Analgesia, sedation, and delirium in pediatric surgical critical care

Pediatric Delirium: An Overlooked Diagnosis?

BACKGROUND

Delirium is well-recognized in adult inpatient care. However, it is often overlooked in children, being mistaken for pain, anxiety, or age-appropriate agitation.

METHODS

To assess the impact of a formal teaching session on the diagnostic rates and management of pediatric delirium (PD) in a tertiary care center, we conducted a retrospective chart review of all hospitalized children diagnosed with PD between August 2003 and August 2018 at the CHU Sainte-Justine (Montreal, Canada). Diagnostic incidence and management were compared before (2003 to 2014) and after (2015 to 2018) a formal teaching session provided to pediatric residents, staff pediatricians, and intensive care physicians in December 2014.

RESULTS

The two cohorts displayed similar demographics, PD symptomatology, PD duration (median: 2 days), and hospital stay duration (median: 11.0 and 10.5 days). However, we saw a major increase in diagnosis frequency after 2014 (from 1.84 to 7.09 cases/year). This increased diagnostic rate was most striking in the pediatric intensive care unit setting. Although symptomatic treatment with antipsychotics and alpha-2 agonists was similar between the two cohorts, patients diagnosed after 2014 were more often weaned from offending medications (benzodiazepines, anesthetics, and anticholinergics). All patients recovered fully.

CONCLUSIONS

Formal teaching on the symptoms and management of PD was associated with an increase in diagnostic rate and an improved management of PD in our institution. Larger studies are required to assess standardized screening tools that may further enhance diagnostic rates and improve care for children with PD.

Impact of different nebulisation systems on patient comfort in bronchiolitis: a randomised controlled cross-over trial

OBJECTIVE

To test the hypothesis that greater comfort is achieved using a nebuliser integrated into a high-flow nasal cannula (nebulisation system integrated in high-flow nasal cannula (NHF)) than using a jet nebuliser (JN), and to explore differences in analgesia requirement and the possibility of feeding during nebulisation.

DESIGN

Randomised cross-over trial.

SETTING

Paediatric intensive care unit.

PATIENTS

Children aged <24 months diagnosed with bronchiolitis between November 2016 and May 2017.

INTERVENTIONS

Nebulisations using NHF and JN.

MAIN OUTCOME MEASURES

COMFORT-Behaviour Scale (CBS) and Numerical Rating Comfort Scale (NRSc) were used to measure comfort, and Numerical Rating Satisfaction Scale (NRSs) was used to assess satisfaction before, during and after nebulisation. Other variables included feeding, analgesia, need for being held and respiratory and heart rates.

RESULTS

Thirty-three children with 233 nebulisations were included in the study. The median age was 3.0 (IQR 2-9) months. Comfort and satisfaction were greater with NHF than with JN. The median staff-recorded CBS, NRSc and NRSs scores for NHF versus JN were 13 (IQR 9-15) vs 17 (IQR 13-23), 8 (IQR 7-0) vs 7 (IQR 4-8), and 4 (IQR 3-4) vs 2 (IQR 2-3), respectively; and caregiver-recorded scores were 12 (IQR 10-15) vs 19 (IQR 13-24), 9 (IQR 7-10) vs 4 (IQR 1-6), and 4 (IQR 3-4) vs 2 (IQR 1-3), respectively (p<0.001). Children who received NHF had lower cardiac and respiratory rates, needed to be held less often during therapy and required less analgesia (p<0.001).

CONCLUSION

Nebulisation through NHF appears to be a better alternative to JN in terms of comfort and satisfaction as well as making feeding possible during nebulisation.

Effectiveness of pharmacologic interventions for prevention of cerebral hyperperfusion syndrome following bypass surgery

BACKGROUND

Cerebral hyperperfusion syndrome (CHS) following bypass surgery is a major cause of neurological morbidity and mortality. However, data regarding its prevention have not been assorted until date.

OBJECTIVE

The objective of this study was to review the literature and evaluate whether any conclusion can be drawn regarding the effectiveness of any measure on preventing bypass-related CHS.

METHODS

We systematically reviewed PubMed and Cochrane Library from September 2008 to September 2018 to collect data regarding the effectiveness of pharmacologic interventions on the refers to pretreatment (PRE) of bypass-related CHS. We categorized interventions regarding their class of drugs and their combinations and calculated overall pooled estimates of proportions of CHS development through random-effects meta-analysis of proportions.

RESULTS

Our search yielded 649 studies, of which 23 fulfilled inclusion criteria. Meta-analysis included 23 studies/2,041 cases. In Group A (blood pressure [BP] control), 202 out of 1,174 pretreated cases developed CHS (23.3% pooled estimate; 95% confidence interval [CI]: 9.9-39.4), Group B (BP control + free radical scavenger [FRS]) 10/263 (0.3%; 95% CI: 0.0-14.1), Group C (BP control + antiplatelet) 22/204 (10.3%; 95% CI: 5.1-16.7), and Group D (BP control + postoperative sedation) 29/400 (6.8%; 95% CI: 4.4-9.6)].

CONCLUSIONS

BP control alone has not been proven effective in preventing CHS. However, BP control along with either a FRS or an antiplatelet agent or postoperative sedation seems to reduce the incidence of CHS.

Effect of intracutaneous pyonex on analgesia and sedation in critically ill patients with mechanical ventilation

The purpose of this study was to evaluate the effect of intracutaneous pyonex on analgesia and sedation in critically ill patients who underwent mechanical ventilation. A total of 88 critically ill patients were divided into a control group and an intervention group. Critical Care Pain Observation Tool (CPOT) and Richmond Agitation and Sedation Scale (RASS) were used to evaluate pain and agitation. The dosage and treatment period of sedative and analgesic drugs in the intervention group were notably lower than the control group (p < 0.05). Analgesia compliance time in the intervention group was superior to control group (p < 0.05). The shallow sedation compliance rate in the intervention group was significantly higher than the control group (p < 0.01). There was significant difference in blood gas analysis before and after treatment between the two groups (p < 0.05). After 2 h of sedation and analgesia, heart rate in the intervention group was lower than control group, but respiratory rate was higher than the control group (p < 0.05). The traditional analgesia and sedation combined with intracutaneous pyonex reduced the total amount and treatment period of sedative and analgesic drugs in critically ill patients throughout the treatment process, and it also decreased the adverse reactions such as blood pressure drops and respiratory depression.

Comfort-holding in critically ill children: a scoping review

Purpose

To understand and summarize the breadth of knowledge on comfort-holding in pediatric intensive care units (PICUs).

Sources

This scoping review was conducted using PRISMA methodology. A literature search was conducted in MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane CENTRAL Register of Controlled Trials. Search strategies were developed with a medical librarian and revised through a peer review of electronic search strategies. All databases were searched from inception to 14 April 2020. Only full-text articles available in English were included. All identified articles were reviewed independently and in duplicate using predetermined criteria. All study designs were eligible if they reported on comfort-holding in a PICU. Data were extracted independently and in duplicate.

Principal findings

Of 13,326 studies identified, 13 were included. Comfort-holding was studied in the context of end-of-life care, developmental care, mobilization, and as a unique intervention. Comfort-holding is common during end-of-life care with 77.8% of children held, but rare during acute management (51% of children < three years, < 5% of children ≥ three years). Commonly reported outcomes included child outcomes (e.g., physiologic measurements), safety outcomes (e.g., accidental line removal), parent outcomes (e.g., psychological symptoms), and frequency of holding.

Conclusion

There is a paucity of literature on comfort-holding in PICUs. This scoping review identifies significant gaps in the literature, including assessment of child-based outcomes of comfort-holding or safety assessment of comfort-holding, and highlights core outcomes to consider in future evaluations of this intervention including child-based outcomes, parent-based outcomes, and safety of the intervention.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12630-021-02090-3.

Epidural analgesia versus intravenous analgesia after minimally invasive repair of pectus excavatum in pediatric patients: a systematic review and meta-analysis

Background

Postoperative pain control after the minimally invasive repair of pectus excavatum (MIRPE) is essential, but there is a controversy about a better analgesic method between epidural and intravenous (IV) analgesia. This systematic review and meta-analysis aimed to compare the effect of epidural versus IV analgesia following MIRPE.

Methods

We searched PubMed, MEDLINE, EMBASE, Cochrane Central Register, and ClinicalTrials.gov for randomized control trials (RCTs) dated up to 31st May 2021. The primary outcome was the area under the curve (AUC) of the weighted mean visual analog scale (VAS) after MIRPE. The secondary outcomes were postoperative nausea, operation time, total operating room time, and postoperative length of hospital stay.

Results

Four RCTs involving 243 patients were finally included in this meta-analysis. The AUC of the weighted mean VAS was 343.62 in the epidural group and 375.24 in IV group. Epidural group showed lower VAS than IV group at 12 hours (mean difference -0.99 [95% CI: -1.52, -0.47], P = 0.001, I2 = 0%), at 24 hours (mean difference -0.65 [95% CI: -1.15, -0.16], P = 0.009, I2 = 0%), and 48 hours (mean difference -0.81 [95% CI: -1.61, -0.01], P = 0.046, I2 = 46%) after the surgery.

Conclusion

Epidural analgesia after the MIRPE had a better analgesic effect than IV analgesia from 12 hours to 48 hours after surgery, and AUC of VAS was lower in the epidural group. However, IV analgesia may also be a viable option, and physicians should wisely choose analgesic modalities after MIRPE.

Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit

Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.

The diagnostic threshold of Cornell assessment of pediatric delirium in detection of postoperative delirium in pediatric surgical patients

Background

Cornell assessment of pediatric delirium (CAPD) showed advantage in diagnosis of pediatric delirium in Chinese critically ill patients. But its performance in surgical patients is still unclear. The present study was designed to validate the diagnostic performance of CAPD in surgical pediatric patients.

Methods

This is a prospective validation study. Pediatric patients who underwent selective surgery and general anesthesia were enrolled. Primary outcome was the incidence of delirium within postoperative three days. CAPD Chinese version was used to evaluate if the patient had delirium one time per day. At the meantime, a psychiatrist employed Diagnostic and Statistical Manual of Mental Disorders fifth edition to diagnose delirium, which was the “gold standard”, and the result was considered as reference standard. Sensitivity, specificity and area under receiver operating characteristic (ROC) curve were calculated to investigate the performance of CAPD.

Results

A total of 170 patients were enrolled. Median age was 4 years old. As diagnosed by psychiatrist, 23 (13.5 %) patients experienced at least one episode of delirium during the follow-up period. When diagnostic threshold was set at 9, CAPD showed the optimal sensitivity (87.0 %, 95 %CI 65.3 %-96.6 %) and specificity (98.0 %, 95 %CI 93.7 %-99.5 %) in comparison with other diagnostic thresholds. ROC analysis showed that CAPD was a good delirium assessment instrument with area under curve of 0.911 (95 % CI 0.812 to 1.000, P < 0.001). Agreement between CAPD and reference standard was 0.849 (Kappa coefficient, P < 0.001).

Conclusions

This study found that Cornell assessment of pediatric delirium could be used as an effective instrument in diagnosis of delirium in pediatric surgical patients.

Trial registration

www.chictr.org.cn Identifier: ChiCTR-DDD-17,012,231, August 3, 2017.