh YN, Poh PF, Buang SNH, Lee JH. Sedation guidelines, protocols, and algorithms in PICUs: a systematic review. Pediatr Crit Care Med 2014; 15:885-92. [PMID: 25230314 DOI: 10.1097/pcc.0000000000000255] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the impact of sedation guidelines, protocols, and algorithms on clinical outcomes in PICUs. DATA SOURCES CINAHL, Medline, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews, STUDY SELECTION : English-only publications from 1966 to December 2013, which included keywords "sedation," "guideline," "algorithm," "protocol," and "pediatric intensive care." We included all primary studies involving critically ill children on sedation guidelines, protocols, and algorithms and excluded those which focused mainly on diagnostic or procedural purposes. DATA EXTRACTION Two authors independently screened each article for inclusion. A standardized data extraction sheet was used to extract data from all included studies. DATA SYNTHESIS Among the 1,283 citations yielded from our search strategy, six observational studies were included in the final review. Due to the heterogeneity of the studies included, clinical outcomes were not combined into a meta-analysis. A descriptive account of the studies was formulated to characterize all included studies. The three outcomes of interest were clinical outcomes, patients' comfort and safety, and sedative use. We found an association between the use of sedation guidelines, protocols, and algorithms and reduced PICU length of stay, frequency of unplanned extubation, prevalence of patients experiencing drug withdrawal, total sedation duration, and doses. Overall, the quality of identified studies is low. CONCLUSIONS Despite widespread recommendation for the use of sedation guidelines, protocols, and algorithms in critically ill children, our systematic review revealed a paucity of high-quality evidence to guide this practice. More robust studies are urgently needed for this important aspect of PICU care.
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Affiliation(s)
- Ya Nee Poh
- 1Division of Nursing, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore. 2Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children Hospital, Singapore. 3Office of Clinical Sciences, Duke-NUS Graduate School of Medicine, Singapore
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