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Drury KM, Hall TA, Orwoll B, Adhikary S, Kirby A, Williams CN. Exposure to Sedation and Analgesia Medications: Short-term Cognitive Outcomes in Pediatric Critical Care Survivors With Acquired Brain Injury. J Intensive Care Med 2024; 39:374-386. [PMID: 37885235 PMCID: PMC11132562 DOI: 10.1177/08850666231210261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Background/Objective: Pediatric intensive care unit (PICU) survivors risk significant cognitive morbidity, particularly those with acquired brain injury (ABI) diagnoses. Studies show sedative and analgesic medication may potentiate neurologic injury, but few studies evaluate impact on survivor outcomes. This study aimed to evaluate whether exposures to analgesic and sedative medications are associated with worse neurocognitive outcome. Methods: A retrospective cohort study was conducted of 91 patients aged 8 to 18 years, undergoing clinical neurocognitive evaluation approximately 1 to 3 months after PICU discharge. Electronic health data was queried for sedative and analgesic medication exposures, including opioids, benzodiazepines, propofol, ketamine, and dexmedetomidine. Doses were converted to class equivalents, evaluated by any exposure and cumulative dose exposure per patient weight. Cognitive outcome was derived from 8 objective cognitive assessments with an emphasis on executive function skills using Principal Components Analysis. Then, linear regression was used to control for baseline cognitive function estimates to calculate a standardized residualized neurocognitive index (rNCI) z-score. Multivariable linear regression evaluated the association between rNCI and medication exposure controlling for covariates. Significance was defined as P < .05. Results: Most (n = 80; 88%) patients received 1 or more study medications. Any exposure and higher cumulative doses of benzodiazepine and ketamine were significantly associated with worse rNCI in bivariate analyses. When controlling for Medicaid, preadmission comorbid conditions, length of stay, delirium, and receipt of other medication classes, receipt of benzodiazepine was associated with significantly worse rNCI (β-coefficient = -0.48, 95% confidence interval = -0.88, -0.08). Conclusions: Exposure to benzodiazepines was independently associated with worse acute phase cognitive outcome using objective assessments focused on executive function skills when controlling for demographic and illness characteristics. Clinician decisions regarding medication regimens in the PICU may serve as a modifiable factor to improve outcomes. Additional inquiry into associations with long-term cognitive outcome and optimal medication regimens is needed.
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Affiliation(s)
- Kurt M. Drury
- Department of Pediatrics, Division of Critical Care, Oregon Health & Science University
- Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health & Science University
| | - Trevor A. Hall
- Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health & Science University
- Department of Pediatrics, Division of Pediatric Psychology, Oregon Health & Science University
| | - Benjamin Orwoll
- Department of Pediatrics, Division of Critical Care, Oregon Health & Science University
| | - Sweta Adhikary
- Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health & Science University
- School of Medicine, Oregon Health and Science University
| | - Aileen Kirby
- Department of Pediatrics, Division of Critical Care, Oregon Health & Science University
| | - Cydni N. Williams
- Department of Pediatrics, Division of Critical Care, Oregon Health & Science University
- Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health & Science University
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Smith HAB, Besunder JB, Betters KA, Johnson PN, Srinivasan V, Stormorken A, Farrington E, Golianu B, Godshall AJ, Acinelli L, Almgren C, Bailey CH, Boyd JM, Cisco MJ, Damian M, deAlmeida ML, Fehr J, Fenton KE, Gilliland F, Grant MJC, Howell J, Ruggles CA, Simone S, Su F, Sullivan JE, Tegtmeyer K, Traube C, Williams S, Berkenbosch JW. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatr Crit Care Med 2022; 23:e74-e110. [PMID: 35119438 DOI: 10.1097/pcc.0000000000002873] [Citation(s) in RCA: 151] [Impact Index Per Article: 75.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
RATIONALE A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available. OBJECTIVE To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility. DESIGN The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to. METHODS Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence. RESULTS The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements. CONCLUSIONS The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.
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Affiliation(s)
- Heidi A B Smith
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
- Division of Pediatric Cardiac Anesthesiology, Vanderbilt University Medical Center, Department of Anesthesiology, Nashville, TN
| | - James B Besunder
- Division of Pediatric Critical Care, Akron Children's Hospital, Akron, OH
- Department of Pediatrics, Northeast Ohio Medical University, Akron, OH
| | - Kristina A Betters
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK
- The Children's Hospital at OU Medical Center, Oklahoma City, OK
| | - Vijay Srinivasan
- Departments of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Anne Stormorken
- Pediatric Critical Care, Rainbow Babies Children's Hospital, Cleveland, OH
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH
| | - Elizabeth Farrington
- Betty H. Cameron Women's and Children's Hospital at New Hanover Regional Medical Center, Wilmington, NC
| | - Brenda Golianu
- Division of Pediatric Anesthesia and Pain Management, Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
| | - Aaron J Godshall
- Department of Pediatrics, AdventHealth For Children, Orlando, FL
| | - Larkin Acinelli
- Division of Critical Care Medicine, Johns Hopkins All Children's Hospital, St Petersburg, FL
| | - Christina Almgren
- Lucile Packard Children's Hospital Stanford Pain Management, Palo Alto, CA
| | | | - Jenny M Boyd
- Division of Pediatric Critical Care, N.C. Children's Hospital, Chapel Hill, NC
- Division of Pediatric Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael J Cisco
- Division of Pediatric Critical Care Medicine, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA
| | - Mihaela Damian
- Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA
- Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Mary L deAlmeida
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA
- Division of Pediatric Critical Care, Emory University School of Medicine, Atlanta, GA
| | - James Fehr
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
- Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA
| | | | - Frances Gilliland
- Division of Cardiac Critical Care, Johns Hopkins All Children's Hospital, St Petersburg, FL
- College of Nursing, University of South Florida, Tampa, FL
| | - Mary Jo C Grant
- Primary Children's Hospital, Pediatric Critical Care Services, Salt Lake City, UT
| | - Joy Howell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | | | - Shari Simone
- University of Maryland School of Nursing, Baltimore, MD
- Pediatric Intensive Care Unit, University of Maryland Medical Center, Baltimore, MD
| | - Felice Su
- Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA
- Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Janice E Sullivan
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Chani Traube
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - Stacey Williams
- Division of Pediatric Critical Care, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - John W Berkenbosch
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY
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Ekinci F, Yildizdas D, Horoz OO, Aslan N. Sedation and Analgesia Practices in Pediatric Intensive Care Units: A Survey of 27 Centers from Turkey. J Pediatr Intensive Care 2020; 10:289-297. [PMID: 34745703 DOI: 10.1055/s-0040-1716886] [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: 06/03/2020] [Accepted: 08/15/2020] [Indexed: 10/23/2022] Open
Abstract
The management and monitoring of sedoanalgesia are important measures in improving the efficacy of procedures and mechanical ventilation, as well as reducing adverse effects and preventing withdrawal syndrome, and delirium in pediatric intensive care units (PICUs). As there is an ongoing need to clarify the best approach to sedoanalgesia in PICUs, we aimed to analyze the current approaches in sedation, analgesia, withdrawal, and delirium practices among PICUs in Turkey. Twenty-seven PICUs completed the survey. Only 9 (33.3%) and 13 (48.1%) centers had a written protocol for analgesia and sedation, respectively. Paracetamol and a combination of midazolam and fentanyl were preferred in 51.8 and 40% of the PICUs for postoperative periods, respectively, and 81.4% of the units preferred ketamine for short-term interventions. For prolonged sedation in mechanically ventilated children, a combination of benzodiazepines and opiates were the most preferred first-line agents with a very high percentage of 81.4%, whereas ketamine and dexmedetomidine accounted for 62.9 and 18.5%, respectively, as second-line options. Although sedative and analgesic agent preferences were comparable with the relevant literature, we should focus on developing a standardized, evidence-based algorithm for sedation and analgesic drugs.
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Affiliation(s)
- Faruk Ekinci
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Dincer Yildizdas
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ozden Ozgur Horoz
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Nagehan Aslan
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine, Adana, Turkey
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Dexmedetomidine Sedation in Mechanically Ventilated Critically Ill Children: A Pilot Randomized Controlled Trial. Pediatr Crit Care Med 2020; 21:e731-e739. [PMID: 32740192 DOI: 10.1097/pcc.0000000000002483] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To assess the feasibility, safety, and efficacy of a sedation protocol using dexmedetomidine as the primary sedative in mechanically ventilated critically ill children. DESIGN Open-label, pilot, prospective, multicenter, randomized, controlled trial. The primary outcome was the proportion of sedation scores in the target sedation range in the first 48 hours. Safety outcomes included device removal, adverse events, and vasopressor use. Feasibility outcomes included time to randomization and protocol fidelity. SETTING Six tertiary PICUs in Australia and New Zealand. PATIENTS Critically ill children, younger than 16 years old, requiring intubation and mechanical ventilation and expected to be mechanically ventilated for at least 24 hours. INTERVENTIONS Children randomized to dexmedetomidine received a dexmedetomidine-based algorithm targeted to light sedation (State Behavioral Scale -1 to +1). Children randomized to usual care received sedation as determined by the treating clinician (but not dexmedetomidine), also targeted to light sedation. MEASUREMENTS AND MAIN RESULTS Sedation with dexmedetomidine as the primary sedative resulted in a greater proportion of sedation measurements in the light sedation range (State Behavioral Scale -1 to +1) over the first 48 hours (229/325 [71%] vs 181/331 [58%]; p = 0.04) and the first 24 hours (66/103 [64%] vs 48/116 [41%]; p < 0.001) compared with usual care. Cumulative midazolam dosage was significantly reduced in the dexmedetomidine arm compared with usual care (p = 0.002).There were more episodes of hypotension and bradycardia with dexmedetomidine (including one serious adverse event) but no difference in vasopressor requirements. Median time to randomization after intubation was 6.0 hours (interquartile range, 2.0-9.0 hr) in the dexmedetomidine arm compared with 3.0 hours (interquartile range, 1.0-7.0 hr) in the usual care arm (p = 0.24). CONCLUSIONS A sedation protocol using dexmedetomidine as the primary sedative was feasible, appeared safe, achieved early, light sedation, and reduced midazolam requirements. The findings of this pilot study justify further studies of sedative agents in critically ill children.
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Joffe AR, Hogan J, Sheppard C, Tawfik G, Duff JP, Garcia Guerra G. Chloral hydrate enteral infusion for sedation in ventilated children: the CHOSEN pilot study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:290. [PMID: 29178963 PMCID: PMC5702481 DOI: 10.1186/s13054-017-1879-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 10/30/2017] [Indexed: 11/24/2022]
Abstract
Background We aimed to test a novel method of delivery of chloral hydrate (CH) sedation in ventilated critically ill young children. Methods Children < 12 years old, within 72 hours of admission, who were ventilated, receiving enteral tube-feeds, with intermittent CH ordered were enrolled after signed consent. Patients received a CH loading-dose of 10 mg/kg enterally, then a syringe-pump enteral infusion at 5 mg/kg/hour, increasing to a maximum of 9 mg/kg/hour. Cases were compared to historical controls matched for age group and Pediatric Risk of Mortality score (PRISM) category, using Fisher’s exact test and the t test. The primary outcome was feasibility, defined as the use of an enteral CH continuous infusion without discontinuation attributable to a pre-specified potential harm. Results There were 21 patients enrolled, at age 11.4 (12.1) months, with bronchiolitis in 10 (48%), a mean Pediatric Logistic Organ Dysfunction (PELOD) score of 6.2 (5.2), and having received enteral CH continuous infusion for 4.5 (2.2) days. Infusion of CH was feasible in 20/21 (95%; 95% CI 76–99%) patients, with one (5%) adverse event of duodenal ulcer perforation on day 3 in a patient with croup receiving regular ibuprofen and dexamethasone. The CH infusion dose (mg/kg/h) on day 2 (n = 20) was 8.9 (IQR 5.9, 9), and on day 4 (n = 11) was 8.8 (IQR 7, 9). Days to titration of adequate sedation (defined as ≤ 3 PRN doses/shift) was 1 (IQR 0.5, 2.5), and hours to awakening for extubation was 5 (IQR 2, 9). Cases (versus controls) had less positive fluid balance at 48 h (-2 (45) vs. 26 (46) ml/kg, p = 0.051), and a decrease in number of PRN sedation doses from 12 h pre to 12 hours post starting CH (4.7 (3.3) to 2.6 (2.8), p = 0.009 versus 2.9 (3.9) to 3.4 (5), p = 0.74). There were no statistically significant differences between cases and controls in inotrope scores, signs or treatment of withdrawal, or PICU days. Conclusions Delivering CH by continuous enteral infusion is feasible, effective, and may be associated with less positive fluid balance. Whether there is a risk of duodenal perforation requires further study. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1879-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ari R Joffe
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, 8440 112 Street, Edmonton, Alberta, T6G 2B7, Canada. .,4-546 Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada.
| | - Jessica Hogan
- Department of Nursing, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, 8440 112 Street, Edmonton, Alberta, T6G 2B7, Canada
| | - Cathy Sheppard
- Department of Nursing, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, 8440 112 Street, Edmonton, Alberta, T6G 2B7, Canada
| | - Gerda Tawfik
- Department of Pharmacy, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, 8440 112 Street, Edmonton, Alberta, T6G 2B7, Canada
| | - Jonathan P Duff
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, 8440 112 Street, Edmonton, Alberta, T6G 2B7, Canada
| | - Gonzalo Garcia Guerra
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, 8440 112 Street, Edmonton, Alberta, T6G 2B7, Canada
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Neunhoeffer F, Hanser A, Esslinger M, Icheva V, Kumpf M, Gerbig I, Hofbeck M, Michel J. Ketamine Infusion as a Counter Measure for Opioid Tolerance in Mechanically Ventilated Children: A Pilot Study. Paediatr Drugs 2017; 19:259-265. [PMID: 28299720 DOI: 10.1007/s40272-017-0218-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Drug rotation to prevent opioid tolerance is well recognized in chronic pain management. However, ketamine infusion as a counter measure for opioid tolerance is rarely described in mechanically ventilated children developing tolerance from prolonged opioid infusion. PATIENTS AND METHODS We performed a retrospective study in a 14-bed medical-surgical-cardiac pediatric intensive care unit. Thirty-two mechanically ventilated children who had developed tolerance from prolonged intravenous infusion of opioids received a continuous intravenous infusion of ketamine as an opioid substitute for more than 2 days, scheduled in a drug rotation protocol. RESULTS Thirty-two children (median age 2.5 years, range 0.1-16.0; weight 11.2 kg [3.8-62.0]) were included. Patients had received continuous intravenous infusion of opioids and benzodiazepines for 16.0 days (4.0-34.0) when drug rotation was started. The median dose of continuous intravenous infusion of ketamine was 4.0 mg·kg-1·h-1 (1.8-6.0) and the median duration was 3.0 days (2.0-6.0). After having restarted opioids, fentanyl doses were significantly lower compared with the time before the drug rotation began (after, 2.9 µg·kg-1·h-1 [0.8-4.9] vs before, 4.15 µg·kg-1·h-1 [1.2-10.0]; p < 0.001). Continuous intravenous infusion of midazolam and clonidine were unchanged during drug rotation. COMFORT-B scoring was significantly lower after having started drug rotation (after, 14.5 [8-19] vs before, 16 [11-22]; p < 0.001). CONCLUSION Drug rotation with ketamine in mechanically ventilated children with opioid tolerance is feasible and seems to reduce the rate of fentanyl infusion.
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Affiliation(s)
- Felix Neunhoeffer
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany.
| | - Anja Hanser
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany
| | - Martin Esslinger
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany
| | - Vanja Icheva
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany
| | - Matthias Kumpf
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany
| | - Ines Gerbig
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany
| | - Michael Hofbeck
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany
| | - Jörg Michel
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany
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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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Baarslag MA, Allegaert K, Knibbe CAJ, van Dijk M, Tibboel D. Pharmacological sedation management in the paediatric intensive care unit. J Pharm Pharmacol 2016; 69:498-513. [DOI: 10.1111/jphp.12630] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/27/2016] [Indexed: 02/06/2023]
Abstract
Abstract
Objective
This review addresses sedation management on paediatric intensive care units and possible gaps in the knowledge of optimal sedation strategies. We present an overview of the commonly used sedatives and their pharmacokinetic and pharmacodynamic considerations in children, as well as the ongoing studies in this field. Also, sedation guidelines and current sedation strategies and assessment methods are addressed.
Key findings
This review shows that evidence and pharmacokinetic data are scarce, but fortunately, there is an active research scene with promising new PK and PD data of sedatives in children using new study designs with application of advanced laboratory methods and modelling. The lack of evidence is increasingly being recognized by authorities and legislative offices such as the US Food and Drug Administration (FDA) and European Medicines Agency (EMA).
Conclusion
The population in question is very heterogeneous and this overview can aid clinicians and researchers in moving from practice-based sedation management towards more evidence- or model-based practice. Still, paediatric sedation management can be improved in other ways than pharmacology only, so future research should aim on sedation assessment and implementation strategies of protocolized sedation as well.
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Affiliation(s)
- Manuel A Baarslag
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of development and regeneration, KU Leuven, Belgium
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
- Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - Monique van Dijk
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Abstract
OBJECTIVES In Israel, the recommendation for the use of propofol is age limited. Furthermore, procedural sedations involving propofol must be performed only by anesthesiologists. Propofol is frequently used in the PICUs in Israel. DESIGN Questionnaire survey. SETTING PICUs in Israel. SUBJECTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Physicians from 13 PICUs (86.6%) responded to the questionnaire. Propofol was used for induction, procedural sedation, and ongoing ICU sedation in 100%, 70%, and 12% of cases, respectively. Eighty-eight percent of the participants limited the duration of propofol infusion to 24 hours at a dose of less than or equal to 4 mg/kg/1 hr, but 40% administered propofol as needed without specifying an upper dose limit. Twenty-five percent encountered adverse effects such as apnea, desaturation, and bradycardia, but only two of the participants suspected propofol infusion syndrome, each in one patient. All the participants agreed to expand the indications for propofol use in the pediatric age group. Ketamine was the drug mostly used instead of propofol (50%), followed by fentanyl (30%), midazolam (30%), and remifentanil (5%). Apart from anesthesiologists, PICU physicians support the use of propofol by physicians who have the technical skills for rapid-sequence intubation and advanced airway management. CONCLUSIONS Off-label use of propofol is an accepted practice in Israeli PICUs. Propofol has a unique profile that makes it an attractive sedative agent in many clinical settings. PICU physicians may want to prescribe it, at least for short periods and at low doses.
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Vet NJ, Kleiber N, Ista E, de Hoog M, de Wildt SN. Sedation in Critically Ill Children with Respiratory Failure. Front Pediatr 2016; 4:89. [PMID: 27606309 PMCID: PMC4995367 DOI: 10.3389/fped.2016.00089] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 08/09/2016] [Indexed: 01/08/2023] Open
Abstract
This article discusses the rationale of sedation in respiratory failure, sedation goals, how to assess the need for sedation as well as effectiveness of interventions in critically ill children, with validated observational sedation scales. The drugs and non-pharmacological approaches used for optimal sedation in ventilated children are reviewed, and specifically the rationale for drug selection, including short- and long-term efficacy and safety aspects of the selected drugs. The specific pharmacokinetic and pharmacodynamic aspects of sedative drugs in the critically ill child and consequences for dosing are presented. Furthermore, we discuss different sedation strategies and their adverse events, such as iatrogenic withdrawal syndrome and delirium. These principles can guide clinicians in the choice of sedative drugs in pediatric respiratory failure.
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Affiliation(s)
- Nienke J Vet
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Niina Kleiber
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Erwin Ista
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Matthijs de Hoog
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Saskia N de Wildt
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pharmacology and Toxicology, Radboud University, Nijmegen, Netherlands
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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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Gamble C, Wolf A, Sinha I, Spowart C, Williamson P. The role of systematic reviews in pharmacovigilance planning and Clinical Trials Authorisation application: example from the SLEEPS trial. PLoS One 2013; 8:e51787. [PMID: 23554852 PMCID: PMC3598865 DOI: 10.1371/journal.pone.0051787] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 11/07/2012] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Adequate sedation is crucial to the management of children requiring assisted ventilation on Paediatric Intensive Care Units (PICU). The evidence-base of randomised controlled trials (RCTs) in this area is small and a trial was planned to compare midazolam and clonidine, two sedatives widely used within PICUs neither of which being licensed for that use. The application to obtain a Clinical Trials Authorisation from the Medicines and Healthcare products Regulatory Agency (MHRA) required a dossier summarising the safety profiles of each drug and the pharmacovigilance plan for the trial needed to be determined by this information. A systematic review was undertaken to identify reports relating to the safety of each drug. METHODOLOGY/PRINCIPAL FINDINGS The Summary of Product Characteristics (SmPC) were obtained for each sedative. The MHRA were requested to provide reports relating to the use of each drug as a sedative in children under the age of 16. Medline was searched to identify RCTs, controlled clinical trials, observational studies, case reports and series. 288 abstracts were identified for midazolam and 16 for clonidine with full texts obtained for 80 and 6 articles respectively. Thirty-three studies provided data for midazolam and two for clonidine. The majority of data has come from observational studies and case reports. The MHRA provided details of 10 and 3 reports of suspected adverse drug reactions. CONCLUSIONS/SIGNIFICANCE No adverse reactions were identified in addition to those specified within the SmPC for the licensed use of the drugs. Based on this information and the wide spread use of both sedatives in routine practice the pharmacovigilance plan was restricted to adverse reactions. The Clinical Trials Authorisation was granted based on the data presented in the SmPC and the pharmacovigilance plan within the clinical trial protocol restricting collection and reporting to adverse reactions.
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Affiliation(s)
- Carrol Gamble
- Clinical Trials Research Centre, University of Liverpool, Liverpool, Merseyside, United Kingdom.
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Bai J, Hsu L. Pain status and sedation level in Chinese children after cardiac surgery: an observational study. J Clin Nurs 2012; 22:137-47. [PMID: 22978412 DOI: 10.1111/j.1365-2702.2012.04263.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES This study explored current pain status, sedation level and their trajectories in Chinese children after cardiac surgery. Background. Pain and sedation management are fundamental care practices in the critical care setting, yet they both are frequently under-implemented for children after major surgery. DESIGN Repeated observational design. METHODS This study was conducted in a paediatric medical centre in Shanghai, China where 170 children who underwent cardiac surgery were recruited. Pain was measured with the face, legs, activity, cry, consolability scale and sedation levels with the COMFORT Behaviour Scale at 18 fixed time-points for three consecutive postoperative days. Results. The study indicated that 95 children (55·9%) received continuous opioids for pain relief, and 61 children (35·9%) received no analgesics. Multiple sedatives were used for these children, including bolus phenobarbital for 117 children (68·8%), phenergan for 81 children (47·6%) and midazolam for three children (1·8%). The mean pain scores significantly decreased throughout the operation day (POD-0) to the 2nd postoperative day (POD-2) with the lowest score on POD-2. Less than 5% of pain assessments were identified as moderate to severe across all 2815 observations. The sedation scores significantly increased through POD-0 to POD-2 with the highest score on POD-2. The rate of over-sedation was 50·3% with <1% under-sedation occurring among all the observations. Results also suggested that the length of stay in the cardiac intensive care unit was a predictor of increased analgesic usage in the critical care setting (odds ratio: 1·72). CONCLUSIONS Usage of analgesic and sedative agents in cardiac intensive care unit was variable and children experienced low pain scores but a high rate of over-sedation, indicating that healthcare providers should address ways to improve postoperative pain and sedation management in this population. RELEVANCE TO CLINICAL PRACTICE The pain and sedation status for children after cardiac surgery changed across the postoperative days. Healthcare providers should be trained in the use of reliable tools to accurately monitor children's pain and sedation levels.
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Affiliation(s)
- Jinbing Bai
- School of Nursing, Tianjin Medical University, Tianjin, China
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McKeever S, Johnston L, Davidson A. A review of the utility of EEG depth of anaesthesia monitors in the paediatric intensive care environment. Intensive Crit Care Nurs 2012; 28:294-303. [PMID: 22537477 DOI: 10.1016/j.iccn.2012.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 01/24/2012] [Accepted: 01/30/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This paper aims to bring together current evidence regarding the use of depth of anaesthesia monitors (DoAM) as objective measures of sedation for paediatric intensive care (PIC) patients. BACKGROUND Delivering appropriate dosages of sedative agents, to individual PIC patients, is important to reduce the many risks of over- or under-sedation. Although based on adult anaesthesia, DoAMs could offer increased objectivity to the titration of sedative agents for children in PIC. This article synthesises the current available evidence from studies investigating DoAM use in the PIC environment. METHOD Literature regarding DoAM use in PIC was reviewed, from 1996 and August 2011, after EMBASE, PubMed, CINAHL and ProQuest Dissertation & Theses Database were searched using key search terms. FINDINGS Fourteen original research articles addressing sedation assessment using DoAMs in PIC were identified. The main findings were that DoAMs generally have a moderate or poor correlation with sedation scores and their performance varies in varying clinical settings. DoAMs do not make reliable conclusions about depth of sedation of individual PIC children, and can be influenced by children's age. CONCLUSION Evidence to support DoAMs in the PIC setting is currently not sufficient to advocate their routine use in clinical practice.
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Affiliation(s)
- Stephen McKeever
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Melbourne, Australia.
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Johnson PN, Miller J, Gormley AK. Continuous-infusion neuromuscular blocking agents in critically ill neonates and children. Pharmacotherapy 2012; 31:609-20. [PMID: 21923445 DOI: 10.1592/phco.31.6.609] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Neuromuscular blocking agents (NMBAs) are often administered as a prolonged (> 24 hrs) continuous infusion in infants and children in the intensive care unit for a variety of reasons including facilitation of oxygenation and ventilation. No guidelines on the use of NMBAs in pediatric patients are available yet in the United States; however, pediatric guidelines are available in the United Kingdom. Based on a 2007 U.S. survey, the most commonly used nondepolarizing NMBAs for sustained neuromuscular blockade in critically ill children are pancuronium and vecuronium. Recent national drug shortages involving NMBAs have been reported for atracurium, cisatracurium, pancuronium, rocuronium, and vecuronium. Therefore, to explore alternative options for neuromuscular blockade, we conducted a literature search to identify articles evaluating prolonged use (> 24 hrs) of NMBAs administered by continuous infusion. The search was limited to English-language articles in the MEDLINE (1950-August 2010), EMBASE (1988-August 2010), International Pharmaceutical Abstracts (1970-August 2010), and Cochrane Library (1996-August 2010) databases. Relevant abstracts, reference citations, and manufacturers' product information were also reviewed. A total of 13 reports representing 208 children were included in the analysis. Many of the reports described wide interpatient variability in dosing for the specific NMBAs evaluated. Selection of the most appropriate NMBA should be based on the patient's clinical status, potential adverse effects, and pharmacoeconomics. All patients receiving sustained neuromuscular blockade should be monitored routinely to ensure that dosing is appropriate in order to obtain the desired level of blockade. The goal is to use the lowest dose possible in an effort to limit adverse effects or prolonged blockade.
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Affiliation(s)
- Peter N Johnson
- Department of Pediatrics, College of Medicine, University of Oklahoma, Oklahoma City, Oklahoma, USA
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Evidence of safety of chloral hydrate for prolonged sedation in PICU in a tertiary teaching hospital in southern Brazil. Eur J Clin Pharmacol 2011; 65:1253-8. [PMID: 19669738 DOI: 10.1007/s00228-009-0694-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Accepted: 06/24/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the utilization of chloral hydrate (CH) for sedation in pediatric intensive care and the incidence of adverse drug reactions. METHODS This was a cohort study including patients with prescription of chloral hydrate hospitalized in the pediatric intensive care unit (PICU) of a university-affiliated, general, tertiary teaching hospital. Data were collected from a spreadsheet for daily monitoring, and clinical events registered in the patient records were analyzed to evaluate the causality of suspected adverse drug reactions (ADR), applying the Naranjo algorithm. RESULTS Three hundred forty-three patients who had been prescribed CH were studied. Ages ranged from 0 to 18 years, and 63% were male. The most frequent cause for PICU admission was bronchiolitis (77.6%), and 58.6% required mechanical ventilation. In 92.7% of cases, CH was indicated to control agitation and in 7.3% for procedural sedation. The median time of CH use was 6 days. The incidence of suspected ADR was 22.7% ± 2.3. Oxygen desaturation was the most frequent adverse event (64.6%), followed by hypotension. Specific treatment was required in 60.9% of the events. Chloral hydrate as cause for suspected ADR was classified as probable in 39 events (35.5%) and as possible in 70 (63.6%), and no event was classified as definite. In the multivariate analysis, only mechanical ventilation was predictive of ADR to CH. CONCLUSIONS The study described the clinical practice of sedation with CH in the PICU setting of a tertiary teaching hospital in southern Brazil. Data suggest that CH is an alternative for prolonged sedation in PICU
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Mencía S, Botrán M, López-Herce J, del Castillo J. Manejo de la sedoanalgesia y de los relajantes musculares en las unidades de cuidados intensivos pediátricos españolas. An Pediatr (Barc) 2011; 74:396-404. [DOI: 10.1016/j.anpedi.2010.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 11/15/2010] [Accepted: 12/09/2010] [Indexed: 10/18/2022] Open
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Da Silva PSL, Neto HM, de Aguiar VE, Lopes E, de Carvalho WB. Impact of sustained neuromuscular blockade on outcome of mechanically ventilated children. Pediatr Int 2010; 52:438-43. [PMID: 20202154 DOI: 10.1111/j.1442-200x.2010.03104.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Neuromuscular blocking agents (NMBA) are commonly administered to critically ill children in pediatric intensive care units (PICU) in the USA and Europe. Although NMBA are frequently used in PICU patients, their role in the PICU setting has not yet been clearly defined. The aim of this study was to describe the sustained administration of NMBA and its impact on outcome of PICU patients. METHODS A 3-year retrospective cohort study was conducted to compare mechanically-ventilated patients who received NMBA for at least 12 h with patients who did not (control group). RESULTS A total of 317 consecutive patients were ventilated over 3473 days. Patients were similar in age, weight and severity scores. Thirty-four children (10.7%) received NMBA. Compared with controls, the neuromuscular blockade (NMB) group had a longer duration of mechanical ventilation (13.7 vs 5.5 days, P= 0.000), longer PICU stay (20 vs 11 days, P= 0.000) and increased occurrence of ventilator-associated pneumonia (6.6 vs 4.1/1000 ventilator days, P= 0.010). The NMB use was not associated with higher mortality (8.8% vs 17.6%, P= 0.287) or longer hospital stay (30.5 vs 23 days, P= 0.117). CONCLUSION Although the use of NMBA was not associated with greater mortality, we found that sustained use of NMBA is associated with prolonged mechanical ventilation, longer PICU stay and higher incidence of ventilator-associated pneumonia when compared with controls. Larger studies are necessary to confirm these findings.
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Affiliation(s)
- Paulo S L Da Silva
- Pediatric Intensive Care Unit, Hospital Estadual de Diadema/Universidade Federal de São Paulo, São Paulo, Brazil.
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Birchley G. Opioid and benzodiazepine withdrawal syndromes in the paediatric intensive care unit: a review of recent literature. Nurs Crit Care 2009; 14:26-37. [PMID: 19154308 DOI: 10.1111/j.1478-5153.2008.00311.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
AIMS AND OBJECTIVES This paper aims to critically review and analyse available literature to inform and advance patient care. BACKGROUND Withdrawal syndromes related to the routine administration of sedation and analgesia in paediatric intensive care unit (PICU) have been recognized since the 1990 s. Common symptoms include tremors, agitation, inconsolable crying and sleeplessness. SEARCH STRATEGIES A critical review was undertaken to assess developments in this area. Four databases were searched using Ovid Online. These were Ovid Medline, CINAHL, BNI and Embase. Key terms included were 'Paediatric', 'Sedation', 'Withdrawal' and 'Intensive care'. INCLUSION AND EXCLUSION CRITERIA Articles from 1980 onwards were reviewed for their relevance to paediatric iatrogenic withdrawal. Additionally, seminal work from the 1970s was included. Because of the scarcity of literature, relevant editorials and opinion pieces were included. RESULTS A total of 2,232,586 papers resulted from keyword searches. Use of Boolean operators to combine terms reduced the number of results to 62. Exclusion criteria reduced the number of suitable papers to 20. Tracking reference lists yielded a further 18 papers. In total, 38 papers were retrieved examining 1375 patients. Four papers surveyed drug usage on PICU, 14 listed withdrawal symptoms, 4 described the frequency of withdrawal in the PICU population, 9 described risk factors, 4 presented or validated clinical tools and 14 describe treatment strategies. CONCLUSIONS Withdrawal syndromes may affect 20% of exposed children and are related to infusion duration and total dose. Fifty-one symptoms are described in the literature. Future studies need accurate, validated clinical tools to be effective. Risk factors, signs and symptoms have been identified, and validation studies must now take place. RELEVANCE TO CLINICAL PRACTICE Withdrawal syndromes continue to be widespread and difficult to diagnose. Awareness of their causes and treatments should influence clinical decisions at the bedside.
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Affiliation(s)
- Giles Birchley
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, UK.
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Hartman ME, McCrory DC, Schulman SR. Efficacy of sedation regimens to facilitate mechanical ventilation in the pediatric intensive care unit: a systematic review. Pediatr Crit Care Med 2009; 10:246-55. [PMID: 19188867 DOI: 10.1097/pcc.0b013e31819a3bb9] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Children admitted to pediatric intensive care units (PICUs) often receive sedatives to facilitate mechanical ventilation. However, despite their widespread use, data supporting appropriate dosing, safety, and optimal regimens for sedation during mechanical ventilation are lacking. Therefore, we conducted a systematic review of published data regarding efficacy of sedation to facilitate mechanical ventilation in PICU patients. Our primary objective was to identify and evaluate the quality of evidence supporting sedatives used in PICUs for this purpose. DATA SOURCES We searched MEDLINE, EMBASE, and The Cochrane Registry of Clinical Trials from 1966 to June 2008 to identify published articles evaluating sedation regimens to facilitate mechanical ventilation in PICU patients. STUDY SELECTION We included only those studies of intubated PICU or pediatric cardiac intensive care unit patients receiving pharmacologic agents to facilitate mechanical ventilation that reported quality of sedation as an outcome. DATA EXTRACTION We analyzed studies separately for study type and by agents being studied. Studies were appraised using criteria of particular importance for reviews evaluating sedatives. DATA SYNTHESIS Our search strategy yielded 39 studies, including 3 randomized trials, 15 cohort studies, and 21 cases series or reports. The 39 studies evaluated a total of 39 different sedation regimens, with 21 different scoring systems, in a total of 901 PICU/cardiac intensive care unit patients ranging in age from 3 days to 19 years old. Most of the studies were small (<30 patients), and only four studies compared one or more agents to another. Few studies thoroughly evaluated drug safety, and only one study met all quality criteria. CONCLUSIONS Despite the widespread use of sedatives to facilitate mechanical ventilation in the PICU, we found that high-quality evidence to guide clinical practice is still limited. Pediatric randomized, controlled trials with reproducible methods and assessment of drug safety are needed.
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Affiliation(s)
- Mary E Hartman
- Department of Pediatric Critical Care Medicine, Duke University, Durham, NC, USA.
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Nolent P, Laudenbach V. Sédation et analgésie en réanimation – Aspects pédiatriques. ACTA ACUST UNITED AC 2008; 27:623-32. [DOI: 10.1016/j.annfar.2008.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Long D, Horn D, Keogh S. A survey of sedation assessment and management in Australian and New Zealand paediatric intensive care patients requiring prolonged mechanical ventilation. Aust Crit Care 2008; 18:152-7. [PMID: 18038536 DOI: 10.1016/s1036-7314(05)80028-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION A retrospective analysis of sedation management for children receiving prolonged ventilation in one Australian paediatric intensive care unit (PICU) revealed no identifiable pattern in sedation management and an inadequacy in the sedation scoring system. Therefore, the investigators sought to explore the current practice of sedation in critically ill children in PICUs across Australia and New Zealand. METHOD This study used a mail-out survey to audit sedation management within the eight dedicated Australian and New Zealand PICUs. RESULTS 100% of the units surveyed replied (n=8). There were a total of 6,133 admissions to 8 Australian and New Zealand PICUs, where 3036 (49.5%) required ventilation. Of these children, 888 (29.2%) required ventilation > or =72 hours. Only 4 units had written guidelines for sedation management. A combined sedation regime of benzodiazepines and opioids was employed in six units. Administration and titration of sedation agents was managed by nursing staff alone in six units. All units indicated that they aimed to achieve a 'moderate level' of sedation. Two units used designated assessment tools for sedation and withdrawal assessment. One unit utilised Bispectral Index (BIS) monitoring. CONCLUSION There were similarities observed in the methods and types of sedation agents used within Australian and New Zealand PICUs. However, only half of the units had guidelines for sedation management, and most units did not use validated paediatric scales to assist staff in assessing patient sedation and pain levels. Therefore it is recommended that a standardised approach to sedation assessment and management of critically ill children requiring prolonged ventilation be developed and tested.
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Playfor S, Jenkins I, Boyles C, Choonara I, Davies G, Haywood T, Hinson G, Mayer A, Morton N, Ralph T, Wolf A. Consensus guidelines for sustained neuromuscular blockade in critically ill children. Paediatr Anaesth 2007; 17:881-7. [PMID: 17683408 DOI: 10.1111/j.1460-9592.2007.02313.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The United Kingdom Paediatric Intensive Care Society Sedation, Analgesia and Neuromuscular Blockade Working Group is a multidisciplinary expert panel created to produce consensus guidelines on sedation, analgesia and neuromuscular blockade in critically ill children and forward knowledge in these areas. Neuromuscular blockade is recognized as an important element in the care of the critically ill and adult clinical practice guidelines in this area have been available for several years. However, similar clinical practice guidelines have not previously been produced for the critically ill pediatric patient. METHODS A modified Delphi technique was employed to allow the Working Group to anonymously consider draft recommendations in up to three Delphi rounds with predetermined levels of agreement. This process was supported by a total of four consensus conferences and once consensus had been achieved, a systematic review of the available literature was carried out. RESULTS A set of consensus guidelines was produced including six key recommendations. An evaluation of the existing literature supporting these recommendations is provided. CONCLUSIONS Multidisciplinary consensus guidelines for maintenance neuromuscular blockade in critically ill children (excluding neonates) have been successfully produced and are supported by levels of evidence. The Working Group has highlighted the paucity of high quality evidence in these important clinical areas and this emphasizes the need for further randomized clinical trials in this area.
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Affiliation(s)
- Stephen Playfor
- Paediatric Intensive Care Unit, Royal Manchester Children's Hospital, Pendlebury, Manchester, UK.
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Cho HH, O'Connell JP, Cooney MF, Inchiosa MA. Minimizing tolerance and withdrawal to prolonged pediatric sedation: case report and review of the literature. J Intensive Care Med 2007; 22:173-9. [PMID: 17569173 DOI: 10.1177/0885066607299556] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Midazolam and fentanyl infusions are commonly used for prolonged sedation and analgesia in the pediatric intensive care setting. Tolerance and withdrawal are major concerns when these infusions are used for days or weeks. Here, we review the current approaches to prolonged pediatric sedation using midazolam and fentanyl and discuss newer strategies to avoid tolerance and withdrawal syndromes. We report the case of a pediatric burn patient who developed tolerance syndrome and a movement disorder in our institution. We also review the relevant literature and methods of minimizing tolerance and withdrawal. Prolonged sedation is often necessary in treating critically ill children, and tolerance and abstinence syndrome can complicate a successful recovery. Scoring systems can be used to minimize oversedation and to titrate effectively. "Drug cycling," "wake-up protocols," and weaning regimens, possibly combined with adjuvant drugs, are being implemented successfully. Such novel approaches may decrease the incidence of tolerance and withdrawal associated with prolonged sedative and analgesic use.
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Affiliation(s)
- Hannah H Cho
- Department of Anesthesiology, New York Medical College, Valhalla, NY, USA.
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Jenkins IA, Playfor SD, Bevan C, Davies G, Wolf AR. Current United Kingdom sedation practice in pediatric intensive care. Paediatr Anaesth 2007; 17:675-83. [PMID: 17564650 DOI: 10.1111/j.1460-9592.2006.02180.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this study was to investigate the current practice of sedation, analgesia, and neuromuscular blockade in critically ill children on pediatric intensive care units (PICUs) in the UK and identify areas that merit further study. METHODS Data were gathered in a prospective observational study of 338 critically ill children in 20 UK PICUs. RESULTS There is considerable variation in clinical practice. A total of 24 different sedative and analgesic agents were used during the study. The most commonly used sedative and analgesic agents were midazolam and morphine. Four different neuromuscular blockers (NMBs) were used, most commonly vecuronium. There were differences in treatment between cardiac and noncardiac children, but there were a greater number of infants and neonates in the cardiac group. NMBs were used in 30% of mechanically ventilated patients. Withdrawal symptoms were reported in 13% of ventilated patients, relatively early in their stay; weaning sedative agents ('tapering') was apparently of no benefit. The use of clonidine in this setting was noted. Physical restraints were used in 7.4%. Propofol was used but in only 2.6% of patients, all over the age of 4 years, and not exceeding 2 mgxkg(-1)xh(-1). No side effects attributable to 'propofol syndrome' were noted. CONCLUSIONS There is considerable heterogeneity of sedation techniques. NMBs are used in a large portion of this population. Withdrawal symptoms were associated with higher doses of sedation and greater lengths of stay and were not ameliorated by withdrawing sedation gradually ('tapering').
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Vidyasagar D. Stress of admission to pediatric intensive care unit on children. Pediatr Crit Care Med 2005; 6:374-6. [PMID: 15880012 DOI: 10.1097/01.pcc.0000161614.70943.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Statler KD, Lugo RA. Surveying sedation and analgesia practice in the pediatric intensive care unit: discomforting data raise further questions. Pediatr Crit Care Med 2004; 5:582-3. [PMID: 15540037 DOI: 10.1097/01.pcc.0000144706.47863.79] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Twite MD, Rashid A, Zuk J, Friesen RH. Sedation, analgesia, and neuromuscular blockade in the pediatric intensive care unit: survey of fellowship training programs. Pediatr Crit Care Med 2004; 5:521-32. [PMID: 15530187 DOI: 10.1097/01.pcc.0000144710.13710.2e] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To survey current sedation, analgesia, and neuromuscular blockade practices in pediatric critical care fellowship training programs in the United States. DESIGN Questionnaire survey sent by all program directors. The survey could be submitted either via a Web site, fax, or mail. SETTING University school of medicine. SUBJECTS Fifty-nine pediatric critical care fellowship training program directors in the United States, listed on the Accreditation Council for Graduate Medical Education Web site. INTERVENTIONS Survey. MEASUREMENTS AND MAIN RESULTS The response rate was 59.3% (35 questionnaires). Midazolam, lorazepam, morphine, and fentanyl are the most frequently used drugs in pediatric intensive care units for analgesia and sedation. Most pediatric intensive care units surveyed have a written sedation policy (66%). The majority of units responding to the survey (85.7%) routinely use a scoring system to assess agitation and pain in children, with the most common being the COMFORT score. All of the pediatric intensive care units surveyed reported weaning drugs slowly to try to prevent drug withdrawal. Movement disorders related to prolonged sedation and analgesia seem to be more common than is reported in the literature, with 65.7% of units reporting cases. There is good consensus on the indications for neuromuscular blockade, with vecuronium being the most popular drug. CONCLUSIONS When compared with a similar survey from 1989, this survey suggests that pediatric critical care units with fellowship training programs have made some changes in their approach to sedation and analgesia over the past decade. More fellowship directors report the use of sedation protocols and better recognition, prevention, and management of drug withdrawal. Similar analgesic, sedative, and neuromuscular blocking drugs are being used but some more commonly than a decade ago.
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Affiliation(s)
- Mark D Twite
- Pediatrics (Critical Care) and Anesthesiology, The Children's Hospital, Denver, CO, USA
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Abstract
BACKGROUND Our aim was to investigate the current patterns of propofol use in pediatric intensive care units (PICUs) in the UK and North America. METHODS An electronic questionnaire was sent to all PICUs in the UK and those units offering PICU training fellowships in the USA and Canada. RESULTS We received responses from 15 UK units (75%) and 33 units in North America (52%). Of units who responded, 47% of UK units used propofol for ongoing sedation, compared with 61% of North American units. Units tended to use propofol in defined clinical circumstances, in limited doses, in older children and for relatively short periods. Propofol was used for sedation during procedures in 100% of units although 35% of UK units said that they would use it less frequently in this setting than in the past. Only 18% of North American Units reported that they would be less likely to use propofol for procedures than in the past. CONCLUSIONS Despite clear guidance from the UK Committee on Safety of Medicines, propofol was still used for ongoing sedation in 47% of UK PICUs responding to our questionnaire. Reasons for this include the utility of the agent and its licensing for use in maintaining anesthesia in children over 3 years, but not for sedation in PICU in similar doses, for similar periods, in the same group of children.
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Affiliation(s)
- Stephen D Playfor
- Paediatric Intensive Care Unit, Royal Manchester Children's Hospital, Pendlebury, Manchester, UK.
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Crean P. Sedation and neuromuscular blockade in paediatric intensive care; practice in the United Kingdom and North America. Paediatr Anaesth 2004; 14:439-42. [PMID: 15153203 DOI: 10.1111/j.1460-9592.2004.01259.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Courtman SP, Wardurgh A, Petros AJ. Comparison of the bispectral index monitor with the Comfort score in assessing level of sedation of critically ill children. Intensive Care Med 2003; 29:2239-2246. [PMID: 13680111 DOI: 10.1007/s00134-003-1997-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2003] [Accepted: 08/07/2003] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To compare the value of bispectral index as a monitor of sedation in critically ill children with a validated sedation scoring system. DESIGN Prospective convenience sample. SETTING Paediatric intensive care unit in a tertiary paediatric centre. PATIENTS AND PARTICIPANTS Forty-three critically ill children receiving sedation and mechanical ventilation. MEASUREMENTS AND RESULTS Simultaneous recording of bispectral index (BIS) and assessment of depth of sedation using the Comfort score were performed at regular intervals. To determine if BIS could detect episodes of arousal, times of endotracheal suctioning and the corresponding BIS score were recorded. There was an overall moderate correlation between BIS scores and Comfort scores ( r=0.50, r(2)=0.25, p<0.0001). Children who had a neurological reason for their current admission ( n=25) showed a weaker correlation ( r=0.26, r(2)=0.06, p<0.007) than those ( n=15) with normal neurology ( r=0.51, r(2)=0.26, p<0.0001). There were no significant differences in the rise in BIS following endotracheal suctioning among any of the predefined depths of sedation. There was a correlation of r=0.84 ( r(2)=0.71) (SE of slope 0.49, CI(95) 1.79-3.88) for mean BIS values for each individual Comfort score from 8-23. Using Spearman's rank correlation of Comfort versus mean BIS, the correlation coefficient was r=0.92. CONCLUSIONS Bispectral index scores correlate with Comfort scores to a moderate degree. BIS is able to discriminate between light and deep levels of sedation, but not between deep and very deep levels of sedation. The BIS monitor may provide a useful method for assessing sedation in critically ill children, especially those receiving neuromuscular blockers.
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Affiliation(s)
- Simon P Courtman
- Great Ormond Street Hospital for Sick Children, Great Ormond Street, London, WC1 N 3JH, UK.
- Department of Anaesthesia, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon, EX2 5DW, UK.
| | - Allan Wardurgh
- Great Ormond Street Hospital for Sick Children, Great Ormond Street, London, WC1 N 3JH, UK
| | - Andy J Petros
- Great Ormond Street Hospital for Sick Children, Great Ormond Street, London, WC1 N 3JH, UK
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