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Kimura S, Shimizu K, Matsuoka Y, Iwasaki T, Kanazawa T, Morimatsu H. An Assessment of the Practice of Neuromuscular Blockade and the Association Between Its Prophylactic Use and Outcomes Among Postoperative Pediatric Cardiac Patients. J Cardiothorac Vasc Anesth 2023; 37:980-987. [PMID: 36933990 DOI: 10.1053/j.jvca.2023.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/13/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVES The authors investigated the management of neuromuscular blocking agents (NMBAs) for pediatric patients after cardiac surgery, and compared the outcomes of patients who received prophylactic NMBA (pNMBA) infusions and patients without pNMBA infusions. DESIGN A retrospective cohort study. SETTING At a tertiary teaching hospital. PARTICIPANTS Patients younger than 18, with congenital heart disease, who underwent cardiac surgery. INTERVENTIONS Commencement of NMBA infusion in the first 2 hours after surgery MEASUREMENTS AND MAIN RESULTS: The primary endpoint was a composite of one or more of the following major adverse events (MAEs) that occurred within 7 days after surgery: death from any cause, a circulatory collapse that needed cardiopulmonary resuscitation, and requirement for extracorporeal membrane oxygenation. The secondary endpoints included the total duration of mechanical ventilation for the first 30 days after surgery. A total of 566 patients were included in this study. The MAEs occurred in 13 patients (2.3%). An NMBA was commenced within 2 hours after surgery in 207 patients (36.6%). There were significant differences in the incidence of postoperative MAEs between the pNMBA group and the non-pNMBA group (5.3% v 0.6%; p < 0.001). In multivariate regression models, pNMBA infusion was not significantly associated with the incidence of MAEs (odds ratio: 1.79, 95% CI: 0.23-13.93, p = 0.58), but was significantly associated with prolonged mechanical ventilation by 3.85 days (p < 0.001). CONCLUSIONS Postoperative prophylactic neuromuscular blockade after cardiac surgery can be associated with prolonged mechanical ventilation, but has no association with MAEs among pediatric patients with congenital heart disease.
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Affiliation(s)
- Satoshi Kimura
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Shikata-cho, Kita-ku, Okayama, Japan.
| | - Kazuyoshi Shimizu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Shikata-cho, Kita-ku, Okayama, Japan
| | - Yoshikazu Matsuoka
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Shikata-cho, Kita-ku, Okayama, Japan
| | - Tatsuo Iwasaki
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Shikata-cho, Kita-ku, Okayama, Japan
| | - Tomoyuki Kanazawa
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Shikata-cho, Kita-ku, Okayama, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Shikata-cho, Kita-ku, Okayama, Japan
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Impact of guided weight-based medication dosing in pediatric patients with obesity. J Am Pharm Assoc (2003) 2023; 63:873-877. [PMID: 36870938 DOI: 10.1016/j.japh.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/06/2023] [Accepted: 02/09/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND Obesity is a common disease state within pediatrics, with 19.7% of children in the United States classified as obese. Medication dosing in this population is a challenge not commonly examined in clinical drug trials. Dosing based on total body weight may not always be appropriate; therefore, ideal body weight (IBW) and adjusted body weight (AdjBW) may provide more effective dosing. OBJECTIVE The goal was to implement a dosing protocol for pediatric patients with obesity to improve adherence. The primary endpoint was to evaluate adherence to evidence-based dosing recommendations and the secondary endpoints included cost saving analysis for immune globulin and accurate charting of IBW and AdjBW. METHODS This was a single center, quality improvement project composed of pre- and post-implementation groups. An IBW and AdjBW calculator were implemented in our electronic health record, as customized enhancements, along with specific weight ordering options. A literature search of pharmacokinetic and pharmacodynamic dosing recommendations based on IBW and AdjBW was conducted. For both groups, patients were included if they were 3-18 years old, had a body mass index greater than or equal to the 95th percentile, and if they received a specified medication. RESULTS A total of 618 patients were identified with 24 and 56 patients included for the pre- and post-implementation groups. There were no statistically significant differences in baseline characteristics of the comparator groups. The usage of correct body weight increased from 1.2% to 24.2% after implementation and education (P < 0.001). Cost savings was analyzed for immune globulin with the potential for a net savings of $9423 ± 3626.92. CONCLUSION Dosing medications for our pediatric patients with obesity improved with the implementation of calculated dosing weights in the electronic health record, provision of an evidence-based dosing chart, and education of providers.
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Daverio M, von Borell F, Ramelet AS, Sperotto F, Pokorna P, Brenner S, Mondardini MC, Tibboel D, Amigoni A, Ista E. Pain and sedation management and monitoring in pediatric intensive care units across Europe: an ESPNIC survey. Crit Care 2022; 26:88. [PMID: 35361254 PMCID: PMC8969245 DOI: 10.1186/s13054-022-03957-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/19/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Management and monitoring of pain and sedation to reduce discomfort as well as side effects, such as over- and under-sedation, withdrawal syndrome and delirium, is an integral part of pediatric intensive care practice. However, the current state of management and monitoring of analgosedation across European pediatric intensive care units (PICUs) remains unknown. The aim of this survey was to describe current practices across European PICUs regarding the management and monitoring of pain and sedation. METHODS An online survey was distributed among 357 European PICUs assessing demographic features, drug choices and dosing, as well as usage of instruments for monitoring pain and sedation. We also compared low- and high-volume PICUs practices. Responses were collected from January to April 2021. RESULTS A total of 215 (60% response rate) PICUs from 27 European countries responded. Seventy-one percent of PICUs stated to use protocols for analgosedation management, more frequently in high-volume PICUs (77% vs 63%, p = 0.028). First-choice drug combination was an opioid with a benzodiazepine, namely fentanyl (51%) and midazolam (71%) being the preferred drugs. The starting doses differed between PICUs from 0.1 to 5 mcg/kg/h for fentanyl, and 0.01 to 0.5 mg/kg/h for midazolam. Daily assessment and documentation for pain (81%) and sedation (87%) was reported by most of the PICUs, using the preferred validated FLACC scale (54%) and the COMFORT Behavioural scale (48%), respectively. Both analgesia and sedation were mainly monitored by nurses (92% and 84%, respectively). Eighty-six percent of the responding PICUs stated to use neuromuscular blocking agents in some scenarios. Monitoring of paralysed patients was preferably done by observation of vital signs with electronic devices support. CONCLUSIONS This survey provides an overview of current analgosedation practices among European PICUs. Drugs of choice, dosing and assessment strategies were shown to differ widely. Further research and development of evidence-based guidelines for optimal drug dosing and analgosedation assessment are needed.
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Affiliation(s)
- Marco Daverio
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Florian von Borell
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
- Department of Pediatric and Adolescent Medicine, University Clinic Carl Gustav Carus, Dresden, Germany
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland.
| | - Francesca Sperotto
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paula Pokorna
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Intensive Care and Department of Paediatric Surgery, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Sebastian Brenner
- Department of Pediatric and Adolescent Medicine, University Clinic Carl Gustav Carus, Dresden, Germany
| | - 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
- Department of Woman's and Child's Health, IRCCS University Hospital of Bologna Policlinico S.Orsola, Bologna, Italy
| | - Dick Tibboel
- Pediatric Intensive Care Unit, Department of Pediatric Surgery, • Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Erwin Ista
- Pediatric Intensive Care Unit, Department of Pediatric Surgery, • Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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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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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: 6.0] [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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Yet That the World May Witness: The Trilogy Concludes for the Prevalence of Acute Rehabilitation for Kids in the PICU Study. Pediatr Crit Care Med 2021; 22:221-223. [PMID: 33528199 DOI: 10.1097/pcc.0000000000002629] [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: 10/22/2022]
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Devsam BU, Kinney S. The clinical utility of the pain assessment tool in ventilated, sedated, and muscle-relaxed neonates. Aust Crit Care 2020; 34:333-339. [PMID: 33223388 DOI: 10.1016/j.aucc.2020.09.005] [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: 11/24/2019] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The neonatal Pain Assessment Tool (PAT) is considered a reliable and valid tool for assessing neonatal pain. No research has been conducted on the clinical utility of the PAT when assessing pain in ventilated, sedated, and muscle-relaxed neonates. OBJECTIVE The objective of the study was to determine the clinical utility of the PAT when assessing pain in ventilated, sedated, and muscle-relaxed neonates. METHODS Neonatal nurses from the Royal Children's Hospital completed online surveys to assess the clinical utility of the PAT. Three focus groups were then conducted to further explore the variation of pain scores from the survey and clarify the challenges in interpreting the pain score. RESULTS Nurses perceived the PAT clinically useful in neonates who were ventilated and minimally sedated. However, the PAT was not clinically useful in neonates who were ventilated and heavily sedated or muscle-relaxed. Further exploration via focus groups highlighted two themes related to the 'variation in the timing of the pain score' and the 'integration of critical thinking and judgement' used when assessing pain in neonates. CONCLUSIONS The clinical utility of the PAT is acceptable for minimally sedated neonates; however, it decreases the more sedated a neonate becomes, and the PAT's usefulness is extremely poor in the muscle-relaxed neonate. A better understanding of the timing and interpretation of the pain score in relation to the neonate's clinical status may enable improved decision-making and pain management. The PAT requires further validity, reliability, and clinical utility research, particularly in critically ill and muscle-relaxed neonates.
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Affiliation(s)
- Bianca U Devsam
- Neonatal Intensive Care Unit (Butterfly Ward), The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, Victoria, 3052, Australia; Nursing Research Department, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, Victoria, 3052, Australia; Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Victoria, 3010, Australia.
| | - Sharon Kinney
- Nursing Research Department, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, Victoria, 3052, Australia; Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Victoria, 3010, Australia
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Koizumi T, Kurosawa H. Survey of analgesia and sedation in pediatric intensive care units in Japan. Pediatr Int 2020; 62:535-541. [PMID: 31910495 DOI: 10.1111/ped.14139] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 12/20/2019] [Accepted: 12/27/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND High-quality evidence of analgesia and sedation management in pediatric intensive care units (PICUs) is lacking. METHODS An online survey concerning the institutional management of pain, sedation, delirium, and withdrawal syndrome, as well as non-pharmacological interventions to reduce pain and / or to provide comfort, was conducted with the medical directors of 31 PICUs in Japan. The survey was conducted from September to November 2016. RESULTS The response rate was 77% (24/31). Pain was routinely assessed in nine (38%) PICUs. Self-report pain scales were used in 14 (58%) PICUs. Observational pain scales for children who were unable to self-report were used in only one PICU. Physician-driven analgesia protocols were used in two (8%) PICUs. Although sedation scales for intubated patients were used in 15 (63%) PICUs, they were used for the goal-directed sedation management in nine (38%). Nurse-driven sedation protocols were used in two (8%) PICUs. Five (21%) PICUs used delirium assessment tools, and delirium screening was not routinely done in any PICU. Five (21%) PICUs regularly used withdrawal assessment tools for a high-risk group of patients with withdrawal syndrome. Non-pharmacological interventions for analgesia and comfort were frequently practiced for mechanically ventilated patients. CONCLUSIONS This study is the first survey conducted by physicians regarding pain and agitation management in PICUs in Japan, and the results revealed great diversity in practice. The implementation strategies to assess pain, delirium, and withdrawal syndrome, as well as to set goals regarding sedation level, are lacking. Protocols for analgesia and sedation management are uncommon.
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Affiliation(s)
- Taku Koizumi
- Department of Intensive Care Medicine, Miyagi Children's Hospital, Sendai, Miyagi, Japan
| | - Hiroshi Kurosawa
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
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Abstract
Abstract
Postoperative residual neuromuscular block has been recognized as a potential problem for decades, and it remains so today. Traditional pharmacologic antagonists (anticholinesterases) are ineffective in reversing profound and deep levels of neuromuscular block; at the opposite end of the recovery curve close to full recovery, anticholinesterases may induce paradoxical muscle weakness. The new selective relaxant-binding agent sugammadex can reverse any depth of block from aminosteroid (but not benzylisoquinolinium) relaxants; however, the effective dose to be administered should be chosen based on objective monitoring of the depth of neuromuscular block.
To guide appropriate perioperative management, neuromuscular function assessment with a peripheral nerve stimulator is mandatory. Although in many settings, subjective (visual and tactile) evaluation of muscle responses is used, such evaluation has had limited success in preventing the occurrence of residual paralysis. Clinical evaluations of return of muscle strength (head lift and grip strength) or respiratory parameters (tidal volume and vital capacity) are equally insensitive at detecting neuromuscular weakness. Objective measurement (a train-of-four ratio greater than 0.90) is the only method to determine appropriate timing of tracheal extubation and ensure normal muscle function and patient safety.
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10
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The Challenges of Providing Effective Pain Management for Children in the Pediatric Intensive Care Unit. Pain Manag Nurs 2016; 17:372-383. [DOI: 10.1016/j.pmn.2016.08.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 08/16/2016] [Accepted: 08/22/2016] [Indexed: 11/20/2022]
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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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Sahni M, Richardson CJ, Jain SK. Sustained Neuromuscular Blockade after Vecuronium Use in a Premature Infant. AJP Rep 2015; 5:e121-3. [PMID: 26495168 PMCID: PMC4603855 DOI: 10.1055/s-0035-1549297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Accepted: 02/25/2015] [Indexed: 11/29/2022] Open
Abstract
Background Prolonged use of neuromuscular blocking agents (NMBAs) is very common in critically ill children both in pediatric and neonatal intensive care units. There are no guidelines available for use of NMBAs in children or neonates in the US, and the data for their safety in this age group is limited. Case Description Our case describes prolonged neuromuscular blockade following concurrent use of a NMBA along with aminoglycosides and steroids in the setting of renal failure in a premature infant. Conclusion Prolonged use of NMBAs in preterm infants should be avoided if possible or should be restricted to the shortest possible duration and the smallest possible physiologically effective dose. Concurrent use of NMBAs with aminoglycoside and steroids should be avoided, especially in the setting of renal failure.
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Affiliation(s)
- Mitali Sahni
- Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas
| | - C Joan Richardson
- Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas
| | - Sunil K Jain
- Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas
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Effect of administration of neuromuscular blocking agents in children with severe traumatic brain injury on acute complication rates and outcomes: a secondary analysis from a randomized, controlled trial of therapeutic hypothermia. Pediatr Crit Care Med 2015; 16:352-8. [PMID: 25599147 PMCID: PMC4424136 DOI: 10.1097/pcc.0000000000000344] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate the association between neuromuscular blocking agents and outcome, intracranial pressure, and medical complications in children with severe traumatic brain injury. DESIGN A secondary analysis of a randomized, controlled trial of therapeutic hypothermia. SETTING Seventeen hospitals in the United States, Australia, and New Zealand. PATIENTS Children (< 18 yr) with severe traumatic brain injury. INTERVENTIONS None for this secondary analysis. MEASUREMENTS AND MAIN RESULTS Children received neuromuscular blocking agent on the majority of days of the study (69.6%), and the modified Pediatric Intensity Level of Therapy scores (modified by removing neuromuscular blocking agent administration from the score) were increased on days when neuromuscular blocking agents were used (9.67 ± 0.21 vs 5.48 ± 0.26; p < 0.001). Children were stratified into groups based on exposure to neuromuscular blocking agents (group 1 received neuromuscular blocking agents each study day; group 2 did not). Group 1 had increased number of daily intracranial pressure readings more than 20 mm Hg (4.4 ± 1.1 vs 2.4 ± 0.5;p = 0.015) and longer ICU and hospital length of stay (p = 0.003 and 0.07, respectively, Kaplan-Meier). The Glasgow Outcome Score-Extended for Pediatrics at hospital discharge and 3, 6, and 12 months after traumatic brain injury and medical complications observed during the acute hospitalization were similar between groups. CONCLUSIONS Administration of neuromuscular blocking agents was ubiquitous and daily administration of neuromuscular blocking agents was associated with intracranial hypertension but not outcomes-likely indicating that increased injury severity prompted their use. Despite this, neuromuscular blocking agent use was not associated with complications. A different study design-perhaps using randomization or methodologies-of a larger cohort will be required to determine if neuromuscular blocking agent use is helpful after severe traumatic brain injury in children.
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14
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Edwards H, Dunlop M, Mallick A, O'Callaghan F. Outcomes following childhood arterial ischaemic stroke: a Delphi Consensus on what parents want from future research. Eur J Paediatr Neurol 2015; 19:181-7. [PMID: 25559069 DOI: 10.1016/j.ejpn.2014.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 12/05/2014] [Accepted: 12/09/2014] [Indexed: 12/29/2022]
Abstract
AIM Currently there are few population-based data on the outcomes of stroke in childhood, and no data on what parents want from such research. We conducted a Delphi Consensus Process among parents of children (n = 26) who had suffered an arterial ischaemic stroke to investigate which research outcomes they think are most important to follow up, and what methods of assessment they would find most acceptable. METHODS A postal Delphi Consensus Process was conducted. RESULTS The Delphi panel reached consensus that motor, cognitive and communication outcomes are the most important outcome domains to assess. They strongly preferred home visits over hospital visits or telephone interview. The majority were happy with assessment visits lasting up to 1.5 h. Ongoing concerns for panel members related to the cause of the original stroke, the risk of recurrence and the long term outcome for their child. INTERPRETATION Future outcome studies should preferably assess outcomes at home and focus on children's motor, cognitive and communication abilities. There is an ongoing need to clarify issues with regards to the likely cause of children's strokes and their risk of recurrence.
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Affiliation(s)
- Hannah Edwards
- University of Bristol, Paediatric Neurology Department, Level 6 Education Centre, Upper Maudlin Street, Bristol BS2 8AE, UK.
| | - Melissa Dunlop
- University of Bristol, Paediatric Neurology Department, Level 6 Education Centre, Upper Maudlin Street, Bristol BS2 8AE, UK.
| | - Andrew Mallick
- University Hospitals Bristol NHS Foundation Trust, Bristol Children's Hospital, Paediatric Neurology Department, Level 6 Education Centre, Upper Maudlin Street, Bristol BS2 8AE, UK.
| | - Finbar O'Callaghan
- University College London, UCL - Institute of Child Health, Neurosciences Unit, 4-5 Long Yard, London WC1N 3LU, UK. f.o'
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15
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Honsel M, Giugni C, Brierley J. Limited professional guidance and literature are available to guide the safe use of neuromuscular block in infants. Acta Paediatr 2014; 103:e370-3. [PMID: 24813671 PMCID: PMC4228760 DOI: 10.1111/apa.12682] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 05/06/2014] [Indexed: 11/26/2022]
Abstract
AIM Neuromuscular blocking agents (NMBAs) are used in a range of critical illnesses in neonates and infants, despite a lack of guidelines and professional standards. This study reviewed the current evidence base and ascertained UK practice regarding the continuous use of these agents in this age range. METHODS We reviewed the literature and carried out a telephone questionnaire of all tertiary units in England and specialist children's hospital neonatal units in the UK. RESULTS No best practice guidelines or general consensus statements were found, and the only randomised trial to feature an NMBA protocol expressed concerns about its use in such young babies. Of the 56 units contacted, 54 (96.4%) shared information. Only three of the 56 (5.4%) used intermittent boluses of NMBAs, 91.1% used NMBA infusions, 11 (19.6%) routinely used regular neuromuscular blocker pause to assess depth, and only one (1.8%) used peripheral nerve stimulation monitoring. All the units carried out clinical assessments, but only one (1.8%) had a written protocol. CONCLUSION There is a paucity of literature and professional standards to guide the safe use of NMBAs in infants. Of the 54 units who participated in the survey, only one had a protocol for using NMBAs in babies.
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Affiliation(s)
- Maik Honsel
- Paediatric and Neonatal Intensive Care Unit; Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
| | - Cristina Giugni
- Paediatric and Neonatal Intensive Care Unit; Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
| | - Joe Brierley
- Paediatric and Neonatal Intensive Care Unit; Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
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16
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Kasdorf E, Engel M, Perlman JM. Amplitude electroencephalogram characterization in preterm infants undergoing patent ductus arteriosus ligation. Pediatr Neurol 2013; 49:102-6. [PMID: 23859855 DOI: 10.1016/j.pediatrneurol.2013.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 02/25/2013] [Accepted: 03/09/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Recent studies suggest an increased risk of neurodevelopmental impairment following patent ductus arteriosus surgical ligation. The mechanisms are unclear, but intraoperative stress or pain may contribute. The objectives of this study were to determine if pain, evidenced by an increase in heart rate and blood pressure, during patent ductus arteriosus ligation would be accompanied by an increase in amplitude-integrated electroencephalogram (aEEG) voltage. METHODS This was an observational, pilot study of infants born at 22.6-35.1 weeks with patent ductus arteriosus requiring surgical ligation. The aEEG was recorded prior to, during surgery, and for 2 hours following surgery. Mean heart rate, blood pressure, and aEEG voltage were analyzed for each recording period. RESULTS Seventeen preterm infants were studied at a mean postmenstrual age of 26.6 weeks. Following anesthetic induction, aEEG became suppressed and remained suppressed during the postoperative period. Heart rate and blood pressure increased significantly intraoperatively. The aEEG voltage did not increase with an increase in heart rate. Infants received between 3.7-47 μg/kg of fentanyl. CONCLUSIONS There was no correlation between aEEG voltage and vital sign changes. aEEG is not a useful tool as a marker of pain during patent ductus arteriosus ligation, rather a more standardized approach to pain management should be considered.
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Affiliation(s)
- Ericalyn Kasdorf
- Department of Pediatrics, Division of Newborn Medicine, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, USA.
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17
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Deindl P, Unterasinger L, Kappler G, Werther T, Czaba C, Giordano V, Frantal S, Berger A, Pollak A, Olischar M. Successful implementation of a neonatal pain and sedation protocol at 2 NICUs. Pediatrics 2013; 132:e211-8. [PMID: 23733799 DOI: 10.1542/peds.2012-2346] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate the implementation of a neonatal pain and sedation protocol at 2 ICUs. METHODS The intervention started with the evaluation of local practice, problems, and staff satisfaction. We then developed and implemented the Vienna Protocol for Neonatal Pain and Sedation. The protocol included well-defined strategies for both nonpharmacologic and pharmacologic interventions based on regular assessment of a translated version of the Neonatal Pain Agitation and Sedation Scale and titration of analgesic and sedative therapy according to aim scores. Health care staff was trained in the assessment by using a video-based tutorial and bedside teaching. In addition, we performed reevaluation, retraining, and random quality checks. Frequency and quality of assessments, pharmacologic therapy, duration of mechanical ventilation, and outcome were compared between baseline (12 months before implementation) and 12 months after implementation. RESULTS Cumulative median (interquartile range) opiate dose (baseline dose of 1.4 [0.5-5.9] mg/kg versus intervention group dose of 2.7 [0.4-57] mg/kg morphine equivalents; P = .002), pharmacologic interventions per episode of continuous sedation/analgesia (4 [2-10] vs 6 [2-13]; P = .005), and overall staff satisfaction (physicians: 31% vs 89%; P < .001; nurses: 17% vs 55%; P < .001) increased after implementation. Time on mechanical ventilation, length of stay at the ICU, and adverse outcomes were similar before and after implementation. CONCLUSIONS Implementation of a neonatal pain and sedation protocol at 2 ICUs resulted in an increase in opiate prescription, pharmacologic interventions, and staff satisfaction without affecting time on mechanical ventilation, length of intensive care stay, and adverse outcomes.
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Affiliation(s)
- Philipp Deindl
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neonatology, Intensive Care, and Neuropediatrics, Medical University of Vienna, Vienna, Austria.
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18
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Opioid analgesia in mechanically ventilated children: results from the multicenter Measuring Opioid Tolerance Induced by Fentanyl study. Pediatr Crit Care Med 2013; 14:27-36. [PMID: 23132396 PMCID: PMC3581608 DOI: 10.1097/pcc.0b013e318253c80e] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the clinical factors associated with increased opioid dose among mechanically ventilated children in the pediatric intensive care unit. DESIGN Prospective, observational study with 100% accrual of eligible patients. SETTING Seven pediatric intensive care units from tertiary-care children's hospitals in the Collaborative Pediatric Critical Care Research Network. PATIENTS Four hundred nineteen children treated with morphine or fentanyl infusions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data on opioid use, concomitant therapy, demographic and explanatory variables were collected. Significant variability occurred in clinical practices, with up to 100-fold differences in baseline opioid doses, average daily or total doses, or peak infusion rates. Opioid exposure for 7 or 14 days required doubling of the daily opioid dose in 16% patients (95% confidence interval 12%-19%) and 20% patients (95% confidence interval 16%-24%), respectively. Among patients receiving opioids for longer than 3 days (n = 225), this occurred in 28% (95% confidence interval 22%-33%) and 35% (95% confidence interval 29%-41%) by 7 or 14 days, respectively. Doubling of the opioid dose was more likely to occur following opioid infusions for 7 days or longer (odds ratio 7.9, 95% confidence interval 4.3-14.3; p < 0.001) or co-therapy with midazolam (odds ratio 5.6, 95% confidence interval 2.4-12.9; p < 0.001), and it was less likely to occur if morphine was used as the primary opioid (vs. fentanyl) (odds ratio 0.48, 95% confidence interval 0.25-0.92; p = 0.03), for patients receiving higher initial doses (odds ratio 0.96, 95% confidence interval 0.95-0.98; p < 0.001), or if patients had prior pediatric intensive care unit admissions (odds ratio 0.37, 95% confidence interval 0.15-0.89; p = 0.03). CONCLUSIONS Mechanically ventilated children require increasing opioid doses, often associated with prolonged opioid exposure or the need for additional sedation. Efforts to reduce prolonged opioid exposure and clinical practice variation may prevent the complications of opioid therapy.
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Validation of the COMFORT Behavior Scale and the FLACC Scale for Pain Assessment in Chinese Children after Cardiac Surgery. Pain Manag Nurs 2012; 13:18-26. [DOI: 10.1016/j.pmn.2010.07.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Revised: 07/02/2010] [Accepted: 07/04/2010] [Indexed: 11/16/2022]
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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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21
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Abstract
In recent years, the importance of appropriate intra-operative anesthesia and analgesia during cardiac surgery has become recognized as a factor in postoperative recovery. This includes the early perioperative management of the neonate undergoing radical surgery and more recently the care surrounding fast-track and ultra fast-track surgery. However, outside these areas, relatively little attention has focused on postoperative sedation and analgesia within the pediatric intensive care unit (PICU). This reflects perceived priorities of the primary disease process over the supporting structure of PICU, with a generic approach to sedation and analgesia that can result in additional morbidities and delayed recovery. Management of the marginal patient requires optimisation of not only cardiac and other attendant pathophysiology, but also every aspect of supportive care. Individualized sedation and analgesia strategies, starting in the operating theater and continuing through to hospital discharge, need to be regarded as an important aspect of perioperative care, to speed the process of recovery.
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Affiliation(s)
- Andrew R Wolf
- Paediatric Intensive Care Unit, Bristol Children's Hospital, Upper Maudlin Street, Bristol, UK.
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22
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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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Mostad U, Fasting S. [Paediatric intensive care]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:40-3. [PMID: 20094123 DOI: 10.4045/tidsskr.08.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Child physiology and disease is not the same as in adults, which implies different challenges within intensive care. The aim of this review article is to shed light on special diagnostic and therapeutic problems in paediatric intensive care. MATERIAL AND METHODS The review is based on literature identified through a non-systematic search in PubMed, and on the authors' own clinical experience. RESULTS Common causes for admitting children to intensive care units are head injuries; septic shock and respiratory failure. Perfusion-directed therapy of severe traumatic head injuries is well recognized, but optimal age-appropriate cut-off values have yet to be defined for cerebral perfusion pressure and intracranial pressure. Therapeutic hypothermia is still controversial and the latest study concludes against this option. Paediatric septic shock is usually caused by low cardiac output, and dopamine or adrenaline are the most suitable agents for pharmacological circulation support, in contradiction to treatment in adults for whom noradrenaline is the preferred vasopressor because of dominating vasoplegia. Activated protein C is not recommended in children. Non-invasive pressure ventilation is used increasingly in children with respiratory failure. The authors have experienced that this reduces the need for intubation, but it has not been documented in studies. Development of tolerance, withdrawal symptoms and physical dependency are substantial clinical problems in long-term sedation and analgesic treatment of children, and are associated with high doses and long duration of infusions. INTERPRETATION Paediatric intensive care is different from that in adults. Therapy is more based on experience than evidence from well-designed clinical studies.
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Affiliation(s)
- Ulf Mostad
- Klinikk for anestesi og akuttmedisin, St. Olavs hospital, 7006 Trondheim, Norway.
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Hammer GB. Sedation and analgesia in the pediatric intensive care unit following laryngotracheal reconstruction. Paediatr Anaesth 2009; 19 Suppl 1:166-79. [PMID: 19572854 DOI: 10.1111/j.1460-9592.2009.03000.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Children undergoing laryngotracheal reconstruction (LTR) may remain electively intubated in the pediatric intensive care unit (PICU) for several days following surgery to facilitate wound healing. These patients require sedation and analgesia with or without neuromuscular blockade in order to prevent excessive head and neck movement with resultant tension on the tracheal anastomosis. Achieving this level of immobility features in caring for these children. AIM The aims of this article are to describe a variety of commonly used sedation and analgesic agents and to provide guidance as to their optimal use following LTR.
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Affiliation(s)
- Gregory B Hammer
- Anesthesiology and Pediatrics, Department of Anesthesia, Stanford University School of Medicine, University Medical Center, 300 Pasteur Drive, Stanford, CA 94305-5640, USA.
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