1
|
Nir R, Sperotto F, Godsay M, Lu M, Kheir JN. Impact of Dexmedetomidine Infusion on Opioid and Benzodiazepine Doses in Ventilated Pediatric Patients in the Cardiac Intensive Care Unit. Paediatr Drugs 2023; 25:709-718. [PMID: 37550522 DOI: 10.1007/s40272-023-00587-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2023] [Indexed: 08/09/2023]
Abstract
INTRODUCTION Dexmedetomidine (DEX) is frequently used as an adjunct agent for prolonged sedation in the intensive care unit (ICU), though its effect on concomitant opioids or benzodiazepines infusions is unclear. We explored the impact of DEX on concomitant analgosedation in a cohort of ventilated pediatric patients in a cardiac ICU, with stratification of patients according to duration of ventilation (< 5 versus ≥ 5 days) following DEX initiation. METHODS We conducted a retrospective analysis on ventilated patients receiving a DEX infusion ≥ 24 h and at least one other sedative/analgesic infusion (January 2011-June 2021). We evaluated trends of daily doses of opioids and benzodiazepines from 24 h before to 72 h following DEX initiation, stratifying patients based on ventilation duration after DEX initiation (< 5 versus ≥ 5 days). RESULTS After excluding 1146 patients receiving DEX only, 1073 patients were included [median age 234 days (interquartile range 90, 879)]. DEX was associated with an opioid infusion in 99% of patients and a benzodiazepine infusion in 62%. Among patients ventilated for < 5 days (N = 761), opioids increased in the first 24 h following DEX initiation [+ 1.12 mg/kg/day (95% CI 0.96, 1.23), P < 0.001], then decreased [- 0.90 mg/kg/day (95% CI - 0.89, - 0.71), P < 0.001]; benzodiazepines slowly decreased [- 0.20 mg/kg/day (95% CI - 0.21, - 0.19), P < 0.001]. Among patients ventilated for ≥ 5 days (N = 312), opioid administration doubled [+ 2.09 mg/kg/day (95% CI 1.82, 2.36), P < 0.001] in the first 24 h, then diminished minimally [- 0.18 mg/kg/day (95% CI - 0.32, - 0.04), P = 0.015] without returning to baseline; benzodiazepine administration decreased minimally [- 0.03 mg/kg/day (95% CI - 0.05, - 0.01), P = 0.010]. Similar trends were confirmed when adjusting for age, gender, surgical complexity, recent major invasive procedures, duration of mechanical ventilation before DEX initiation, extubation within 72 h following DEX initiation, mean hourly DEX dose, and use of neuromuscular blocking infusion. CONCLUSION While in patients ventilated < 5 days opioids initially increased and then quickly decreased in the 72 h following DEX initiation, among patients ventilated ≥ 5 days opioids doubled, then decreased only minimally; benzodiazepines decreased minimally in both groups, although more slowly in the long-ventilation cohort. These findings may inform decision-making on timing of DEX initiation in ventilated patients already being treated with opioid or benzodiazepine infusions.
Collapse
Affiliation(s)
- Reuth Nir
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Francesca Sperotto
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Manasee Godsay
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - John N Kheir
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
2
|
Sperotto F, Ramelet AS, Daverio M, Mondardini MC, von Borell F, Brenner S, Tibboel D, Ista E, Pokorna P, Amigoni A. Assessment and management of iatrogenic withdrawal syndrome and delirium in pediatric intensive care units across Europe: An ESPNIC survey. Pharmacotherapy 2023; 43:804-815. [PMID: 37203273 DOI: 10.1002/phar.2831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 05/20/2023]
Abstract
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.
Collapse
Affiliation(s)
- Francesca Sperotto
- Cardiovascular Critical Care Unit, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine University of Lausanne, Lausanne, Switzerland
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Maria Cristina Mondardini
- Pediatric Anesthesia and Intensive Care Unit, Department of Woman's and Child's Health, IRCCS University Hospital of Bologna Policlinico S.Orsola, Bologna, Italy
| | - Florian von Borell
- Department of Pediatrics, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Sebastian Brenner
- Department of Pediatrics, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Dick Tibboel
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erwin Ista
- Department of Neonatal & Pediatric Intensive Care, Division Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Paula Pokorna
- Department of Neonatal & Pediatric Intensive Care, Division Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| |
Collapse
|
3
|
Olszewski AE, Dervan LA, Smith MB, Asaro LA, Wypij D, Curley MAQ, Watson RS. Risk Factors for Positive Post-Traumatic Stress Disorder Screening and Associated Outcomes in Children Surviving Acute Respiratory Failure: A Secondary Analysis of the Randomized Evaluation of Sedation Titration for Respiratory Failure Clinical Trial. Pediatr Crit Care Med 2023; 24:222-232. [PMID: 36728954 PMCID: PMC9992163 DOI: 10.1097/pcc.0000000000003150] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To identify risk factors and outcomes associated with a positive post-traumatic stress disorder (PTSD) screen following pediatric acute respiratory failure treated with invasive mechanical ventilation. DESIGN Nonprespecified secondary analysis of a randomized clinical trial. SETTING Thirty-one U.S. PICUs. PATIENTS Children in the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) trial (NCT00814099, ClinicalTrials.gov ) over 8 years old who completed PTSD screening 6 months after discharge. INTERVENTIONS RESTORE sites were randomized to a targeted, nurse-directed sedation strategy versus usual care. MEASUREMENTS AND MAIN RESULTS PTSD screening was completed by 102 subjects using the Child Post-Traumatic Stress Disorder Symptom Scale; a score of greater than or equal to 11 was considered screening positive for PTSD. Cognitive status was categorized using Pediatric Cerebral Performance Category; health-related quality of life (HRQL) was evaluated using child-reported Pediatric Quality of Life Inventory, Version 4.0. Thirty-one children (30%) screened positive for PTSD. Children with a positive screen endorsed symptoms in all categories: reexperiencing, avoidance, and hyperarousal. Most endorsed that symptoms interfered with schoolwork ( n = 18, 58%) and happiness ( n = 17, 55%). Screening positive was not associated with RESTORE treatment group. In a multivariable logistic model adjusting for age, sex, and treatment group, screening positive was independently associated with lower median income in the family's residential zip code (compared with income ≥ $80,000; income < $40,000 odds ratio [OR], 32.8; 95% CI, 2.3-458.1 and $40,000-$79,999 OR, 15.6; 95% CI, 1.3-182.8), renal dysfunction (OR 5.3, 95% CI 1.7-16.7), and clinically significant pain in the PICU (OR, 8.3; 95% CI, 1.9-35.7). Children with a positive screen experienced decline in cognitive function and impaired HRQL more frequently than children with a negative screen. CONCLUSIONS Screening positive for PTSD is common among children following acute respiratory failure and is associated with lower HRQL and decline in cognitive function. Routine PTSD screening may be warranted to optimize recovery.
Collapse
Affiliation(s)
- Aleksandra E Olszewski
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington, Seattle, WA
| | - Leslie A Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Clinical & Translational Research, Seattle Children's Research Institute, Seattle, WA
| | - Mallory B Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA
| | - Lisa A Asaro
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - David Wypij
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington, Seattle, WA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Clinical & Translational Research, Seattle Children's Research Institute, Seattle, WA
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
- Center for Child Health, Behavior, & Development, Seattle Children's Research Institute, Seattle, WA
| | - Martha A Q Curley
- Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Child Health, Behavior, & Development, Seattle Children's Research Institute, Seattle, WA
| |
Collapse
|
4
|
Huiming G, Yuming W, Mingliang Y, Changbin L, Qiuchen H, Jianjun L. Study on the characteristics of microcirculation in the site of pressure ulcer in patients with spinal cord injury. Sci Prog 2021; 104:368504211028726. [PMID: 34495784 PMCID: PMC10450762 DOI: 10.1177/00368504211028726] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To investigate the characteristics of pressure ulcer microcirculation in SCI patients with pressure ulcer, and to provide evidence for the treatment of pressure ulcer in patients with SCI. Group 1 (n = 12) SCI patients with pressure ulcer, 23 pressure ulcers were included. Group 2 (n = 15) SCI patients without pressure ulcer and the control group (n = 16) healthy adults. The application of laser Doppler perfusion imaging system (Moor FLPI) detector to the microcirculation perfusion of the sacrum area of the control group, the observation group 2 and the pressure ulcer site of the observation group 1, record the microcirculation perfusion (PU), The data of microcirculation perfusion (PU) were compared and analyzed. The correlation between microcirculation perfusion and healing time of pressure ulcer was analyzed. (1) The microcirculation perfusion was highest in the pressure ulcer center. (2) SCI patients and healthy adults had no significant difference of microcirculation perfusion at sacrococcygeal skin. (3) The lower the microcirculation perfusion of the pressure ulcer center, the longer the healing time of pressure ulcer. The healing time and the microcirculation perfusion of pressure ulcer center was negatively correlated. Microcirculation perfusion detection is a noninvasive and effective method for the determination of the scope of pressure ulcer, detection and direction judgment of pressure ulcer sinus tract, monitoring and guidance of pressure ulcer treatment, and prediction of the healing time of pressure ulcer.
Collapse
Affiliation(s)
- Gong Huiming
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center, Beijing, China
- China Rehabilitation Science Institute, Beijing, China
- Center of Neural Injury and Repair, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| | - Wang Yuming
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center, Beijing, China
- China Rehabilitation Science Institute, Beijing, China
- Center of Neural Injury and Repair, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| | - Yang Mingliang
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center, Beijing, China
- China Rehabilitation Science Institute, Beijing, China
- Center of Neural Injury and Repair, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| | - Liu Changbin
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center, Beijing, China
- China Rehabilitation Science Institute, Beijing, China
- Center of Neural Injury and Repair, Beijing Institute for Brain Disorders, Beijing, China
- Department of Rehabilitation Medicine, Beijing Tiantan Hospital, Beijing, China
| | - Huang Qiuchen
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- China Rehabilitation Science Institute, Beijing, China
- Department of Physical Therapy, China Rehabilitation Research Center, Beijing, China
| | - Li Jianjun
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center, Beijing, China
- China Rehabilitation Science Institute, Beijing, China
- Center of Neural Injury and Repair, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| |
Collapse
|
5
|
Massaud-Ribeiro L, Barbosa MCDM, Panisset AG, Robaina JR, Lima-Setta F, Prata-Barbosa A, Cunha AJLAD. Cross-cultural adaptation of the Richmond Agitation-Sedation Scale to Brazilian Portuguese for the evaluation of sedation in pediatric intensive care. Rev Bras Ter Intensiva 2021; 33:102-110. [PMID: 33886859 PMCID: PMC8075341 DOI: 10.5935/0103-507x.20210011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 05/28/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To perform a cross-cultural adaptation of the Richmond Agitation-Sedation Scale (RASS) to Brazilian Portuguese for the evaluation of sedation in pediatric intensive care. METHODS Cross-cultural adaptation process including the conceptual, item, semantic and operational equivalence stages according to current recommendations. RESULTS Pretests, divided into two stages, included 30 professionals from the pediatric intensive care unit of a university hospital, who administered the translated RASS to patients aged 29 days to 18 years. The pretests showed a content validity index above 0.90 for all items: 0.97 in the first stage of pretests and 0.99 in the second. CONCLUSION The cross-cultural adaptation of RASS to Brazilian Portuguese resulted in a version with excellent comprehensibility and acceptability in a pediatric intensive care setting. Reliability and validity studies should be performed to evaluate the psychometric properties of the Brazilian Portuguese version of the RASS.
Collapse
Affiliation(s)
- Letícia Massaud-Ribeiro
- Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brasil
| | | | - Anderson Gonçalves Panisset
- Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brasil
| | | | | | - Arnaldo Prata-Barbosa
- Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro - Rio de Janeiro (RJ), Brasil
| | | |
Collapse
|
6
|
Ávila-Alzate JA, Gómez-Salgado J, Romero-Martín M, Martínez-Isasi S, Navarro-Abal Y, Fernández-García D. Assessment and treatment of the withdrawal syndrome in paediatric intensive care units: Systematic review. Medicine (Baltimore) 2020; 99:e18502. [PMID: 32000360 PMCID: PMC7004796 DOI: 10.1097/md.0000000000018502] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Sedoanalgesia secondary iatrogenic withdrawal syndrome (IWS) in paediatric intensive units is frequent and its assessment is complex. Therapies are heterogeneous, and there is currently no gold standard method for diagnosis. In addition, the assessment scales validated in children are scarce. This paper aims to identify and describe both the paediatric diagnostic and assessment tools for the IWS and the treatments for the IWS in critically ill paediatric patients. METHODS A systematic review was conducted according to the PRISMA guidelines. This review included descriptive and observational studies published since 2000 that analyzed paediatric scales for the evaluation of the iatrogenic withdrawal syndrome and its treatments. The eligibility criteria included neonates, newborns, infants, pre-schoolers, and adolescents, up to age 18, who were admitted to the paediatric intensive care units with continuous infusion of hypnotics and/or opioid analgesics, and who presented signs or symptoms of deprivation related to withdrawal and prolonged infusion of sedoanalgesia. RESULTS Three assessment scales were identified: Withdrawal Assessment Tool-1, Sophia Observation Withdrawal Symptoms, and Opioid and Benzodiazepine Withdrawal Score. Dexmedetomidine, methadone and clonidine were revealed as options for the treatment and prevention of the iatrogenic withdrawal syndrome. Finally, the use of phenobarbital suppressed symptoms of deprivation that are resistant to other drugs. CONCLUSIONS The reviewed scales facilitate the assessment of the iatrogenic withdrawal syndrome and have a high diagnostic quality. However, its clinical use is very rare. The treatments identified in this review prevent and effectively treat this syndrome. The use of validated iatrogenic withdrawal syndrome assessment scales in paediatrics clinical practice facilitates assessment, have a high diagnostic quality, and should be encouraged, also ensuring nurses' training in their usage.
Collapse
Affiliation(s)
| | - Juan Gómez-Salgado
- Department of Sociology, Social Work and Public Health, University School of Social Work, Huelva
- Safety and Health Postgraduate Programme, Universidad Espíritu Santo, Guayaquil, Ecuador
| | | | - Santiago Martínez-Isasi
- CLINURSID Research Group, Nursing Department, University of Santiago de Compostela, Santiago de Compostela, Galicia
| | - Yolanda Navarro-Abal
- Department of Social, Developmental and Education Psychology, University of Huelva
| | | |
Collapse
|
7
|
Liu Z, Ge X. The sedation practices of paediatric intensive care unit nurses and the influencing factors in China. Nurs Crit Care 2019; 24:306-312. [PMID: 31140704 DOI: 10.1111/nicc.12426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 02/09/2019] [Accepted: 02/20/2019] [Indexed: 02/02/2023]
Abstract
Nurses play a key role in administering sedation to mechanically ventilated children, which impacts children's psychological, physiological and cognitive changes in the paediatric intensive care unit. This study aimed to survey the sedation practices of paediatric intensive care unit nurses on mechanically ventilated children in China and explored the influencing factors. A cross-sectional survey was conducted based on electronic questionnaires comprised of the Nurse Sedation Practices Scale (Chinese version) in 14 different types of paediatric intensive care units of 11 academic hospitals in China from 15 February to 15 April 2017. A convenience sample of 495 nurses [73·4% response rate, (674)] completed the survey. Seven units applied Ramsay Sedation Scale as a sedative assessment tool. The majority of the nurses used observed behaviours and physiological changes of the ventilated children as indicators to assess the sedation level, and they had a positive attitude and intention, which may influence practice positively, whereas high clinical workload and the lack of communication between the nurses and families might hinder practice. The practice of sedation varied greatly in different regions, and the respondents of the northwest region scored lower. Paediatric nurses in China rarely used a validated paediatric instrument to assess sedation, and most nurses relied on physiological and behavioural cues. The quality of sedation training, nursing workload and regional economic disparity affected the sedation practice. The restricted visiting policy and lack of clearly defined nursing responsibilities around sedation may hinder effective sedation assessment and management. This study found that there was no paediatric-validated tool popularized in paediatric intensive care units in China and explored influencing factors. We suggest that a validated tool, high-quality training and hospital's policy, such as visiting regulation, should be promoted to improve the sedation practice.
Collapse
Affiliation(s)
- Zuojia Liu
- Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, National Children's Medical Center (Shanghai), Shanghai, China
| | - Xiaohua Ge
- Doctor Student, Director, Department of Nursing, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
8
|
Multi-modal Educational Curriculum to Improve Richmond Agitation-sedation Scale Inter-rater Reliability in Pediatric Patients. Pediatr Qual Saf 2018; 3:e096. [PMID: 30584623 PMCID: PMC6221595 DOI: 10.1097/pq9.0000000000000096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 07/10/2018] [Indexed: 12/19/2022] Open
Abstract
Introduction: The Richmond Agitation-sedation Scale (RASS) is a reliable and valid scale for assessing sedation in critically ill pediatric patients. This investigation evaluates the inter-rater reliability of the RASS in mechanically ventilated pediatric patients before and after an educational intervention. Methods: This prospective, interventional quality improvement study was completed in a 20-bed pediatric intensive care unit from July 2013 to July 2014. Children 0–18 years of age requiring mechanical ventilation and receiving sedative or analgesic medications were eligible. Staff completed simultaneous paired RASS assessments in 3 phases: baseline, after educational intervention, and maintenance. Results: Staff completed 347 paired assessments on 45 pediatric intensive care unit patients: 49 in the baseline phase, 228 in the postintervention phase, and 70 in the maintenance phase. There was a significant increase in the weighted κ after the intervention, from 0.56 (95% CI, 0.39–0.72) to 0.86 (95% CI, 0.77–0.95; P < 0.001). The improvement was maintained months later with weighted κ 0.78 (95% CI, 0.61–0.94). In subgroup analysis, there was an increase in weighted κ in patients less than 1 year of age (0.41–0.87) and those with developmental delay (0.49–0.84). Conclusions: The RASS is a reliable tool for sedation assessment in mechanically ventilated, sedated pediatric patients after implementation of an educational intervention. It is also reliable in patients less than 12 months of age and patients with developmental delay. The ability to easily educate providers to utilize a valid, reliable sedation tool is an important step toward using it to provide consistent care to optimize sedation.
Collapse
|
9
|
Lebet RM, Asaro LA, Zuppa AF, Curley MAQ. Face and content validity of variables associated with the difficult-to-sedate child in the paediatric intensive care unit: A survey of paediatric critical care clinicians. Aust Crit Care 2018; 31:167-173. [PMID: 29567042 DOI: 10.1016/j.aucc.2017.12.091] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 12/12/2017] [Accepted: 12/28/2017] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Clinicians recognise that some critically ill children are difficult-to-sedate. It may be possible to identify this clinical phenotype for sedation response using statistical modelling techniques adopted from machine learning. This requires identification of a finite number of variables to include in the statistical model. OBJECTIVE To establish face and content validity for 17 candidate variables identified in the international literature as characteristic of the difficult-to-sedate child phenotype. METHODS Paediatric critical care clinicians rated the relevance of 17 variables characterising the difficult-to-sedate child using a four-point scale ranging from not (1) to highly relevant (4). Face and content validity of these variables were assessed by calculating a mean score for each item and computing an item-level content validity index. Items with a mean score >1 were rated as having adequate face validity. An item-level content validity index ≥0.70 indicated good to excellent content validity. SETTING AND PARTICIPANTS Web-based survey emailed to members of the Pediatric Acute Lung Injury and Sepsis Investigators Network or the Society of Critical Care Medicine Pediatric Sedation Study Group. RESULTS Of 411 possible respondents, 121 useable surveys were returned for a response rate of 29%. All items had a mean score >1, indicating adequate face validity. Ten of 17 items scored an item-level content validity index ≥0.70. The highest scoring items were requiring three or more sedation classes simultaneously, daily modal sedation score indicating agitation, sedation score indicating agitation for 2 consecutive hours, receiving sedatives at a dose >90th percentile of the usual starting dose, and receiving intermittent paralytic doses for sedation. CONCLUSIONS Computation of an item-level content validity index validated variables to include in statistical modelling of the difficult-to-sedate phenotype. The results indicate consensus among paediatric critical care clinicians that the majority of candidate variables identified through literature review are characteristic of the difficult-to-sedate child.
Collapse
Affiliation(s)
- Ruth M Lebet
- University of Pennsylvania School of Nursing, 418 Curie Boulevard, Philadelphia, PA 19104, USA; Department of Nursing Research and Evidence-based Practice, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Lisa A Asaro
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Athena F Zuppa
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA; The Children's Hospital of Philadelphia, Anesthesiology and Critical Care, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Martha A Q Curley
- University of Pennsylvania School of Nursing, 418 Curie Boulevard, Philadelphia, PA 19104, USA; Children's Hospital of Philadelphia Research Institute, 3615 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| |
Collapse
|
10
|
Abstract
OBJECTIVES To evaluate the impact of a nurse-driven sedation protocol on the length of mechanical ventilation, total daily doses of sedatives, and complications of sedation. DESIGN A single-center prospective before and after study was conducted from October 2010 to December 2013. SETTING Twelve-bed surgical and medical PICU of the university-affiliated hospital in Nantes, France. PATIENTS A total of 235 patients, between 28 days and 18 years old, requiring mechanical ventilation for at least 24 hours were included in the study; data from 194 patients were analyzed. INTERVENTIONS During the first study phase, no protocol was used. During the second phase, patients were sedated according to a nurse-driven protocol. MEASUREMENTS AND MAIN RESULTS In the whole population, the length of mechanical ventilation did not differ between protocol and control groups (protocol, 4 [3-8] vs control, 5 [3-7.5]; p = 0.44). Analyzing age subgroups, the length of mechanical ventilation was significantly shorter in the protocol group than in the control group in children older than 12 months (4 [3-8] vs 5 [2.75-11.25] d; p = 0.04). Daily dose of midazolam decreased during the protocol phase compared with the control phase (1 [0.56-1.8] and 1.2 [0.85-2.4] mg/kg/d, respectively; p = 0.02). No differences were shown regarding other daily dose of drugs. In the control group, 68% of children had more than 20% of COMFORT-behavior scale assessment under the target (oversedation) versus 59% in the protocol group (p = 0.139). CONCLUSIONS Implementation of a nurse-driven sedation protocol in a PICU is feasible and safe, allowed a decrease in daily dose of benzodiazepines, and decreased the duration of mechanical ventilation in older patients.
Collapse
|
11
|
HRONOVÁ K, POKORNÁ P, POSCH L, SLANAŘ O. Sufentanil and Midazolam Dosing and Pharmacogenetic Factors in Pediatric Analgosedation and Withdrawal Syndrome. Physiol Res 2016; 65:S463-S472. [DOI: 10.33549/physiolres.933519] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Our aim was to describe the effect of dosing and genetic factors on sufentanil- and midazolam-induced analgosedation and withdrawal syndrome (WS) in pediatric population. Analgosedation and withdrawal syndrome development were monitored using COMFORT-neo/-B scores and SOS score. Length of therapy, dosing of sufentanil and midazolam were recorded. Genotypes of selected candidate polymorphisms in CYP3A5, COMT, ABCB1, OPRM1 and PXR were analysed. In the group of 30 neonates and 18 children, longer treatment duration with midazolam of 141 h (2 – 625) vs. 88 h (7 – 232) and sufentanil of 326.5 h (136 – 885) vs. 92 h (22 – 211) (median; range) was found in the patients suffering from WS vs. non-WS group, respectively. Median midazolam cumulative doses were in the respective values of 18.22 mg/kg (6.93 – 51.25) vs. 9.94 mg/kg (2.12 – 49.83); P=0.03, and the respective values for sufentanil were 88.60 µg/kg (20.21 – 918.52) vs. 21.71 µg/kg (4.5 – 162.29); P<0.01. Cut off value of 177 hours for sufentanil treatment duration represented predictive factor for WS development with 81 % sensitivity and 94 % specificity. SNPs in the candidate genes COMT, PXR and ABCB1 affected the dosing of analgosedative drugs, but were not associated with depth of analgosedation or WS. Cumulative dose and length of analgosedative therapy with sufentanil significantly increases the risk of WS in critically ill neonates and children.
Collapse
Affiliation(s)
- K. HRONOVÁ
- Institute of Pharmacology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | | | | |
Collapse
|
12
|
da Silva PSL, Reis ME, Fonseca TSM, Fonseca MCM. Predicting Reintubation After Unplanned Extubations in Children: Art or Science? J Intensive Care Med 2016; 33:467-474. [PMID: 29806510 DOI: 10.1177/0885066616675130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Reintubation following unplanned extubation (UE) is often required and associated with increased morbidity; however, knowledge of risk factors leading to reintubation and subsequent outcomes in children is still lacking. We sought to determine the incidence, risk factors, and outcomes related to reintubation after UEs. METHODS All mechanically ventilated children were prospectively tracked for UEs over a 7-year period in a pediatric intensive care unit. For each UE event, data associated with reintubation within 24 hours and outcomes were collected. RESULTS Of 757 intubated patients, 87 UE occurred out of 11 335 intubation days (0.76 UE/100 intubation days), with 57 (65%) requiring reintubation. Most of the UEs that did not require reintubation were already weaning ventilator settings prior to UE (73%). Univariate analysis showed that younger children (<1 year) required reintubation more frequently after an UE. Patients experiencing UE during weaning experienced significantly fewer reintubations, whereas 90% of patients with full mechanical ventilation support required reintubation. Logistic regression revealed that requirement of full ventilator support (odds ratio: 37.5) and a COMFORT score <26 (odds ratio: 5.5) were associated with UE failure. There were no differences between reintubated and nonreintubated patients regarding the length of hospital stay, ventilator-associated pneumonia rate, need for tracheostomy, and mortality. Cardiovascular and respiratory complications were seen in 33% of the reintubations. CONCLUSION The rate of reintubation is high in children experiencing UE. Requirement of full ventilator support and a COMFORT score <26 are associated with reintubation. Prospective research is required to better understand the reintubation decisions and needs.
Collapse
Affiliation(s)
- Paulo Sérgio Lucas da Silva
- 1 Department of Pediatrics, Pediatric Intensive Care Unit, Hospital do Servidor Público Municipal, São Paulo, Brazil
| | - Maria Eunice Reis
- 2 Division of Neonatology, Hospital e Maternidade Santa Joana, São Paulo, Brazil
| | | | | |
Collapse
|
13
|
da Silva PSL, Reis ME, de Aguiar VE, Fonseca MCM. Use of fentanyl and midazolam in mechanically ventilated children--Does the method of infusion matter? J Crit Care 2015; 32:108-13. [PMID: 26775184 DOI: 10.1016/j.jcrc.2015.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 11/16/2015] [Accepted: 12/02/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVE Benzodiazepines and opioids are commonly used in pediatric intensive care unit. However, there is no previous study assessing the use of administering these drugs combined (single solution) or separately. We sought to evaluate the impact of these 2 different methods of providing sedation/analgesia in pediatric intensive care unit. METHODS One hundred twelve patients mechanically ventilated for more than 48 hours were randomized to receive a protocolized sedation regime comprising midazolam and fentanyl either separately (group 1, 57 patients) or combined as a single solution (group 2, 55 patients). Primary end point variable was the cumulated dose of midazolam and fentanyl. RESULTS The median cumulated doses of both fentanyl (0.19 vs 0.37 mg/kg, P < .05) and midazolam (28.8 vs 45.6 mg/kg, P < .05) required in group 2 were higher when compared with those of group 1. Moreover, group 2 patients had a significantly longer time of vasopressor drugs requirement and a higher number of patients developing tolerance. CONCLUSION Patients who received a single solution of midazolam and fentanyl had a higher cumulated dose of compared with those patients who did not. The potential risk for long-term neurologic effects on developing brains associated with this finding should be considered.
Collapse
Affiliation(s)
- Paulo Sérgio Lucas da Silva
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital do Servidor Público Municipal, São Paulo, Brazil.
| | | | - Vânia Euzébio de Aguiar
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital do Servidor Público Municipal, São Paulo, Brazil.
| | | |
Collapse
|
14
|
Peron KR, Taminato M, dos Santos MLB, Delgado AF, de Carvalho WB. Iatrogenic pneumothorax: What can we do? Heart Lung 2015; 44:458. [DOI: 10.1016/j.hrtlng.2015.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 05/21/2015] [Indexed: 11/30/2022]
|
15
|
|
16
|
Nonpulmonary treatments for pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015; 16:S73-85. [PMID: 26035367 DOI: 10.1097/pcc.0000000000000435] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To describe the recommendations from the Pediatric Acute Lung Injury Consensus Conference on nonpulmonary treatments in pediatric acute respiratory distress syndrome. DESIGN Consensus conference of experts in pediatric acute lung injury. METHODS A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The nonpulmonary subgroup comprised three experts. When published data were lacking, a modified Delphi approach emphasizing strong professional agreement was utilized. RESULTS The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 30 of which related to nonpulmonary treatment. All 30 recommendations had strong agreement. Patients with pediatric acute respiratory distress syndrome should receive 1) minimal yet effective targeted sedation to facilitate mechanical ventilation; 2) neuromuscular blockade, if sedation alone is inadequate to achieve effective mechanical ventilation; 3) a nutrition plan to facilitate their recovery, maintain their growth, and meet their metabolic needs; 4) goal-directed fluid management to maintain adequate intravascular volume, end-organ perfusion, and optimal delivery of oxygen; and 5) goal-directed RBC transfusion to maintain adequate oxygen delivery. Future clinical trials in pediatric acute respiratory distress syndrome should report sedation, neuromuscular blockade, nutrition, fluid management, and transfusion exposures to allow comparison across studies. CONCLUSIONS The Consensus Conference developed pediatric-specific definitions for pediatric acute respiratory distress syndrome and recommendations regarding treatment and future research priorities. These recommendations for nonpulmonary treatment in pediatric acute respiratory distress syndrome are intended to promote optimization and consistency of care for patients with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.
Collapse
|
17
|
Sen S, Heather J, Palmieri T, Greenhalgh D. Tracheostomy in pediatric burn patients. Burns 2014; 41:248-51. [PMID: 25459218 DOI: 10.1016/j.burns.2014.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 10/03/2014] [Accepted: 10/08/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Tracheostomy is often performed in the pediatric burn population to establish secure airways. Tracheostomy is safe in this population, but the duration of tracheostomy may be related to age and extent and severity of burn. We hypothesized that burn related factors and not age determine the time to removal of a tracheostomy in pediatric burn patients. METHODS A 5-year retrospective review was performed for pediatric burn patients (age ≤18 years) who underwent tracheostomy. Patients were divided into three groups by age (group 1: 0 to ≤2 years, group 2: >2 to ≤12 years, group 3: >12 to ≤18 years). Data collected included: age, total body surface area burn injured (TBSA), gender, mechanism of injury, diagnosis of inhalation injury, mortality, time from injury to admission, time from admission to placement of tracheostomy, time of injury to placement of tracheostomy, duration of tracheostomy, days of mechanical ventilation, and tracheostomy related complications. RESULTS 45 patients were reviewed. There were no differences in TBSA, length of ICU stay, length of hospital stay, and mortality between the three groups. Additionally, there were no differences in ventilator days and duration of tracheostomy. Multivariate linear regression analysis indicated that TBSA and not age independently increased the duration of tracheostomy. CONCLUSION Tracheostomy duration is dependent on the extent of burn in pediatric burn patients.
Collapse
Affiliation(s)
- Soman Sen
- Department of Surgery, Division of Burn Surgery, Shriners Hospital for Children Northern California, University of California Davis, Sacramento, CA, United States.
| | - Jonathan Heather
- Middlemore Hospital, Department of Plastic Surgery, Auckland, New Zealand
| | - Tina Palmieri
- Department of Surgery, Division of Burn Surgery, Shriners Hospital for Children Northern California, University of California Davis, Sacramento, CA, United States
| | - David Greenhalgh
- Department of Surgery, Division of Burn Surgery, Shriners Hospital for Children Northern California, University of California Davis, Sacramento, CA, United States
| |
Collapse
|
18
|
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.
Collapse
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
| | | | | | | |
Collapse
|