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Velez C, Anderson JJ, Resser JJ, Liu D, Betters KA. Cost-Benefit Analysis of a Pediatric ICU Sedation Weaning Protocol. J Pediatr Pharmacol Ther 2024; 29:501-507. [PMID: 39411413 PMCID: PMC11472412 DOI: 10.5863/1551-6776-29.5.501] [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: 12/02/2023] [Accepted: 02/28/2024] [Indexed: 10/19/2024]
Abstract
OBJECTIVE A risk stratified sedation weaning protocol improved patient outcomes in a pediatric intensive care unit (PICU). We sought to determine the protocol effect on medication costs. METHODS This was a retrospective observational cohort study in an academic tertiary care children's hospital PICU (2018-2020) comparing the cost when weaning benzodiazepine, alpha agonist, and/or opioid infusions in intubated children <18 years of age. RESULTS There were 84 total sedation weaning instances (pre-protocol n = 41 and post-protocol n = 41); 2 patients had 2 encounters, 1 in each phase. The total cost (in 2022 United States Dollars) of sedation weaning was $400,328.87 ($15,994.44/kg) pre-protocol compared with $170,458.85 ($11,227.52/kg) post-protocol. The median cost of sedation wean per patient for pre-protocol patients was $3197.42 (IQR: $322.66-$12,643.29) and post-protocol patients was $1851.44 (IQR: $425.05-$5355.85; p = 0.275). A linear regression model estimated the expected cost of sedation wean for post-protocol patients to be $5173.20 lower than for pre-protocol patients of the same weight and overall drug risk (p = 0.036). The proportion of withdrawal symptoms in the pre-protocol patients (16%) was not significantly different from the proportion in the post-protocol patients (14%; p = 0.435). CONCLUSIONS Implementation of a PICU sedation weaning protocol in a single-center conferred cost benefit without negatively impacting patient outcomes. A larger multicenter study would provide insight to the applicability to PICUs in varied settings with differing patient populations.
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Affiliation(s)
- Chiara Velez
- 99 MDG (CV) of the United States Air Force at Nellis Air Force Base, NV
| | - Jessica J. Anderson
- Departments of Pediatric Critical Care (KB) and Pharmacy (JA), Monroe Carell Jr. Children’s Hospital at Vanderbilt University Medical Center, Nashville, TN
| | - J. Jackson Resser
- Department of Biostatistics at Vanderbilt University Medical Center (JR, DL), Nashville, TN
| | - Dandan Liu
- Department of Biostatistics at Vanderbilt University Medical Center (JR, DL), Nashville, TN
| | - Kristina A. Betters
- Departments of Pediatric Critical Care (KB) and Pharmacy (JA), Monroe Carell Jr. Children’s Hospital at Vanderbilt University Medical Center, Nashville, TN
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Santiago R, Gorenberg BJ, Hurtubise C, Senekki-Florent P, Kudchadkar SR. Speech-language pathologist involvement in the paediatric intensive care unit. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024; 26:674-681. [PMID: 37778370 PMCID: PMC10982122 DOI: 10.1080/17549507.2023.2244195] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
PURPOSE To measure the prevalence of speech-language pathologist (SLP) involvement and associated trends for critically ill children in United States (US) paediatric intensive care units (PICU) through secondary analysis of the Prevalence of Acute Rehab for Kids in the PICU (PARK-PICU) study data. METHOD A secondary analysis of cross-sectional point prevalence study conducted over 1 day in 82 US PICUs. Data collected included SLP presence, patients' age, length of stay, medical interventions, aetiology, admission data, Glasgow Coma Scale scores, staffing involvement, and family presence. RESULT Among 961 patients, 82 were visited by an SLP on the study day for a prevalence of 8.5%. Most visits were for children <3 years old. The odds of SLP involvement were lower for children who were 7-12 years old (vs. age 0-2; adjusted odds ratio [aOR] 0.28; 95% CI 0.1-0.8), were mechanically ventilated via endotracheal tube (vs. room air; aOR 0.02; 95% CI 0.005-0.11), or had mild or severe disability (mild vs. no disability; aOR 0.34; 95% CI 0.16-0.76 and severe vs. no disability; aOR 0.39; 95% CI 0.17-0.90). Concurrent physical and/or occupational therapy involvement was associated with higher odds of SLP involvement (aOR 3.6; 95% CI 2.1-6.4). CONCLUSION SLP involvement is infrequent in US PICUs. PICU teams should be educated about the scope of SLP practice, to support communication and oral feeding needs during early recovery from critical illness.
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Affiliation(s)
- Rachel Santiago
- Department of Otolaryngology & Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | | | | | - Panayiota Senekki-Florent
- Department of Physical Medicine and Rehabilitation, Charlotte R. Bloomberg Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sapna R. Kudchadkar
- Department of Physical Medicine and Rehabilitation, Charlotte R. Bloomberg Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children’s Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Shu Wen Toh T, R. R. P, Ho KHY, Sultana R, Couban R, Choong K, Lee JH. Daily Sedation Interruption vs Continuous Sedation in Pediatric Patients Receiving Mechanical Ventilation: A Systematic Review and Meta-analysis. JAMA Netw Open 2024; 7:e2426225. [PMID: 39110460 PMCID: PMC11307139 DOI: 10.1001/jamanetworkopen.2024.26225] [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] [Received: 03/22/2024] [Accepted: 06/09/2024] [Indexed: 08/10/2024] Open
Abstract
Importance The effectiveness of daily sedation interruption (DSI, defined as temporary interruption of sedation) has yet to be demonstrated in critically ill pediatric patients. Objective To compare the clinical outcomes of DSI vs continuous intravenous (IV) sedation in patients receiving invasive mechanical ventilation (MV) support in the pediatric intensive care unit (PICU). Data Sources A systematic search for studies was conducted using predefined keywords and Medical Subject Headings in 5 major databases (PubMed, Embase, Web of Science, CINAHL [Cumulated Index to Nursing and Allied Health Literature], and Cochrane Central Register of Controlled Trials) from database inception to October 31, 2023. Study Selection Retrospective and prospective observational studies, randomized clinical trials (RCTs), and systematic reviews were assessed for inclusion. Studies were eligible if they compared DSI to continuous IV sedation in patients aged 18 years or younger requiring MV in the PICU. Data Extraction and Synthesis Study characteristics, including the types of sedation, sedation protocols, and clinical outcomes, were extracted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline was followed. A random-effects model was used to pool results from articles for the meta-analysis. Main Outcomes and Measures The primary outcomes of interest were duration of MV and length of PICU stay. Secondary outcomes included total sedative dose requirement, adverse events (eg, complications associated with MV, withdrawal, and delirium), and mortality. Results A total of 6 RCTs with 2810 pediatric patients (1569 males [55.8%]; mean age, 26.5 [95% CI, 15.0-37.9] months) were included in the final analysis; patients had a mean PRISM (Pediatric Risk of Mortality) score of 13.68 (95% CI, 10.75-16.61). Compared with continuous IV sedation, DSI was associated with a reduction in length of PICU stay (5 studies, n = 2770; mean difference [MD], -1.45 [95% CI, -2.75 to -0.15] days; P = .03]. There was no difference in MV duration (5 studies, n = 2750; MD, -0.93 [95% CI, -1.89 to 0.04] days; P = .06), total doses of midazolam (3 studies, n = 191; MD, -1.66 [95% CI, -3.95 to 0.63] mg/kg) and morphine used (2 studies, n = 189; MD, -2.63 [95% CI, -7.01 to 1.75] mg/kg), or adverse events (risk ratio [RR], 1.03 [95% CI, 0.74-1.42]; P = .88). There was no difference in mortality between patients exposed vs not exposed to DSI (RR, 0.89 [95% CI, 0.55-1.46]; P = .65). Conclusions and Relevance This systematic review and meta-analysis found that use of DSI in pediatric patients was associated with reduced length of PICU stay with no increase in adverse events. Further research is needed to ascertain whether this strategy is associated with improved neurodevelopmental outcomes in PICU survivors.
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Affiliation(s)
- Theresa Shu Wen Toh
- Department of Pediatric Subspecialties, Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
| | - Pravin R. R.
- Department of Pediatric Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Karen Hwee Ying Ho
- Department of Pediatric Subspecialties, Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
| | - Rehena Sultana
- Center for Quantitative Medicine, Duke-NUS Medical School, The Academia, Singapore
| | - Rachel Couban
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Karen Choong
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jan Hau Lee
- Department of Pediatric Subspecialties, Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
- Paediatrics Academic Clinical Program, Duke-NUS Medical School, Singapore
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Panda CK, Karim HMR. Deep Machine Learning Might Aid in Combating Intensive Care Unit-Acquired Weakness. Cureus 2024; 16:e58963. [PMID: 38800279 PMCID: PMC11126887 DOI: 10.7759/cureus.58963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 05/29/2024] Open
Abstract
Secondary muscle weakness in critically ill patients like intensive care unit (ICU)-associated weakness is frequently noted in patients with prolonged mechanical ventilation and ICU stay. It can be a result of critical illness, myopathy, or neuropathy. Although ICU-acquired weakness (ICU-AW) has been known for a while, there is still no effective treatment for it. Therefore, prevention of ICU-AW becomes the utmost priority, and knowing the risk factors is crucial. Nevertheless, the pathophysiology and the attributing causes are complex for ICU-AW, and proper delineation and formulation of a preventive strategy from such vast, multifaceted data are challenging. Artificial intelligence has recently helped healthcare professionals understand and analyze such intricate data through deep machine learning. Hence, using such a strategy also helps in knowing the risk factors and their weight as contributors, applying them in formulating a preventive path for ICU-AW worth trials.
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Affiliation(s)
- Chinmaya K Panda
- Anaesthesiology, Critical Care, and Pain Medicine, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Habib Md R Karim
- Anesthesiology, Critical Care, and Pain Medicine, All India Institute of Medical Sciences, Guwahati, Guwahati, IND
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Mondardini MC, Sperotto F, Daverio M, Amigoni A. Analgesia and sedation in critically ill pediatric patients: an update from the recent guidelines and point of view. Eur J Pediatr 2023; 182:2013-2026. [PMID: 36892607 DOI: 10.1007/s00431-023-04905-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/14/2023] [Accepted: 02/26/2023] [Indexed: 03/10/2023]
Abstract
In the last decades, the advancement of knowledge in analgesia and sedation for critically ill pediatric patients has been conspicuous and relevant. Many recommendations have changed to ensure patients' comfort during their intensive care unit (ICU) stay and prevent and treat sedation-related complications, as well as improve functional recovery and clinical outcomes. The key aspects of the analgosedation management in pediatrics have been recently reviewed in two consensus-based documents. However, there remains a lot to be researched and understood. With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field. Conclusion: With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field. What is Known: • Critically ill pediatric patients receiving intensive care required analgesia and sedation to attenuate painful and stressful stimuli. •Optimal management of analgosedation is a challenge often burdened with complications such as tolerance, iatrogenic withdrawal syndrome, delirium, and possible adverse outcomes. What is New: •The new insights on the analgosedation treatment for critically ill pediatric patients delineated in the recent guidelines are summarized to identify strategies for changes in clinical practice. •Research gaps and potential for quality improvement projects are also highlighted.
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Affiliation(s)
- 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
| | - Francesca Sperotto
- Cardiovascular Critical Care Unit, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy.
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Zhao X, Yan J, Wu B, Zheng D, Fang X, Xu W. Sleep cycle in children with severe acute bronchopneumonia during mechanical ventilation at different depths of sedation. BMC Pediatr 2022; 22:589. [PMID: 36224544 PMCID: PMC9553625 DOI: 10.1186/s12887-022-03658-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 10/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate the characteristics of sleep cycle in children with severe acute bronchopneumonia treated with invasive mechanical ventilation at different sedation depths. METHODS We included 35 pediatric patients with severe acute bronchopneumonia treated using mechanical ventilation in Pediatric Intensive Care Unit of Shengjing Hospital of China Medical University. They were divided into deep sedation group (n = 21; ramsay score 5-6) and light sedation group (n = 14; ramsay score3-4) based on sedation depth achieved during mechanical ventilation. Long-term video electroencephalography (EEG) monitoring was performed within the first 24 h after starting mechanical ventilation and after weaning from mechanical ventilation and discontinuing sedatives and analgesics. The results were analyzed and compared with those of normal children to analyze changes in sleep cycle characteristics at different sedation depths and mechanical ventilation stages. RESULTS There were 29 cases altered sleep architecture. The deep sedation group had a significantly higher incidence of sleep architecture altered, total sleep duration, and non-rapid eye movement sleep-1 (NREM-1) loss incidence than the light sedation group. Moreover, the deep sedation group had a significantly lower awakening number and rapid eye movement sleep (REM) percentage than the light sedation group. The sleep cycle returned to normal in 27 (77%) patients without NREM-1 or REM sleep loss. CONCLUSIONS Deep sedation during mechanical ventilation allows longer total sleep duration, fewer awakenings, and an increased deep sleep proportion, but sleep architecture is severely altered. After weaning from mechanical ventilation and sedative discontinuation, lightly sedated children exhibit better sleep recovery.
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Affiliation(s)
- XueShan Zhao
- Department of Pediatrics, Shengjing Hospital of China Medical University, No.36, San Hao Street, Heping District, Shenyang, LiaoNing Province, China
| | - JingLi Yan
- Department of Pediatrics, Shengjing Hospital of China Medical University, No.36, San Hao Street, Heping District, Shenyang, LiaoNing Province, China
| | - Bo Wu
- Department of Pediatrics, Shengjing Hospital of China Medical University, No.36, San Hao Street, Heping District, Shenyang, LiaoNing Province, China
| | - Duo Zheng
- Department of Nerve Function, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiuying Fang
- Department of Nerve Function, Shengjing Hospital of China Medical University, Shenyang, China
| | - Wei Xu
- Department of Pediatrics, Shengjing Hospital of China Medical University, No.36, San Hao Street, Heping District, Shenyang, LiaoNing Province, China.
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Kudchadkar SR, Berger J, Patel R, Barnes S, Twose C, Walker T, Mitchell R, Song J, Anton B, Punjabi NM. Non-pharmacological interventions for sleep promotion in hospitalized children. Cochrane Database Syst Rev 2022; 6:CD012908. [PMID: 35703367 PMCID: PMC9199068 DOI: 10.1002/14651858.cd012908.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Healthy sleep is an important component of childhood development. Changes in sleep architecture, including sleep stage composition, quantity, and quality from infancy to adolescence are a reflection of neurologic maturation. Hospital admission for acute illness introduces modifiable risk factors for sleep disruption that may negatively affect active brain development during a period of illness and recovery. Thus, it is important to examine non-pharmacologic interventions for sleep promotion in the pediatric inpatient setting. OBJECTIVES To evaluate the effect of non-pharmacological sleep promotion interventions in hospitalized children and adolescents on sleep quality and sleep duration, child or parent satisfaction, cost-effectiveness, delirium incidence, length of mechanical ventilation, length of stay, and mortality. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, three other databases, and three trials registers to December 2021. We searched Google Scholar, and two websites, handsearched conference abstracts, and checked reference lists of included studies. SELECTION CRITERIA Randomized controlled trials (RCTs) or quasi-RCTs, including cross-over trials, investigating the effects of any non-pharmacological sleep promotion intervention on the sleep quality or sleep duration (or both) of children aged 1 month to 18 years in the pediatric inpatient setting (intensive care unit [ICU] or general ward setting). DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility, evaluated risk of bias, extracted and synthesized data, and used the GRADE approach to assess certainty of evidence. The primary outcomes were changes in both objective and subjective validated measures of sleep in children; secondary outcomes were child and parent satisfaction, cost-effectiveness ratios, delirium incidence or delirium-free days at time of hospital discharge, duration of mechanical ventilation, length of hospital stay, and mortality. MAIN RESULTS We included 10 trials (528 participants; aged 3 to 22 years) in inpatient pediatric settings. Seven studies were conducted in the USA, two in Canada, and one in Brazil. Eight studies were funded by government, charity, or foundation grants. Two provided no information on funding. Eight studies investigated behavioral interventions (massage, touch therapy, and bedtime stories); two investigated physical activity interventions. Duration and timing of interventions varied widely. All studies were at high risk of performance bias due to the nature of the intervention, as participants, parents, and staff could not be masked to group assignment. We were unable to perform a quantitative synthesis due to substantial clinical heterogeneity. Behavioral interventions versus usual care Five studies (145 participants) provided low-certainty evidence of no clear difference between multicomponent relaxation interventions and usual care on objective sleep measures. Overall, evidence from single studies found no clear differences in daytime or nighttime sleep measures (33 participants); any sleep parameter (48 participants); or daytime or nighttime sleep or nighttime arousals (20 participants). One study (34 participants) reported no effect of massage on nighttime sleep, sleep efficiency (SE), wake after sleep onset (WASO), or total sleep time (TST) in adolescents with cancer. Evidence from a cross-over study in 10 children with burns suggested touch therapy may increase TST (391 minutes, interquartile range [IQR] 251 to 467 versus 331 minutes, IQR 268 to 373; P = 0.02); SE (76, IQR 53 to 90 versus 66, IQR 55 to 78; P = 0.04); and the number of rapid eye movement (REM) periods (4.5, IQR 2 to 5 versus 3.5, IQR 2 to 4; P = 0.03); but not WASO, sleep latency (SL), total duration of REM, or per cent of slow wave sleep. Four studies (232 participants) provided very low-certainty evidence on subjective measures of sleep. Evidence from single studies found that sleep efficiency may increase, and the percentage of nighttime wakefulness may decrease more over a five-day period following a massage than usual care (72 participants). One study (48 participants) reported an improvement in Children's Sleep Habits Questionnaire scores after discharge in children who received a multicomponent relaxation intervention compared to usual care. In another study, mean sleep duration per sleep episode was longer (23 minutes versus 15 minutes), and time to fall asleep was shorter (22 minutes versus 27 minutes) following a bedtime story versus no story (18 participants); and children listening to a parent-recorded story had longer SL than when a parent was present (mean 57.5 versus 43.5 minutes); both groups reported longer SL than groups who had a stranger-recorded story, and those who had no story and absent parents (94 participants; P < 0.001). In one study (34 participants), 87% (13/15) of participants felt they slept better following massage, with most parents (92%; 11/12) reporting they wanted their child to receive a massage again. Another study (20 participants) reported that parents thought the music, touch, and reading components of the intervention were acceptable, feasible, and had positive effects on their children (very low-certainty evidence). Physical activity interventions versus usual care One study (29 participants) found that an enhanced physical activity intervention may result in little or no improvement in TST or SE compared to usual care (low-certainty evidence). Another study (139 participants), comparing play versus no play found inconsistent results on subjective measures of sleep across different ages (TST was 49% higher for the no play groups in 4- to 7-year olds, 10% higher in 7- to 11-year olds, and 22% higher in 11- to 14-year olds). This study also found inconsistent results between boys and girls (girls in the first two age groups in the play group slept more than the no play group). No study evaluated child or parent satisfaction for behavioral interventions, or cost-effectiveness, delirium incidence or delirium-free days at hospital discharge, length of mechanical ventilation, length of hospital stay, or mortality for either behavioral or physical activity intervention. AUTHORS' CONCLUSIONS The included studies were heterogeneous, so we could not quantitatively synthesize the results. Our narrative summary found inconsistent, low to very low-certainty evidence. Therefore, we are unable to determine how non-pharmacologic sleep promotion interventions affect sleep quality or sleep duration compared with usual care or other interventions. The evidence base should be strengthened through design and conduct of randomized trials, which use validated and highly reliable sleep assessment tools, including objective measures, such as polysomnography and actigraphy.
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Affiliation(s)
- Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jessica Berger
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ruchit Patel
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sean Barnes
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Claire Twose
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tracie Walker
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Riley Mitchell
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jaehyun Song
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Blair Anton
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Naresh M Punjabi
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
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Morrow BM. Building a culture of early mobilization in the pediatric intensive care unit-a nuts and bolts approach. Transl Pediatr 2021; 10:2845-2857. [PMID: 34765506 PMCID: PMC8578759 DOI: 10.21037/tp-20-324] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/26/2021] [Indexed: 12/13/2022] Open
Abstract
The culture of sedation and immobilization in the pediatric intensive care unit (PICU) is associated with PICU-acquired weakness, delirium, and poor functional, neurocognitive and psychosocial outcomes. A structured approach to introducing physical activity, as early as possible after PICU admission, may prevent these complications and optimize the holistic outcomes of critically ill children. Changing culture and introducing new clinical practice in PICU is complex, but can be approached systematically, using a "nuts and bolts" approach targeting the basic, practical considerations and essential required elements or components. Extending the construction analogy, this article reviews the relevant literature to describe the essential elements required to build and sustain a successful and safe early mobility program in the PICU. Effective early mobilization requires individual patient assessment and goal setting, using a collaborative inter-disciplinary, patient- and family-centered approach, to ensure mobility goals and physical activities are appropriate for the patient's age, condition/s, premorbid function, strength, endurance and developmental level. Early mobility activities for the pediatric age spectrum include active or active-assisted range of motion exercises, neurodevelopmental play, use of mobility devices, in-bed exercises, transfers, sitting or standing tolerance, crawling, pre-gait activities, ambulation and activities of daily living, with a focus on play as function. Although there are few complete contraindications to early mobilization, appropriate precautions and preparation should be taken to mitigate potential safety concerns. Although there are many perceived barriers to early mobilization in the PICU, at the level of patient, provider, institution and knowledge translation; these are not objectively associated with increased risk during mobilization and can be overcome through an engaged process of practice change by all members of the interprofessional clinical team. Early mobility programs could be initiated in PICU as systematic quality improvement initiatives, with established processes to optimize structural, process and system elements and to provide continual feedback, measurement, benchmarking and collaboration; to ultimately impact on measurable patient outcomes. Early, graded, and individually prescribed mobilization should be considered as part of the standard PICU "package of care" for all critically ill and injured children, in order to improve their functional status and quality of life after PICU discharge.
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Affiliation(s)
- Brenda M Morrow
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
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Development and Implementation of Pediatric ICU-based Mobility Guidelines: A Quality Improvement Initiative. Pediatr Qual Saf 2021; 6:e414. [PMID: 34046543 PMCID: PMC8143751 DOI: 10.1097/pq9.0000000000000414] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 12/08/2020] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Critical illness results in physical impairments which may be mitigated by intensive care unit (ICU)-based early mobility. This initiative aimed to develop and implement ICU-based mobility guidelines for critically ill children.
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Egbuta C, Mason KP. Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit. J Clin Med 2021; 10:1847. [PMID: 33922824 PMCID: PMC8122992 DOI: 10.3390/jcm10091847] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA;
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Abstract
OBJECTIVES The objective of this study was to determine the prevalence of ICU delirium in children less than 18 years old that underwent cardiac surgery within the last 30 days. The secondary aim of the study was to identify risk factors associated with ICU delirium in postoperative pediatric cardiac surgical patients. DESIGN A 1-day, multicenter point-prevalence study of delirium in pediatric postoperative cardiac surgery patients. SETTING Twenty-seven pediatric cardiac and general critical care units caring for postoperative pediatric cardiac surgery patients in North America. PATIENTS All children less than 18 years old hospitalized in the cardiac critical care units at 06:00 on a randomly selected, study day. INTERVENTIONS Eligible children were screened for delirium using the Cornell Assessment of Pediatric Delirium by the study team in collaboration with the bedside nurse. MEASUREMENT AND MAIN RESULTS Overall, 181 patients were enrolled and 40% (n = 73) screened positive for delirium. There were no statistically significant differences in patient demographic information, severity of defect or surgical procedure, past medical history, or postoperative day between patients screening positive or negative for delirium. Our bivariate analysis found those patients screening positive had a longer duration of mechanical ventilation (12.8 vs 5.1 d; p = 0.02); required more vasoactive support (55% vs 26%; p = 0.0009); and had a higher number of invasive catheters (4 vs 3 catheters; p = 0.001). Delirium-positive patients received more total opioid exposure (1.80 vs 0.36 mg/kg/d of morphine equivalents; p < 0.001), did not have an ambulation or physical therapy schedule (p = 0.02), had not been out of bed in the previous 24 hours (p < 0.0002), and parents were not at the bedside at time of data collection (p = 0.008). In the mixed-effects logistic regression analysis of modifiable risk factors, the following variables were associated with a positive delirium screen: 1) pain score, per point increase (odds ratio, 1.3; 1.06-1.60); 2) total opioid exposure, per mg/kg/d increase (odds ratio, 1.35; 1.06-1.73); 3) SBS less than 0 (odds ratio, 4.01; 1.21-13.27); 4) pain medication or sedative administered in the previous 4 hours (odds ratio, 3.49; 1.32-9.28); 5) no progressive physical therapy or ambulation schedule in their medical record (odds ratio, 4.40; 1.41-13.68); and 6) parents not at bedside at time of data collection (odds ratio, 2.31; 1.01-5.31). CONCLUSIONS We found delirium to be a common problem after cardiac surgery with several important modifiable risk factors.
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Mencía S, Cieza R, Del Castillo J, López-Herce J. MONISEDA Project: Improving Analgosedation Monitoring in Spanish Pediatric Intensive Care Units. Front Pediatr 2021; 9:781509. [PMID: 34950619 PMCID: PMC8691263 DOI: 10.3389/fped.2021.781509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Analgosedation (AS) assessment using clinical scales is crucial to follow the international recommendations about analgosedation. The Analgosedation workgroup of the Spanish Society of Pediatric Intensive Care (SECIP) carried out two surveys in 2008 and 2015, which verified the gap in analgosedation assessment in Spanish pediatric intensive care unit (PICUs). The objective of the study was to analyze how analgosedation assessment by clinical scales changed after a multicenter intervention program. Methods: This is a multicenter pre-post study comparing the use of sedation, analgesia, withdrawal, and delirium scales before and after the MONISEDA project. Results were also compared with a control group formed by non-participating units. A survey about analgosedation management and monitoring was filled out before (year 2015) and after (year 2020) the implementation of the MONISEDA project in 2016. Results were compared not only between those periods of time but also between participant and non-participant PICUs in the MONISEDA project (M-group and non-M group, respectively). Data related to analgosedation of all patients admitted to a MONISEDA-participant PICU were also collected for 2 months. Results: Fifteen Spanish PICUs were enrolled in the MONISEDA project and another 15 non-participant PICUs formed the control group. In the M-group, the number of PICUs with a written analgosedation protocol increased from 53 to 100% (p = 0.003) and withdrawal protocol from 53 to 100% (p = 0.003), whereas in the non-M group, the written AS protocol increased from 80 to 87% and the withdrawal protocol stayed on 80%. The number of PICUs with an analgosedation team increased from 7 to 47% in the M-group (p = 0.01) and from 13 to 33% in the non-M group (p = 0.25). In the M-group, routine use of analgosedation clinical scales increased from 7 to 100% (p < 0.001), withdrawal scales from 7% to 86% (p = 0.001), and delirium scales from 7 to 33% (p = 0.125). In the non-M group, the number of PICUs using AS scales increased from 13 to 100% (p < 0.001), withdrawal scales from 7 to 27% (p = 0.125), and delirium scales from 0 to 7% (p = 1). Conclusions: The development of a specific training program improves monitoring and management of analgosedation in PICUs.
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Affiliation(s)
- Santiago Mencía
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain.,Public Health and Mother-Child Department, School of Medicine, Complutense University, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain.,Mother-Child Health and Development Network (Red SAMID) of ISCIII-Sub-Directorate General for Research Assessment and Promotion, European Regional Development Fund, Madrid, Spain
| | - Raquel Cieza
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain.,Public Health and Mother-Child Department, School of Medicine, Complutense University, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain.,Mother-Child Health and Development Network (Red SAMID) of ISCIII-Sub-Directorate General for Research Assessment and Promotion, European Regional Development Fund, Madrid, Spain
| | - Jimena Del Castillo
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain.,Public Health and Mother-Child Department, School of Medicine, Complutense University, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain.,Mother-Child Health and Development Network (Red SAMID) of ISCIII-Sub-Directorate General for Research Assessment and Promotion, European Regional Development Fund, Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Department, Gregorio Marañón General University Hospital, Madrid, Spain.,Public Health and Mother-Child Department, School of Medicine, Complutense University, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain.,Mother-Child Health and Development Network (Red SAMID) of ISCIII-Sub-Directorate General for Research Assessment and Promotion, European Regional Development Fund, Madrid, Spain
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13
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Colleti Junior J, Araujo ORD, Andrade ABD, Carvalho WBD. Practices related to assessment of sedation, analgesia and delirium among critical care pediatricians in Brazil. EINSTEIN-SAO PAULO 2020; 18:eAO5168. [PMID: 31994609 PMCID: PMC6980295 DOI: 10.31744/einstein_journal/2020ao5168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 09/11/2019] [Indexed: 11/05/2022] Open
Abstract
Objective To understand the use of tools, protocols and comfort measures related to sedation/analgesia, and to screen the occurrence of delirium in pediatric intensive care units. Methods A survey with 14 questions was distributed by e-mail to Brazilian critical care pediatricians. Eight questions addressed physician and hospital demographics, and six inquired practices to assess sedation, analgesia, and delirium in pediatric intensive care units. Results Of 373 questionnaires sent, 61 were answered (16.3%). The majority of physicians were practicing in the Southeast region (57.2%). Of these, 46.5% worked at public hospitals, 28.6% of which under direct state administration. Of respondents, 57.1% used formal protocols for sedation and analgesia, and the Ramsay scale was the most frequently employed (52.5%). Delirium screening scores were not used by 48.2% of physicians. The Cornell Assessment of Pediatric Delirium was the score most often used (23.2%). The majority (85.7%) of physicians did not practice daily sedation interruption, and only 23.2% used non-pharmacological measures for patient comfort frequently, with varied participation of parents in the process. Conclusion This study highlights the heterogeneity of practices for assessment of sedation/analgesia and lack of detection of delirium among critical care pediatricians in Brazil.
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Affiliation(s)
| | - Orlei Ribeiro de Araujo
- Instituto de Oncologia Pediátrica, Grupo de Apoio ao Adolescente e à Criança com Câncer (GRAAC), São Paulo, SP, Brazil
| | | | - Werther Brunow de Carvalho
- Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Howes C, Hiatt K, Turlington K, Foster C, Holloway A, Graciano AL, Custer J, Bhutta A, Bagdure D. Botulism in the Pediatric Intensive Care Units in the United States: Interrogating a National Database. J Pediatr Intensive Care 2019; 9:12-15. [PMID: 31984151 DOI: 10.1055/s-0039-1695045] [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: 05/18/2019] [Accepted: 07/11/2019] [Indexed: 10/26/2022] Open
Abstract
Botulism in children can have severe complications necessitating intensive care. The current literature lacks data of children with botulism requiring critical care. We aim to describe the outcomes of pediatric botulism in the pediatric intensive care unit (PICU). Retrospective cohort data from Virtual Pediatric Systems (VPS, LLC, Los Angeles, California), from 2009 to 2016 including all PICU admissions among children with botulism, were analyzed. Characteristics and outcomes were compared with similar studies. A total of 380 children were identified over 8 years. Our cohort had the shortest length of stay (median 4.6 days), the smallest percent requiring mechanical ventilation (40%), and the highest median age (120 days) amongst comparable studies. Length of mechanical ventilation and PICU stay has decreased among children with botulism. Advances in PICU care may have contributed to these improved outcomes.
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Affiliation(s)
- Cynthia Howes
- Department of Pediatrics, Division of Pediatric Critical Care, University of Maryland Medical Center, Baltimore, Maryland, United States
| | - Kerith Hiatt
- Department of Pediatrics, Division of Pediatric Critical Care, University of Maryland Medical Center, Baltimore, Maryland, United States
| | - Katherine Turlington
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Cortney Foster
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Adrian Holloway
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Ana Lia Graciano
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Jason Custer
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Adnan Bhutta
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Dayanand Bagdure
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States
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15
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Piva TC, Ferrari RS, Schaan CW. Early mobilization protocols for critically ill pediatric patients: systematic review. Rev Bras Ter Intensiva 2019; 31:248-257. [PMID: 31215603 PMCID: PMC6649221 DOI: 10.5935/0103-507x.20190038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/01/2018] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To describe the existing early mobilization protocols in pediatric intensive care units. METHODS A systematic literature review was performed using the databases MEDLINE®, Embase, SciELO, LILACS and PeDRO, without restrictions of date and language. Observational and randomized and nonrandomized clinical trials that described an early mobilization program in patients aged between 29 days and 18 years admitted to the pediatric intensive care unit were included. The methodological quality of the studies was evaluated using the Newcastle-Ottawa Scale, Methodological Index for Non-Randomized Studies and the Cochrane Collaboration. RESULTS A total of 8,663 studies were identified, of which 6 were included in this review. Three studies described the implementation of an early mobilization program, including activities such as progressive passive mobilization, positioning, and discussion of mobilization goals with the team, in addition to contraindications and interruption criteria. Cycle ergometer and virtual reality games were also used as resources for mobilization. Four studies considered the importance of the participation of the multidisciplinary team in the implementation of early mobilization protocols. CONCLUSION In general, early mobilization protocols are based on individualized interventions, depending on the child's development. In addition, the use of a cycle ergometer may be feasible and safe in this population. The implementation of institutional and multidisciplinary protocols may contribute to the use of early mobilization in pediatric intensive care units; however, studies demonstrating the efficacy of such intervention are needed.
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Affiliation(s)
- Taila Cristina Piva
- Programa de Residência Integrada Multiprofissional em Saúde da Criança, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Renata Salatti Ferrari
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Camila Wohlgemuth Schaan
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
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16
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Sedation Optimization: A Core Priority of Modern Quality Improvement in Critical Care. Pediatr Crit Care Med 2019; 20:382-383. [PMID: 30950990 DOI: 10.1097/pcc.0000000000001890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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17
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Cunningham ME, Vogel AM. Analgesia, sedation, and delirium in pediatric surgical critical care. Semin Pediatr Surg 2019; 28:33-42. [PMID: 30824132 DOI: 10.1053/j.sempedsurg.2019.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.
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Affiliation(s)
- Megan E Cunningham
- Texas Children's Hospital, Division of Pediatric Surgery, Department of Surgery, 6701 Fannin Street, Houston, TX 77030, USA.
| | - Adam M Vogel
- Texas Children's Hospital, Division of Pediatric Surgery, Department of Surgery, 6701 Fannin Street, Houston, TX 77030, USA; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
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Abstract
Survivors of critical illness often experience multiple morbidities that start in the intensive care unit and impact their quality of life after discharge. Reduced physical function, cognitive decline, feeding disorders, and psychological stress are just a few of the potential complications. Many of these morbidities can lead to a reduced quality of life and lifelong impediments. Early mobilization, an intervention that is intended to maintain or restore musculoskeletal strength in the critically ill, has the potential to also yield positive psychological and cognitive benefits. In adults, early mobilization has been shown to be safe, decrease the incidence of delirium, and decrease length of stay. Early mobilization of the pediatric critically ill patient is still a novel topic with a growing body of research. This article will review the current literature on early mobilization of the pediatric critically ill patient.
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Affiliation(s)
- Tracie C Walker
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD, USA
| | - Sapna R Kudchadkar
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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19
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Child Psychiatry Engagement in the Management of Delirium in Critically Ill Children. Crit Care Res Pract 2018; 2018:9135618. [PMID: 29854450 PMCID: PMC5944292 DOI: 10.1155/2018/9135618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/11/2018] [Accepted: 03/31/2018] [Indexed: 01/30/2023] Open
Abstract
Objectives To characterize the engagement of child psychiatry by pediatric intensivists in cases of suspected delirium in a pediatric intensive care unit (PICU) prior to implementation of a delirium management algorithm with regards to recommendations, antipsychotic prescribing, and follow-up after PICU discharge. Design Retrospective chart review. Setting Single-center tertiary PICU. Subjects Sixteen patients who received child psychiatry consultation for suspected delirium while in the PICU. Measurements and Main Results Child psychiatry was consulted for 50 patients in the PICU during the 2-year period. Sixteen (32%) of these consultations were for delirium, and 15 (94%) of these patients were diagnosed with hyperactive delirium. Eighty-one percent of the patients were prescribed an antipsychotic, and over half of these patients had been initiated on the antipsychotic prior to child psychiatry consultation. All patients who transitioned from the PICU to the general floor received child psychiatry follow-up. Conclusions Child psychiatry can play an integral role in collaborative management of PICU delirium. Continuity of care with child psychiatry after transfer or discharge is particularly important given the prevalence of antipsychotic use. Furthermore, the results of this retrospective study would suggest that staff education surrounding the delirium screening tool increased awareness of delirium, resulting in an increase in child psychiatry consultations.
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Kudchadkar SR, Barnes S, Anton B, Gergen DJ, Punjabi NM. Non-pharmacological interventions for sleep promotion in hospitalized children. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2017. [DOI: 10.1002/14651858.cd012908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sapna R Kudchadkar
- Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children’s Center; Department of Anesthesiology and Critical Care Medicine; 1800 Orleans Street, Suite 6318B Baltimore MD USA 21287
| | - Sean Barnes
- Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children’s Center; Department of Anesthesiology and Critical Care Medicine; 1800 Orleans Street, Suite 6318B Baltimore MD USA 21287
| | - Blair Anton
- Johns Hopkins University School of Medicine; William H Welch Medical Library; 2024 E. Monument Street Baltimore MD USA 21287
| | - Daniel J Gergen
- Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children’s Center; Department of Anesthesiology and Critical Care Medicine; 1800 Orleans Street, Suite 6318B Baltimore MD USA 21287
| | - Naresh M Punjabi
- Johns Hopkins University School of Medicine; Department of Medicine; Division of Pulmonary and Critical Care Medicine 5501 Hopkins Bayview Circle, 4B-36 Baltimore MD USA 21224
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21
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Physical and occupational therapy utilization in a pediatric intensive care unit. J Crit Care 2017; 40:15-20. [PMID: 28297684 DOI: 10.1016/j.jcrc.2017.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/23/2017] [Accepted: 03/06/2017] [Indexed: 12/20/2022]
Abstract
PURPOSE To characterize the use of physical therapy (PT) and occupational therapy (OT) consultation in our pediatric intensive care unit (PICU). MATERIALS AND METHODS We studied children aged 1week-18years admitted to a tertiary care PICU for ≥3days. Patient characteristics, details of PT and OT sessions and adverse events were collected. A multivariable logistic regression was performed to determine factors associated with receipt of PT and OT consultation with propensity analysis followed by a regression for factors associated with outcome. RESULTS Of 138 children studied, 40 (29%) received PT and OT consultation. Services were initiated 6.9±10.0 (mean±standard deviation) days after PICU admission. Range of motion (83%) was the most common therapy provided and 28% of patients were ambulated. Sixty-four of 297 (21.5%) sessions were deferred and 7 (2.4%) sessions were terminated early due to physiologic instability with no serious adverse events. Children who received PT and OT were older, more likely to require neuromuscular blocking agents, and had lower pre-PICU POPC scores (all p<0.05). CONCLUSIONS Data are needed to inform on the efficacy of rehabilitative therapies initiated in the ICU to improve outcome for critically ill children.
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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: 2.9] [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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