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Vallabhaneni P, Khera D, Choudhary B, Singh S, Singh K, Didel S, Saurabh S, Toteja N. Protocolized Sedation Utilizing COMFORT-B Scale versus Non-protocol-directed Sedation in Mechanically Ventilated Children - An Open-label, Randomized Controlled Trial. Indian J Pediatr 2024; 91:845-847. [PMID: 38060153 DOI: 10.1007/s12098-023-04959-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 11/17/2023] [Indexed: 12/08/2023]
Abstract
This study aimed to determine the effect of protocolized sedation using the COMFORT-B scale on the duration of mechanical ventilation (DMV). Eighty children with anticipated Duration of mechanical ventilation (DMV) >24 h admitted to the Pediatric intensive care unit (PICU) were randomized into one group that received protocolized sedation (PS) using the COMFORT behavioural (COMFORT-B) scale, and another group that received non-protocolized sedation (NPS). The primary outcome was the impact on the DMV. The DMV was significantly lower in PS (PS: 3.5 [3-7] vs. NPS group: 8.5 [4.25-13.75] d; p = 0.008). The cumulative dose and duration of fentanyl in the PS group was significantly lower (median [IQR]; 120 [62.88-279.12] vs. 320.4 [110.88-851.52] μg/kg; p = 0.007 and 4 [2.25-7.75] vs. 8 [4-17.5] d; p = 0.009, respectively). The authors found a decrease in DMV and sedation related adverse events (SRAE) like ventilator associated pneumonia (VAP), accidental extubation, post-extubation stridor and dose and duration of sedative agents with PS.
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Affiliation(s)
- Pujitha Vallabhaneni
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Daisy Khera
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Jodhpur, India.
| | - Bharat Choudhary
- Department of Trauma and Emergency (Pediatrics), All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Surjit Singh
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Kuldeep Singh
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Siyaram Didel
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Suman Saurabh
- Department of Community and Family Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Nisha Toteja
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Guwahati, India
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Kolmar AR, Kerley L, Melliere MG, Fuller BM. Sedation Experiences of Pediatric Intensive Care Nurses: Exploring PICU Nurse Perspectives on Sedative Management and Communication. J Intensive Care Med 2024:8850666241266475. [PMID: 39043371 DOI: 10.1177/08850666241266475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
Objective: This study's purpose is to better understand pediatric intensive care nursing perspectives on sedative management as a precursor to improving aspects of sedation assessment, titration, and communication. Methods/Design: We queried nurses in the pediatric intensive care unit at a 40+ bed quaternary care using an electronic survey about their experiences with sedation management. Data was collected using REDCap and statistical analyses were performed to assess for differences between experience levels in areas. Results: Seventy nurses responded with 42% response rate. More than 95% were comfortable calculating sedation and delirium scores. Those with less than 5 years' experience were significantly more likely to consider sedation scores helpful (P = .04) and also significant more likely to agree that delirium scores are used effectively (P = .01). Eighty-eight percent of respondents were comfortable raising concerns about sedation to the multidisciplinary team, but those with less than 5 years' experience were significantly less likely to express concerns to attending (P = .001). Conclusion: Newer nurses are more inclined to support use of standardized scoring systems for sedation and delirium, but less comfortable approaching attending clinicians with their concerns. Intensive care teams should pay careful attention to team dynamics, particularly as they apply to sedative management and work to improve communication, collaboration, and educational interventions to improve patient care. Further work understanding nursing perspectives and further attempts to improve interprofessional communication seems a wise investment and could obviate barriers that may exist.
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Affiliation(s)
- Amanda R Kolmar
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, MO, USA
| | - Lindsey Kerley
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, MO, USA
| | - M Grace Melliere
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, MO, USA
| | - Brian M Fuller
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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MacDonald I, de Goumoëns V, Marston M, Alvarado S, Favre E, Trombert A, Perez MH, Ramelet AS. Effectiveness, quality and implementation of pain, sedation, delirium, and iatrogenic withdrawal syndrome algorithms in pediatric intensive care: a systematic review and meta-analysis. Front Pediatr 2023; 11:1204622. [PMID: 37397149 PMCID: PMC10313131 DOI: 10.3389/fped.2023.1204622] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/15/2023] [Indexed: 07/04/2023] Open
Abstract
Background Pain, sedation, delirium, and iatrogenic withdrawal syndrome are conditions that often coexist, algorithms can be used to assist healthcare professionals in decision making. However, a comprehensive review is lacking. This systematic review aimed to assess the effectiveness, quality, and implementation of algorithms for the management of pain, sedation, delirium, and iatrogenic withdrawal syndrome in all pediatric intensive care settings. Methods A literature search was conducted on November 29, 2022, in PubMed, Embase, CINAHL and Cochrane Library, ProQuest Dissertations & Theses, and Google Scholar to identify algorithms implemented in pediatric intensive care and published since 2005. Three reviewers independently screened the records for inclusion, verified and extracted data. Included studies were assessed for risk of bias using the JBI checklists, and algorithm quality was assessed using the PROFILE tool (higher % = higher quality). Meta-analyses were performed to compare algorithms to usual care on various outcomes (length of stay, duration and cumulative dose of analgesics and sedatives, length of mechanical ventilation, and incidence of withdrawal). Results From 6,779 records, 32 studies, including 28 algorithms, were included. The majority of algorithms (68%) focused on sedation in combination with other conditions. Risk of bias was low in 28 studies. The average overall quality score of the algorithm was 54%, with 11 (39%) scoring as high quality. Four algorithms used clinical practice guidelines during development. The use of algorithms was found to be effective in reducing length of stay (intensive care and hospital), length of mechanical ventilation, duration of analgesic and sedative medications, cumulative dose of analgesics and sedatives, and incidence of withdrawal. Implementation strategies included education and distribution of materials (95%). Supportive determinants of algorithm implementation included leadership support and buy-in, staff training, and integration into electronic health records. The fidelity to algorithm varied from 8.2% to 100%. Conclusions The review suggests that algorithm-based management of pain, sedation and withdrawal is more effective than usual care in pediatric intensive care settings. There is a need for more rigorous use of evidence in the development of algorithms and the provision of details on the implementation process. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021276053, PROSPERO [CRD42021276053].
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Affiliation(s)
- Ibo MacDonald
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
| | - Véronique de Goumoëns
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
- Bureau d’Echange des Savoirs pour des praTiques exemplaires de soins (BEST) a JBI Center of Excellence, Lausanne, Switzerland
| | - Mark Marston
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Silvia Alvarado
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Eva Favre
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Department of Adult Intensive Care, Lausanne University Hospital, Lausanne, Switzerland
| | - Alexia Trombert
- Medical Library, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Maria-Helena Perez
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Bureau d’Echange des Savoirs pour des praTiques exemplaires de soins (BEST) a JBI Center of Excellence, Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
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Smith-Parrish M, Vargas Chaves DP, Taylor K, Achuff BJ, Lasa JJ, Hopper A, Ramamoorthy C. Analgesia, Sedation, and Anesthesia for Neonates With Cardiac Disease. Pediatrics 2022; 150:189889. [PMID: 36317978 DOI: 10.1542/peds.2022-056415k] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Abstract
Analgesia, sedation, and anesthesia are a continuum. Diagnostic and/or therapeutic procedures in newborns often require analgesia, sedation, and/or anesthesia. Newborns, in general, and, particularly, those with heart disease, have an increased risk of serious adverse events, including mortality under anesthesia. In this section, we discuss the assessment and management of pain and discomfort during interventions, review the doses and side effects of commonly used medications, and provide recommendations for their use in newborns with heart disease. For procedures requiring deeper levels of sedation and anesthesia, airway and hemodynamic support might be necessary. Although associations of long-term deleterious neurocognitive effects of anesthetic agents have received considerable attention in both scientific and lay press, causality is not established. Nonetheless, an early multimodal, multidisciplinary approach is beneficial for safe management before, during, and after interventional procedures and surgery to avoid problems of tolerance and delirium, which can contribute to long-term cognitive dysfunction.
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Affiliation(s)
- Melissa Smith-Parrish
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | | | - Barbara-Jo Achuff
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Javier J Lasa
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Andrew Hopper
- Loma Linda University Children's Hospital, Loma Linda, California
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Michel J, Sauter L, Neunhoeffer F, Hofbeck M, Kumpf M, Paulsen F, Schmidt A, Fuchs J. Sedation practices during high dose rate brachytherapy for children with urogenital and perianal rhabdomyosarcoma. J Pediatr Surg 2022; 57:1432-1438. [PMID: 33189299 DOI: 10.1016/j.jpedsurg.2020.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/19/2020] [Accepted: 10/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND A novel concept for an organ-preserving treatment of pediatric urogenital and perianal rhabdomyosarcoma includes high dose rate brachytherapy following surgical tumor resection. For the duration of the brachytherapy of 6 days plus 2-day recovery break the patients are not allowed to move and are kept under deep sedation, which can lead to difficult weaning from mechanical ventilation, withdrawal, delirium, and prolonged hospital stay. The aim of this study was to evaluate a protocol which includes a switch from fentanyl to ketamine 3 days prior to extubation to help ensure a rapid extubation and transfer from PICU. METHODS Patients who underwent surgical tumor resection of rhabdomyosarcoma and subsequent brachytherapy were treated according to a standardized protocol. We evaluated doses of fentanyl, midazolam and clonidine, time of extubation, length of PICU stay and occurrence of withdrawal symptoms and delirium. We compared fentanyl dose at time of extubation, duration of weaning from mechanical ventilation and time to discharge from PICU with patients after isolated severe traumatic brain injury. RESULTS Twentytwo patients (age 39.9 ± 29.8 months) were treated in our PICU to undergo brachytherapy. Extubation was performed 21.6 ± 13.5 h after the last brachytherapy session with an average fentanyl dose of 1.5 ± 0.5 µg/kg/h and patients were discharged from PICU 58.4 ± 30.3 h after extubation, which all is significantly lower compared to the control group (extubation after 88.0 ± 42.2 h, p < 0.001; fentanyl dose at the time of extubation 2.5 ± 0.6 µg/kg/h, p < 0.001; PICU discharge after 130.1 ± 148.4 h, p < 0.009). Withdrawal symptoms were observed in 9 patients and delirium in 13 patients. CONCLUSION A standardized analgesia and sedation protocol including an opioid break, scoring systems to detect withdrawal symptoms and delirium, and tapering plans contributes to successful early extubation and discharge from PICU after long-term deep sedation.
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Affiliation(s)
- Jörg Michel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany.
| | - Luisa Sauter
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - Andreas Schmidt
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany
| | - Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany
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Engel J, von Borell F, Baumgartner I, Kumpf M, Hofbeck M, Michel J, Neunhoeffer F. Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like? Front Pediatr 2022; 10:886334. [PMID: 35586826 PMCID: PMC9108250 DOI: 10.3389/fped.2022.886334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 04/11/2022] [Indexed: 11/24/2022] Open
Abstract
Background and Significance Advances in pediatric intensive care have led to markedly improved survival rates in critically ill children. Approximately 70% of those children survive with varying forms of complex chronic diseases or impairment/disabilities. Length of stay, length of mechanical ventilation and number of interventions per patient are increasing with rising complexity of underlying diseases, leading to increasing pain, agitation, withdrawal symptoms, delirium, immobility, and sleep disruption. The ICU-Liberation Collaborative of the Society of Critical Care Medicine has developed a number of preventative measures for prevention, early detection, or treatment of physical and psychiatric/psychological sequelae of oftentimes traumatic intensive care medicine. These so called ABCDEF-Bundles consist of elements for (A) assessment, prevention and management of pain, (B) spontaneous awakening and breathing trials (SAT/SBT), (C) choice of analgesia and sedation, (D) assessment, prevention and management of delirium, (E) early mobility and exercise and (F) family engagement and empowerment. For adult patients in critical care medicine, research shows significant effects of bundle-implementation on survival, mechanical ventilation, coma, delirium and post-ICU discharge disposition. Research regarding PICS in children and possible preventative or therapeutic intervention is insufficient as yet. This narrative review provides available information for modification and further research on the ABCDEF-Bundles for use in critically ill children. Material and Methods A narrative review of existing literature was used. Results One obvious distinction to adult patients is the wide range of different developmental stages of children and the even closer relationship between patient and family. Evidence for pediatric ABCDEF-Bundles is insufficient and input can only be collected from literature regarding different subsections and topics. Conclusion In addition to efforts to improve analgesia, sedation and weaning protocols with the aim of prevention, early detection and effective treatment of withdrawal symptoms or delirium, efforts are focused on adjusting ABCDEF bundle for the entire pediatric age group and on strengthening families' decision-making power, understanding parents as a resource for their child and involving them early in the care of their children.
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Affiliation(s)
- Juliane Engel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Florian von Borell
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Isabella Baumgartner
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Jörg Michel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
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Standardized Scoring Tool and Weaning Guideline to Reduce Opioids in Critically Ill Neonates. Pediatr Qual Saf 2022; 7:e562. [PMID: 35720868 PMCID: PMC9197367 DOI: 10.1097/pq9.0000000000000562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/02/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Pain impacts brain development for neonates, causing deleterious neurodevelopmental outcomes. Prescription opioids for analgesia or sedation are common; however, prolonged opioid exposure in neonates is associated with neurodevelopmental impairment. Balancing the impact of inadequate pain control against prolonged opioid exposure in neonates is a clinical paradox. Therefore, we sought to decrease the average days of opioids used for analgesia or sedation in critically ill neonates at a level IV Neonatal Intensive Care Unit by 10% within 1 year. Methods A multidisciplinary quality improvement team used the model for improvement, beginning with a Pareto analysis, and identified a lack of consistent approach to weaning opioids as a primary driver for prolonged exposure. The team utilized 2 main interventions: (1) a standardized withdrawal assessment tool-1 and (2) a risk-stratified opioid weaning guideline. Results We demonstrated a reduction in mean opioid duration from 34.3 to 14.1 days, an increase in nursing withdrawal assessment tool-1 documentation from 20% to 90%, and an increase in the documented rationale for daily opioid dose in provider notes from 20% to 70%. Benzodiazepine use did not change. Conclusion Standardized withdrawal assessments combined with risk-stratified weaning guidelines can decrease opioid use in critically ill neonates.
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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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Recommendations for analgesia and sedation in critically ill children admitted to intensive care unit. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2022. [PMCID: PMC8853329 DOI: 10.1186/s44158-022-00036-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We aim to develop evidence-based recommendations for intensivists caring for children admitted to intensive care units and requiring analgesia and sedation. A panel of national paediatric intensivists expert in the field of analgesia and sedation and other specialists (a paediatrician, a neuropsychiatrist, a psychologist, a neurologist, a pharmacologist, an anaesthesiologist, two critical care nurses, a methodologist) started in 2018, a 2-year process. Three meetings and one electronic-based discussion were dedicated to the development of the recommendations (presentation of the project, selection of research questions, overview of text related to the research questions, discussion of recommendations). A telematic anonymous consultation was adopted to reach the final agreement on recommendations. A formal conflict-of-interest declaration was obtained from all the authors. Eight areas of direct interest and one additional topic were considered to identify the best available evidence and to develop the recommendations using the Evidence-to-Decision framework according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. For each recommendation, the level of evidence, the strength of the recommendation, the benefits, the harms and the risks, the benefit/harm balance, the intentional vagueness, the values judgement, the exclusions, the difference of the opinions, the knowledge gaps, and the research opportunities were reported. The panel produced 17 recommendations. Nine were evaluated as strong, 3 as moderate, and 5 as weak. Conclusion: a panel of national experts achieved consensus regarding recommendations for the best care in terms of analgesia and sedation in critically ill children.
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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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11
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Hazwani T, Al Ahmady A, Kazzaz Y, Al Smari A, Al Enizy S, Alali H. Implementation of a sedation protocol: a quality improvement project to enhance sedation management in the paediatric intensive care unit. BMJ Open Qual 2022; 11:bmjoq-2021-001501. [PMID: 34980589 PMCID: PMC8724811 DOI: 10.1136/bmjoq-2021-001501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 12/21/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Proper sedation is integral to ensuring the safety and comfort of children on mechanical ventilation (MV). Sedation protocols help to achieve this goal and reduce the duration of MV. We have observed varied sedation approaches, sedation score targets and sedative use by our physicians, which were manifested as oversedation and undersedation with associated accidental extubation. Hence, we aimed to implement a standardised sedation protocol and assess its impact on mechanically ventilated paediatric patients. METHODS A multidisciplinary quality improvement team was formed to develop and implement a standardised sedation protocol for mechanically ventilated paediatric patients. COMFORT-Behaviour (COMFORT-B) Scale score was used to assess the sedation targets and define undersedation, oversedation or adequate sedation. Our goal was to achieve adequate sedation during 90% of the sedation period. Based on the model for improvement methodology, we used plan-do-study-act cycles to develop, test and implement the new sedation protocol. RESULTS There was an immediate percentage increase in COMFORT-B Scale scores within the target sedation level, which was associated with a gradual decrease in the need for intermittent sedation doses over sedation infusion in the preimplementation, improvement and control phases (6.3, 4.9 and 3.1 sedation doses/12 hours/patient, respectively) to achieve adequate sedation target. CONCLUSIONS The standardisation of sedation protocols was safe and efficient, and improved the sedation quality in mechanically ventilated paediatric patients.
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Affiliation(s)
- Tarek Hazwani
- Department of Pediatrics, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia .,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Arwa Al Ahmady
- Nursing Service, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Yasser Kazzaz
- Department of Pediatrics, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abeer Al Smari
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Pharmaceutical Care Services, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Seham Al Enizy
- Nursing Service, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Hamza Alali
- Department of Pediatrics, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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12
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Yang Y, Geva A, Madden K, Mehta NM. Implementation Science in Pediatric Critical Care - Sedation and Analgesia Practices as a Case Study. Front Pediatr 2022; 10:864029. [PMID: 35859943 PMCID: PMC9289107 DOI: 10.3389/fped.2022.864029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022] Open
Abstract
Sedation and analgesia (SA) management is essential practice in the pediatric intensive care unit (PICU). Over the past decade, there has been significant interest in optimal SA management strategy, due to reports of the adverse effects of SA medications and their relationship to ICU delirium. We reviewed 13 studies examining SA practices in the PICU over the past decade for the purposes of reporting the study design, outcomes of interest, SA protocols used, strategies for implementation, and the patient-centered outcomes. We highlighted the paucity of evidence-base for these practices and also described the existing gaps in the intersection of implementation science (IS) and SA protocols in the PICU. Future studies would benefit from a focus on effective implementation strategies to introduce and sustain evidence-based SA protocols, as well as novel quasi-experimental study designs that will help determine their impact on relevant clinical outcomes, such as the occurrence of ICU delirium. Adoption of the available evidence-based practices into routine care in the PICU remains challenging. Using SA practice as an example, we illustrated the need for a structured approach to the implementation science in pediatric critical care. Key components of the successful adoption of evidence-based best practice include the assessment of the local context, both resources and barriers, followed by a context-specific strategy for implementation and a focus on sustainability and integration of the practice into the permanent workflow.
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Affiliation(s)
- Youyang Yang
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Alon Geva
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Kate Madden
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
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13
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Michel J, Schepan E, Hofbeck M, Engel J, Simma A, Neunhoeffer F. Implementation of a Delirium Bundle for Pediatric Intensive Care Patients. Front Pediatr 2022; 10:826259. [PMID: 35198518 PMCID: PMC8859429 DOI: 10.3389/fped.2022.826259] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/19/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Delirium represents the most common form of acute cerebral dysfunction in critical illness. The prevention, recognition, and treatment of delirium must become the focus of modern pediatric intensive care, as delirium can lead to increased morbidity and mortality. The aim of this study is to evaluate the impact of a delirium bundle consisting of mainly non-pharmacological measures. MATERIAL AND METHODS This is a pre-/post-implementation study in an interdisciplinary pediatric intensive care unit of a tertiary care university hospital. In the pre-implementation period, pediatric intensive care delirium was monitored using the Sophia Observation withdrawal Symptoms and Pediatric Delirium scale. After introduction of a delirium bundle consisting of non-pharmacological prevention and treatment measures a period of 4 months was interposed to train the PICU staff and ensure that the delirium bundle was implemented consistently before evaluating the effects in the post-implementation period. Data collection included prevalence of delirium and withdrawal, length of PICU stay, duration of mechanical ventilation, and cumulative dose of sedatives and analgesics. RESULTS A total of 792 critically ill children aged 0-18 years were included in this study. An overall delirium prevalence of 30% was recorded in the pre-implementation group and 26% in the post-implementation group (p = 0.13). A significant reduction in the prevalence of pediatric delirium from was achieved in the subgroup of patients under 5 years of age (27.9 vs. 35.8%, p = 0.04) and in patients after surgery for congenital heart disease (28.2 vs. 39.5%, p = 0.04). Young age, length of PICU stay, and iatrogenic withdrawal syndrome were found to be risk factors for developing delirium. CONCLUSIONS Based on a validated delirium monitoring, our study gives new information regarding the prevalence of pediatric delirium and the characteristics of intensive care patients at risk for this significant complication. Especially young patients and patients after surgery for congenital heart disease seem to benefit from the implementation of non-pharmacological delirium bundles. Based on our findings, it is important to promote change in pediatric intensive care-toward a comprehensive approach to prevent delirium in critically ill children as best as possible.
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Affiliation(s)
- Jörg Michel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Elena Schepan
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Juliane Engel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Alexander Simma
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
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14
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Balit CR, LaRosa JM, Ong JSM, Kudchadkar SR. Sedation protocols in the pediatric intensive care unit: fact or fiction? Transl Pediatr 2021; 10:2814-2824. [PMID: 34765503 PMCID: PMC8578750 DOI: 10.21037/tp-20-328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 03/03/2021] [Indexed: 11/06/2022] Open
Abstract
Comfort of the critically unwell pediatric patient is paramount to ensuring good outcomes. Analgesia-based, multimodal sedative approaches are the foundation for comfort, whereby pain is addressed first and then sedation titrated to a predefined target based on the goals of care. Given the heterogeneity of patients within the pediatric critical care population, the approach must be individualized based on the age and developmental stage of the child, physiologic status, and degree of invasive treatment required. In both the adult and pediatric intensive care unit (PICU), sedation titration is practiced as standard of care to meet therapeutic goals with a focus on facilitating early rehabilitation and extubation while avoiding under- and over-sedation. Sedation protocols have been developed as methods to reduce variability and optimize goal-directed therapy. Components of a sedation protocol include routine analgesia and sedation scoring with validated tools at specified intervals and a predefined algorithm that allows the titration of analgesia and sedation based on those assessments. Sedation protocols are designed to improve communication and documentation of sedation goals while also empowering the bedside team to respond rapidly to changes in a patient's clinical status. Previously it was thought that sedation protocols would consistently reduce duration of mechanical ventilation (MV) and length of stay (LOS) for patients in the PICU, however, this has not been the case. Nonetheless, introduction of sedation protocols has provided several benefits, including: (I) reduction in benzodiazepine usage; (II) improvements in interprofessional communication surrounding sedation goals and management of sedation goals; and (III) reductions in iatrogenic withdrawal symptoms. Successful implementation of sedation protocols requires passionate clinical champions and a robust implementation, education, and sustainability plan. Emerging evidence suggests that sedation protocols as part of a bundle of quality improvement initiatives will form the basis of future studies to improve short- and long-term outcomes after PICU discharge. In this review, we aim to define sedation protocols in the context of pediatric critical care and highlight important considerations for clinical practice and research.
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Affiliation(s)
- Corrine R Balit
- Paediatric Intensive Care Unit, John Hunter Hospital, Newcastle, Australia
| | - Jessica M LaRosa
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jacqueline S M Ong
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - 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
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15
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Pediatric Critical Care Nurses' Practices Related to Sedation and Analgesia. Dimens Crit Care Nurs 2021; 40:280-287. [PMID: 34398564 DOI: 10.1097/dcc.0000000000000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Pediatric intensive care unit (PICU) nurses may consider additional factors beyond validated tools when managing pain and sedation of children. However, these other factors and related beliefs, practices, and decision-making for analgesia and sedation have not been well described. OBJECTIVES This study describes nurses' beliefs, practices, and decision-making related to sedation and analgesia for mechanically ventilated children on a PICU and a pediatric cardiovascular ICU at a tertiary academic children's medical center in the United States. METHODS A 35-item web-based survey tool was developed to more fully identify nurses' pain, sedation, comfort, and analgesia beliefs, decisions, planning, and procedures for children who were mechanically ventilated in the ICU. It was distributed to 102 nurses in the PICU, pediatric cardiovascular ICU, and pediatric critical care float pool. RESULTS Twenty-six nurses (25%) responded; a majority worked the night shift and had 5 years or less of ICU experience. While participants believed intubated pediatric patients required moderate to deep sedation, approximately only half reported patients were adequately sedated. They reported that they were more likely to manage pain and sedation using specific behaviors and changes in vital signs than scores on a standardized scale. Nurses also reported routinely incorporating nonpharmacologic comfort measures. Premedication was more common for invasive procedures than for routine nursing care. DISCUSSION Pediatric ICU nurses in this study considered factors beyond standardized scales when evaluating and managing pain and sedation of ventilated children. Nurses prioritized children's specific behaviors, vital signs, and their own nursing judgment above standardized scales. Research is needed to describe nurses' practices beyond this small study and to define and validate additional assessment parameters to incorporate into decision-making to improve management and care outcomes.
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16
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Muirhead R, Kynoch K, Peacock A, Lewis PA. Safety and effectiveness of parent- or nurse-controlled analgesia in neonates: a systematic review. JBI Evid Synth 2021; 20:3-36. [PMID: 34387281 DOI: 10.11124/jbies-20-00385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The aim of this systematic review was to determine the safety and effectiveness of parent- or nurse-controlled analgesia on neonatal patient outcomes. More specifically, the objective was to determine the effect of parent- or nurse-controlled analgesia on neonatal pain scores, analgesic use, and incidence of iatrogenic withdrawal syndrome, as well as any opioid-associated adverse events. INTRODUCTION Despite recent innovations in neonatology leading to significant improvements in short- and long-term outcomes for newborns requiring intensive care, optimal management of pain and distress remains a challenge for the treating multidisciplinary team. The inability of neonates to communicate pain easily, inconsistent practice among health professionals, insufficient analgesic prescriptions, and delays in medical reviews all impact effective pain management. Exploring the effect of parent- or nurse-controlled analgesia may identify a modality that negates these concerns and improves the pharmacological management of pain in newborns. INCLUSION CRITERIA This review considered experimental and observational studies evaluating the safety and effectiveness of parent- or nurse-controlled analgesia that included babies born at 23 weeks' gestation to four weeks post-term. The interventions considered for inclusion were any type of analgesia delivered by an infusion pump that allowed bolus dosing or a continuous analgesic infusion with bolus dosing as required. Studies using algorithms and protocols to guide timing and dosage were eligible for inclusion. Comparators included the standard management of pain for neonates in the newborn intensive care unit. A modification to the a priori protocol was made to include all neonates nursed outside of a neonatal intensive care unit to ensure all studies that examined the use of parent- or nurse-controlled analgesia in the neonatal population were included in the review. METHODS An extensive search of six major databases was conducted (CINAHL, Cochrane Library, Embase, PubMed, PsycINFO, and Web of Science). Studies published from 1997 to 2020 in English were considered for inclusion in this review. Databases searched for unpublished studies included MedNar and ProQuest Dissertations and Theses. RESULTS Fourteen studies were included in this review: two randomized controlled trials, six quasi-experimental studies, one case-control study, and five case series. There was considerable heterogeneity in the interventions and study outcome measures within the studies, resulting in an inability to statistically pool results. The small sample sizes and inability to distinguish data specific to neonates in six of the studies resulted in low quality of evidence for the safety and effectiveness of parent- or nurse-controlled analgesia in neonates. However, studies reporting neonatal data demonstrated low pain scores and a trend in reduced opioid consumption when parent- or nurse-controlled analgesia was used. CONCLUSIONS The use of parent- or nurse-controlled analgesia in the neonatal population has shown some effect in reducing the amount of opioid analgesia required without compromising pain relief or increasing the risk of adverse events. Due to the paucity of evidence available, certainty of the results is compromised; therefore, larger trials exploring the use of parent- or nurse-controlled analgesia in neonates and the development of nurse-led models for analgesia delivery are needed. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42018114382.
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Affiliation(s)
- Renee Muirhead
- Neonatal Critical Care Unit, Mater Misericordiae Limited, Brisbane, QLD, Australia School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, QLD, Australia The Queensland Centre for Evidence Based Nursing and Midwifery: A JBI Centre of Excellence, Mater Misercordiae Limited, South Brisbane, QLD, Australia
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17
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Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Sedation, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Engagement/Empowerment Bundle Practices for Critically Ill Children: An International Survey of 161 PICUs in 18 Countries. Crit Care Med 2021; 50:114-125. [PMID: 34259659 DOI: 10.1097/ccm.0000000000005168] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate current international practice in PICUs regarding components of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Sedation, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Engagement/Empowerment" ("ABCDEF") bundle. DESIGN Online surveys conducted between 2017 and 2019. SETTING One-hundred sixty-one PICUs across the United States (n = 82), Canada (n = 14), Brazil (n = 27), and Europe (n = 38) participating in the Prevalence of Acute Rehabilitation for Kids in the PICU study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 161 participating PICUs, 83% were in academic teaching hospitals and 42% were in free-standing children's hospitals. Median size was 16 beds (interquartile range, 10-24 beds). Only 15 PICUs (9%) had incorporated all six ABCDEF bundle components into routine practice. Standardized pain assessment (A) was the most common (91%), followed by family engagement (F, 88%) and routine sedation assessment (C) with validated scales (84%). Protocols for testing extubation readiness or conducting spontaneous breathing trials (B) were reported in 57%, with 34% reporting a ventilator weaning protocol. Routine delirium monitoring with a validated screening tool (D) was reported by 44% of PICUs, and 26% had a guideline, protocol, or policy for early exercise/mobility (E). Practices for spontaneous breathing trials were variable in 29% of Canadian PICUs versus greater than 50% in the other regions. Delirium monitoring was lowest in Brazilian PICUs (18%) versus greater than 40% in other regions, and family engagement was reported in 55% of European PICUs versus greater than 90% in other regions. CONCLUSIONS ABCDEF bundle components have been adopted with substantial variability across regions. Additional research must rigorously evaluate the efficacy of specific elements with a focus on B, D, E, and full ABCDEF bundle implementation. Implementation science is needed to facilitate an understanding of the barriers to ABCDEF implementation and sustainability with a focus on specific cultural and regional differences.
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18
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Sneyers B, Duceppe MA, Frenette AJ, Burry LD, Rico P, Lavoie A, Gélinas C, Mehta S, Dagenais M, Williamson DR, Perreault MM. Strategies for the Prevention and Treatment of Iatrogenic Withdrawal from Opioids and Benzodiazepines in Critically Ill Neonates, Children and Adults: A Systematic Review of Clinical Studies. Drugs 2021; 80:1211-1233. [PMID: 32592134 PMCID: PMC7317263 DOI: 10.1007/s40265-020-01338-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Critically ill patients are at high risk of iatrogenic withdrawal syndrome (IWS), due to exposure to high doses or prolonged periods of opioids and benzodiazepines. PURPOSE To examine pharmacological management strategies designed to prevent and/or treat IWS from opioids and/or benzodiazepines in critically ill neonates, children and adults. METHODS We included non-randomised studies of interventions (NRSI) and randomised controlled trials (RCTs), reporting on interventions to prevent or manage IWS in critically ill neonatal, paediatric and adult patients. Database searching included: PubMed, CINAHL, Embase, Cochrane databases, TRIP, CMA Infobase and NICE evidence. Additional grey literature was examined. Study selection and data extraction were performed in duplicate. Data collected included: population, definition of opioid, benzodiazepine or mixed IWS, its assessment and management (drug or strategy, route of administration, dosage and titration), previous drug exposures and outcomes measures. Methodological quality assessment was performed by two independent reviewers using the Cochrane risk of bias tool for RCTs and the ROBINS-I tool for NRSI. A qualitative synthesis of the results is provided. For the subset of studies evaluating multifaceted protocolised care, we meta-analysed results for 4 outcomes and examined the quality of evidence using GRADE post hoc. RESULTS Thirteen studies were eligible, including 10 NRSI and 3 RCTs; 11 of these included neonatal and paediatric patients exclusively. Eight studies evaluated multifaceted protocolised interventions, while 5 evaluated individual components of IWS management (e.g. clonidine or methadone at varying dosages, routes of administration and duration of tapering). IWS was measured using an appropriate tool in 6 studies. Ten studies reported upon occurrence of IWS, showing significant reductions (n = 4) or no differences (n = 6). Interventions failed to impact duration of mechanical ventilation, ICU length of stay, and adverse effects. Impact on opioid and/or benzodiazepine total doses and duration showed no differences in 4 studies, while 3 showed opioid and benzodiazepine cumulative doses were significantly reduced by 20-35% and 32-66%, and treatment durations by 1.5-11 and 19 days, respectively. Variable effects on intervention drug exposures were found. Weaning durations were reduced by 6-12 days (n = 4) for opioids and/or methadone and by 13 days (n = 1) for benzodiazepines. In contrast, two studies using interventions centred on transition to enteral routes or longer tapering durations found significant increases in intervention drug exposures. Interventions had overall non-significant effects on additional drug requirements (except for one study). Included studies were at high risk of bias, relating to selection, detection and reporting bias. CONCLUSION Interventions for IWS management fail to impact duration of mechanical ventilation or ICU length of stay, while effect on occurrence of IWS and drug exposures is inconsistent. Heterogeneity in the interventions used and methodological issues, including inappropriate and/or subjective identification of IWS and bias due to study design, limited the conclusions.
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Affiliation(s)
- Barbara Sneyers
- Pharmacy Department, Centre Hospitalier Universitaire UCL Namur, Yvoir, Belgium.
| | | | - Anne Julie Frenette
- Faculté de Pharmacie, Université de Montréal, Montreal, Canada.,Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
| | - Lisa D Burry
- Pharmacy Department, Mount Sinai Hospital, Sinai Health System, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Philippe Rico
- Faculté de Médicine, Université de Montréal, Montreal, Canada.,Department of Critical Care, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
| | - Annie Lavoie
- Pharmacy Department, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montreal, Canada.,Centre for Nursing Research/Lady Davis Institute, Jewish General Hospital, Montreal, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Maryse Dagenais
- Paediatric Intensive Care Unit, McGill University Health Centre, Montreal, Canada
| | - David R Williamson
- Faculté de Pharmacie, Université de Montréal, Montreal, Canada.,Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
| | - Marc M Perreault
- Pharmacy Department, McGill University Health Centre, Montreal, Canada.,Faculté de Pharmacie, Université de Montréal, Montreal, Canada
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19
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Isaac L, van den Hoogen NJ, Habib S, Trang T. Maternal and iatrogenic neonatal opioid withdrawal syndrome: Differences and similarities in recognition, management, and consequences. J Neurosci Res 2021; 100:373-395. [PMID: 33675100 DOI: 10.1002/jnr.24811] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/01/2021] [Indexed: 11/12/2022]
Abstract
Opioids are potent analgesics used to manage pain in both young and old, but the increased use in the pregnant population has significant individual and societal implications. Infants dependent on opioids, either through maternal or iatrogenic exposure, undergo neonatal opioid withdrawal syndrome (NOWS), where they may experience withdrawal symptoms ranging from mild to severe. We present a detailed and original review of NOWS caused by maternal opioid exposure (mNOWS) and iatrogenic opioid intake (iNOWS). While these two entities have been assessed entirely separately, recognition and treatment of the clinical manifestations of NOWS overlap. Neonatal risk factors such as age, genetic predisposition, drug type, and clinical factors like type of opioid, cumulative dose of opioid exposure, and disease status affect the incidence of both mNOWS and iNOWS, as well as their severity. Recognition of withdrawal is dependent on clinical assessment of symptoms, and the use of clinical assessment tools designed to determine the need for pharmacotherapy. Treatment of NOWS relies on a combination of non-pharmacological therapies and pharmacological options. Long-term consequences of opioids and NOWS continue to generate controversy, with some evidence of anatomic brain changes, but conflicting animal and human clinical evidence of significant cognitive or behavioral impacts on school-age children. We highlight the current knowledge on clinically relevant recognition, treatment, and consequences of NOWS, and identify new advances in clinical management of the neonate. This review brings a unique clinical perspective and critically analyzes gaps between the clinical problem and our preclinical understanding of NOWS.
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Affiliation(s)
- Lisa Isaac
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nynke J van den Hoogen
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
| | - Sharifa Habib
- Department of Neonatology, Hospital for Sick Children, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Tuan Trang
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
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20
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Geven BM, Maaskant JM, Ward CS, van Woensel JBM. Dexmedetomidine and Iatrogenic Withdrawal Syndrome in Critically Ill Children. Crit Care Nurse 2021; 41:e17-e23. [PMID: 33560432 DOI: 10.4037/ccn2021462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Iatrogenic withdrawal syndrome is a well-known adverse effect of sedatives and analgesics commonly used in patients receiving mechanical ventilation in the pediatric intensive care unit, with an incidence of up to 64.6%. When standard sedative and analgesic treatment is inadequate, dexmedetomidine may be added. The effect of supplemental dexmedetomidine on iatrogenic withdrawal syndrome is unclear. OBJECTIVE To explore the potentially preventive effect of dexmedetomidine, used as a supplement to standard morphine and midazolam regimens, on the development of iatrogenic withdrawal syndrome in patients receiving mechanical ventilation in the pediatric intensive care unit. METHODS This retrospective observational study used data from patients on a 10-bed general pediatric intensive care unit. Iatrogenic withdrawal syndrome was measured using the Sophia Observation withdrawal Symptoms-scale. RESULTS In a sample of 102 patients, the cumulative dose of dexmedetomidine had no preventive effect on the development of iatrogenic withdrawal syndrome (P = .19). After correction for the imbalance in the baseline characteristics between patients who did and did not receive dexmedetomidine, the cumulative dose of midazolam was found to be a significant risk factor for iatrogenic withdrawal syndrome (P < .03). CONCLUSION In this study, supplemental dexmedetomidine had no preventive effect on iatrogenic withdrawal syndrome in patients receiving sedative treatment in the pediatric intensive care unit. The cumulative dose of midazolam was a significant risk factor for iatrogenic withdrawal syndrome.
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Affiliation(s)
- Barbara M Geven
- Barbara M. Geven is a pediatric intensive care nurse and clinical epidemiologist, Amsterdam UMC/Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands
| | - Jolanda M Maaskant
- Jolanda M. Maaskant is a senior nurse researcher and clinical epidemiologist, Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam UMC/University of Amsterdam
| | - Catherine S Ward
- Catherine S. Ward is a general and pediatric anesthesiologist, Amsterdam UMC/Emma Children's Hospital
| | - Job B M van Woensel
- Job B.M. van Woensel is medical director of the pediatric intensive care unit, Amsterdam UMC/Emma Children's Hospital
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21
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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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22
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Andersen RD, Olsson E, Eriksson M. The evidence supporting the association between the use of pain scales and outcomes in hospitalized children: A systematic review. Int J Nurs Stud 2020; 115:103840. [PMID: 33360247 DOI: 10.1016/j.ijnurstu.2020.103840] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Systematic use of pain intensity scales is considered a prerequisite for treatment of pain in hospitalized children, but already a decade ago, attention was called to the lack of robust evidence supporting the presumed positive association between their use and desired outcomes. OBJECTIVES To re-evaluate the evidence supporting the association between the use of pain scales and patient and process outcomes in hospitalized children. DESIGN Systematic literature review. DATA SOURCES The online databases PubMed and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched from inception to April 15, 2020. REVIEW METHODS We performed single screening of all records followed by duplicate screening of full texts of interest with a disagreement procedure in place. Studies where the authors evaluated outcomes from the use of self-report or behavioral-based pain scales in children 0-18 years in a hospital setting were included. Emergency care settings were excluded. RESULTS In a majority of the 32 included studies, complex interventions that included one or more pain scales were evaluated. Process outcomes (e.g., documentation) were most frequently studied. Interventions were commonly associated with improved documentation of pain assessment, while the effect on pain management documentation was inconsistent. However, improvements in process outcomes did not necessarily result in better patient outcomes. In regard to patient outcomes (e.g., pain intensity, side effects, or satisfaction with treatment), some authors reported reduced pain intensity on group level, but the effect on other functional outcomes, child and parent satisfaction, and aspects of safety were inconsistent. Methodological issues, e.g., weak study designs and small samples, biased the results, and it was not possible to determine how pain scales contributed to the overall effects since they were studied as part of complex interventions. CONCLUSIONS Although both a theoretically founded understanding of pain and clinical experience suggest that the use of pain scales will make a difference for hospitalized children with pain, there is still limited evidence to support this notion. As pain scales have been almost exclusively studied as an aspect of complex interventions, research that determines the active ingredient(s) in a complex intervention and their joint and individual effects on outcomes that are meaningful for the child (for example reduced pain intensity or improved function) are urgently needed. Tweetable abstract: Limited #research supports association between use of pediatric #pain scales and patient outcomes @_randida @PainPearl.
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Affiliation(s)
- Randi Dovland Andersen
- Department of Child and Adolescent Health Services and Department of Research, Telemark Hospital Trust, P.O. Box 2900 Kjørbekk, Skien 3710, Norway; Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro 701 82, Sweden.
| | - Emma Olsson
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro 701 82, Sweden; Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro 701 82, Sweden
| | - Mats Eriksson
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro 701 82, Sweden; Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro 701 82, Sweden
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24
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Hanser A, Neunhoeffer F, Hayer T, Hofbeck M, Schlensak C, Mustafi M, Kumpf M, Michel J. A nurse-driven analgesia and sedation protocol reduces length of PICU stay and cumulative dose of benzodiazepines after corrective surgery for tetralogy of Fallot. J SPEC PEDIATR NURS 2020; 25:e12291. [PMID: 32243076 DOI: 10.1111/jspn.12291] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/13/2020] [Accepted: 03/17/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Analgesia and sedation protocols are reported to reduce the requirement of sedative and analgesic agents, duration of mechanical ventilation, and length of pediatric intensive care unit (PICU) stay. However, these studies often were conducted based on inhomogeneous cohorts. The aim of this study was the evaluation of a nurse-driven analgesia and sedation protocol in a homogenous population of infants following corrective surgery for tetralogy of Fallot (TOF). DESIGN AND METHODS This retrospective analysis was conducted in a cardiac PICU of a tertiary referral center. Two cohorts of patients who underwent corrective surgery for TOF below the age of 7 months, were retrospectively evaluated before and after implementation of a nurse-driven analgesia and sedation protocol. We compared peak and cumulative doses of midazolam, morphine, and clonidine, length of PICU stay and time on mechanical ventilation. RESULTS A total of 33 patients were included in the preimplementation period and 32 during the postimplementation period. Implementation of the nurse-driven analgesia and sedation protocol had no effect on time on mechanical ventilation (72 hr [24-141] vs. 49 hr [24-98]), but significantly on length of PICU stay (7 days [5-14] vs. 5 days [4-7]). Cumulative doses of midazolam (7.37 mg/kg [4.70-17.65] vs. 5.0 mg/kg [2.70-9.12]) as well as peak doses of midazolam (0.22 mg·kg-1 ·hr-1 [0.20-0.33] vs. 0.15 mg·kg-1 ·hr-1 [0.13-0.20]) and morphine (50.0 µg·kg-1 ·hr-1 [39.7-79.9] vs. 42.5 µg·kg-1 ·hr-1 [29.7-51.8]) were significantly reduced. The postimplemantation group showed no increase in postoperative complications and adverse events. PRACTICE IMPLICATIONS The implementation of a nurse-driven analgesia and sedation protocol is safe in infants following corrective surgery for TOF. It reduces significantly the length of PICU stay, cumulative and peak doses of midazolam and peak doses of morphine.
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Affiliation(s)
- Anja Hanser
- Department of Pediatric Cardiology, Pulmonology, and, Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology, and, Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Tobias Hayer
- Department of Pediatric Cardiology, Pulmonology, and, Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmonology, and, Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Thoracic, Cardiac, and Vascular Surgery, University Hospital, Tübingen, Tübingen, Germany
| | - Migdat Mustafi
- Department of Thoracic, Cardiac, and Vascular Surgery, University Hospital, Tübingen, Tübingen, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmonology, and, Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Jörg Michel
- Department of Pediatric Cardiology, Pulmonology, and, Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
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25
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Magner C, Valkenburg AJ, Doherty D, van Dijk M, O'Hare B, Segurado R, Cowman S. The impact of introducing nurse-led analgesia and sedation guidelines in ventilated infants following cardiac surgery. Intensive Crit Care Nurs 2020; 60:102879. [PMID: 32448630 DOI: 10.1016/j.iccn.2020.102879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/07/2020] [Accepted: 04/18/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Enhanced clinical outcomes in the Paediatric Intensive Care Unit following standardisation of analgesia and sedation practice are reported. Little is known about the impact of standardisation of analgesia and sedation practice including incorporation of a validated distress assessment instrument on infants post cardiac surgery, a subset of whom have Trisomy 21. This study investigated whether the parallel introduction of nurse-led analgesia and sedation guidelines including regular distress assessment would impact on morphine administered to infants post cardiac surgery, and whether any differences observed would be amplified within the Trisomy 21 population. METHODOLOGY A retrospective single centre before/after study design was used. Patients aged between 44 weeks postconceptual age and one year old who had open cardiothoracic surgery were included. RESULTS 61 patients before and 64 patients after the intervention were included. After the intervention, a reduction in the amount of morphine administered was not evident, while greater use of adjuvant sedatives and analgesics was observed. Patients with Trisomy 21 had a shorter duration of mechanical ventilation after the change in practice. CONCLUSION The findings from this study affirm the importance of the nurses' role in managing prescribed analgesia and sedation supported by best available evidence. A continued education and awareness focus on analgesia and sedation management in the pursuit of best patient care is imperative.
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Affiliation(s)
- Claire Magner
- Lecturer In Children's Nursing, University College Dublin, Belfield, Dublin, Ireland, D04 V1W8.
| | - Abraham J Valkenburg
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Monique van Dijk
- Pediatric Surgery and Nursing Science, Department of Internal Medicine, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Brendan O'Hare
- Department of Anaesthesia and Critical Care Medicine, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Ricardo Segurado
- UCD CSTAR and School of Public Health, Physiotherapy & Sports Science, University College Dublin, Ireland
| | - Seamus Cowman
- Professor Emeritus, Royal College of Surgeons in Ireland, Dublin, Ireland
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Abstract
PURPOSE OF REVIEW We briefly review post-intensive care syndrome (PICS) and the morbidities associated with critical illness that led to the intensive care unit (ICU) liberation movement. We review each element of the ICU liberation bundle, including pediatric support data, as well as tips and strategies for implementation in a pediatric ICU (PICU) setting. RECENT FINDINGS Numerous studies have found children have cognitive, physical, and psychiatric deficits after a PICU stay. The effects of the full ICU liberation bundle in children have not been published, but in adults, bundle implementation (even partial) resulted in significant improvement in survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition. SUMMARY Although initially described in adults, children also suffer from PICS. The ICU liberation bundle is feasible in children and may ameliorate the effects of a PICU stay. Further studies are needed to characterize the benefits of the ICU liberation bundle in children.
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Affiliation(s)
- Alice Walz
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC USA
| | - Marguerite Orsi Canter
- Department of Pediatrics, NYU Winthrop Hospital, Long Island School of Medicine, Mineola, NY USA
| | - Kristina Betters
- Department of Pediatrics, Vanderbilt University School of Medicine, Doctors Office Tower 5114, 2200 Children’s Way, Nashville, TN 37232 USA
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27
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Michel J, Hofbeck M, Peper AK, Kumpf M, Neunhoeffer F. Evaluation of an updated sedation protocol to reduce benzodiazepines in a pediatric intensive care unit. Curr Med Res Opin 2020; 36:1-6. [PMID: 31526142 DOI: 10.1080/03007995.2019.1663689] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aim: Midazolam like other benzodiazepines is supposed to be neurotoxic in small children and to represent a risk factor for the development of delirium. The aim of this study was to evaluate whether a modified analgesia and sedation protocol is feasible and effective to reduce the requirement of midazolam in neonates and young infants after cardiac surgery.Methods: Patients aged 6 months or younger who underwent surgery for congenital heart disease with cardiopulmonary bypass were enrolled and divided into a pre-modification group (January-December 2016) and after adjusting our sedation protocol into a post-modification group (January-December 2018). We assessed the doses of midazolam, morphine and clonidine as well as sedation scores according to our nurse-driven sedation protocol every 8 h until 120 h after cardiac surgery. During weaning from analgesia and sedation, children were monitored regarding withdrawal symptoms and pediatric delirium.Results: Sixty-five patients were included (33 patients in the pre-modification group, 32 patients in the post-modification group). The number of patients receiving midazolam and the cumulative dose of midazolam could be successfully reduced. The sedation scores were still within the desired target range for adequate sedation without any negative side effects.Conclusions: It is feasible and safe to reduce the use of midazolam in infants after cardiac surgery maintaining sedation goals based on a modified nurse-driven analgesia and sedation protocol.
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Affiliation(s)
- Jörg Michel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Ann-Kathrin Peper
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
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28
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Sng QW, Ong C, Ang SLL, Kirk AHP, Lee JH. Use of an Electronic Feeds Calorie Calculator in the Pediatric Intensive Care Unit. Pediatr Qual Saf 2020; 5:e249. [PMID: 32766483 PMCID: PMC7056286 DOI: 10.1097/pq9.0000000000000249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 12/03/2019] [Indexed: 12/13/2022] Open
Abstract
Supplemental Digital Content is available in the text. Strategies to improve nutritional management are associated with better outcomes in pediatric intensive care units. We implemented a calorie-based protocol that integrated an electronic feeds calculator and stepwise feeds increment algorithm.
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Affiliation(s)
- Qian Wen Sng
- Division of Nursing, KK Women's and Children's Hospital, Singapore.,Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Chengsi Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore
| | - Su Ling Linda Ang
- Division of Nursing, KK Women's and Children's Hospital, Singapore.,Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | | | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore
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30
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Sedative and Analgesic Drug Rotation Protocol in Critically Ill Children With Prolonged Sedation: Evaluation of Implementation and Efficacy to Reduce Withdrawal Syndrome. Pediatr Crit Care Med 2019; 20:1111-1117. [PMID: 31261229 DOI: 10.1097/pcc.0000000000002071] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The first aim of this study was to assess the implementation of a sedative and analgesic drug rotation protocol in a PICU. The second aim was to analyze the incidence of withdrawal syndrome, drug doses, and time of sedative or analgesic drug infusion in children after the implementation of the new protocol. DESIGN Prospective observational study. SETTING PICU of a tertiary care hospital between June 2012 and June 2016. PATIENTS All patients between 1 month and 16 years old admitted to the PICU who received continuous IV infusion of sedative or analgesic drugs for more than 4 days were included in the study. INTERVENTIONS A sedative and analgesic drug rotation protocol was designed. The level of sedation, analgesia, and withdrawal syndrome were monitored with validated scales. The relationship between compliance with the protocol and the incidence of withdrawal syndrome was studied. MEASUREMENTS AND MAIN RESULTS One-hundred pediatric patients were included in the study. The protocol was followed properly in 35% of patients. Sixty-seven percent of the overall cohort presented with withdrawal syndrome. There was a lower incidence rate of withdrawal syndrome (34.3% vs 84.6%; p < 0.001), shorter PICU length of stay (median 16 vs 25 d; p = 0.003), less time of opioid infusion (median 5 vs 7 d for fentanyl; p = 0.004), benzodiazepines (median 5 vs 9 d; p = 0.001), and propofol (median 4 vs 8 d; p = 0.001) in the cohort of children in which the protocol was followed correctly. CONCLUSIONS Our results show that compliance with the drug rotation protocol in critically ill children requiring prolonged sedation may reduce the appearance of withdrawal syndrome without increasing the risk of adverse effects. Furthermore, it may reduce the time of continuous IV infusions for most sedative and analgesic drugs and the length of stay in PICU.
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31
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Schiller RM, Allegaert K, Hunfeld M, van den Bosch GE, van den Anker J, Tibboel D. Analgesics and Sedatives in Critically Ill Newborns and Infants: The Impact on Long-Term Neurodevelopment. J Clin Pharmacol 2019; 58 Suppl 10:S140-S150. [PMID: 30248203 DOI: 10.1002/jcph.1139] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/23/2018] [Indexed: 12/12/2022]
Abstract
Inadequate pain and/or stress management in preterm- and term-born infants has been associated with increased morbidity and even mortality. However, exposure to analgosedatives during early infancy may also be one of the risk factors for subsequent neurodevelopmental impairment, at least in animal studies. Because infants admitted to neonatal or pediatric intensive care units may receive high amounts of these drugs for prolonged periods of time and the majority of these infants nowadays survive to discharge, this is of major concern. A balanced approach that incorporates the assessment and quantification of both wanted effects as well as unwanted side effects is therefore needed. In this article, the optimal dose determination of commonly used analgosedative drugs as well as their potential long-term effects on the developing human brain and neuropsychological functioning are reviewed.
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Affiliation(s)
- R M Schiller
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - K Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Maayke Hunfeld
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - G E van den Bosch
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - John van den Anker
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Division of Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - D Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
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Konishi U, Hatachi T, Ikebe R, Inata Y, Takemori K, Takeuchi M. Incidence and risk factors for readmission to a paediatric intensive care unit. Nurs Crit Care 2019; 25:149-155. [PMID: 31576633 DOI: 10.1111/nicc.12471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 07/03/2019] [Accepted: 08/09/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Unscheduled readmission to a paediatric intensive care unit can lead to unfavourable patient outcomes. Therefore, determining the incidence and risk factors is important. Previous studies on such readmissions have only focused on the first 48 hours after discharge and described the relative risk factors as unmodifiable. AIM To identify the incidence and risk factors of unscheduled readmission to a paediatric intensive care unit within 7 days of discharge. DESIGN This was a retrospective observational study. METHODS Our study population comprised consecutive patients admitted to the paediatric intensive care unit of our tertiary hospital in Japan in 2012 to 2016. We determined the incidence of unscheduled readmission to the unit within 7 days of discharge and identified potential risk factors using multivariable logistic regression analysis. RESULTS Among the 2432 admissions (1472 patients), 60 admissions (2.5%, 44 patients) were followed by ≥1 unscheduled readmission. The median time to readmission was 3.5 days. The most common causes for readmission were respiratory issues and cardiovascular symptoms. The significant risk factors for readmission within 7 days of discharge were unscheduled initial admission (odds ratio [OR]: 3.02; 95% confidence interval [CI:] 1.45-6.31), admission from a general ward (OR: 5.13; 95% CI: 1.75-15.0), and withdrawal syndrome during the initial stay (OR: 3.95; 95% CI: 1.53-10.2). CONCLUSIONS The incidence of unscheduled readmission within 7 days was not high (2.5%), and one of the three identified risk factors for readmissions (withdrawal syndrome) is potentially modifiable. RELEVANCE TO CLINICAL PRACTICE Appropriate treatment of withdrawal syndrome may reduce readmissions and improve patient outcomes. Although unscheduled initial admission and admission from general ward are not modifiable risk factors, careful discharge judgement and follow up after discharge from paediatric intensive care units for high-risk patients may be beneficial.
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Affiliation(s)
- Umi Konishi
- Registered Nurse, Department of Nursing, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Takeshi Hatachi
- Physician, Department of Intensive Care Medicine, Osaka Womens and Children's Hospital 840 Murodocho, Osaka, Japan
| | - Ryo Ikebe
- Registered Nurse, Department of Nursing, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Yu Inata
- Physician, Department of Intensive Care Medicine, Osaka Womens and Children's Hospital 840 Murodocho, Osaka, Japan
| | - Kazumi Takemori
- Registered Nurse, Department of Nursing, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Muneyuki Takeuchi
- Physician, Department of Intensive Care Medicine, Osaka Womens and Children's Hospital 840 Murodocho, Osaka, Japan
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Michel J, Hofbeck M, Merz T, Kumpf M, Meiers A, Neunhoeffer F. Gamma-hydroxybutyrate: is it a feasible alternative to midazolam in long-term mechanically ventilated children? Curr Med Res Opin 2019; 35:1721-1726. [PMID: 31079504 DOI: 10.1080/03007995.2019.1618253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aim: Benzodiazepines like midazolam are commonly used for long-term sedation of critically ill children requiring mechanical ventilation. Tolerance to midazolam may occur in these patients resulting in a ceiling effect with insufficient or missing sedative response to increases of midazolam infusion or bolus application. The aim of this study was to evaluate the feasibility of a drug rotation protocol replacing continuous infusion of midazolam with gamma-hydroxybutyrate (GHB) to counteract midazolam tolerance. Methods: This retrospective, observational study was conducted in a 14-bed pediatric intensive care unit of a tertiary referral center. Thirty-three mechanically ventilated children with tolerance to midazolam who received continuous infusion of GHB were included. Success of drug rotation from midazolam to GHB was defined as adequate sedation with GHB and subsequent reduction of required doses of midazolam. Results: In our cohort, drug rotation for at least 2 days could be successfully performed in 10 out of 34 children resulting in subsequent reduction of required doses of midazolam. Drug rotation to GHB failed in 24 patients due to insufficient sedation resulting in a premature termination of the protocol. In these children, dosing of midazolam could not be reduced following drug rotation. We could not identify factors which predict success or failure of drug rotation from midazolam to GHB. Conclusions: The data from our single-center study suggest that drug rotation from midazolam to GHB may be worth trying in children with midazolam tolerance during long-term sedation, but physicians should be aware of possible treatment failure.
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Affiliation(s)
- Jörg Michel
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
| | - Timo Merz
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
| | - Anna Meiers
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen , Tübingen , Germany
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Pollak U, Bronicki RA, Achuff BJ, Checchia PA. Postoperative Pain Management in Pediatric Patients Undergoing Cardiac Surgery: Where Are We Heading? J Intensive Care Med 2019:885066619871432. [PMID: 31446831 DOI: 10.1177/0885066619871432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Adequate postoperative pain management is crucial in pediatric patients undergoing cardiac surgery because pain can lead to devastating short- and long-term consequences. This review discusses the limitations of current postoperative pain assessment and management in children after cardiac surgery, the obstacles to providing optimal treatment, and concepts to consider that may overcome these barriers. DATA SOURCE MEDLINE and PubMed. CONCLUSIONS Effective pain management in infants and young children undergoing cardiac surgery continues to evolve with innovative methods of both assessment and therapy using newer drugs or novel routes of administration. Artificial intelligence- and machine learning-based pain assessment and patient-tailored management in both pain measurement and prevention are already being integrated into the routine of current practice.
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Affiliation(s)
- Uri Pollak
- 1 Pediatric Cardiac Critical Care Unit, Hadassah University Medical Center, Ein Kerem, Jerusalem, Israel
- 2 Pediatric Cardiology, Hadassah University Medical Center, Ein Kerem, Jerusalem, Israel
- 3 Pediatric Extracorporeal Support Program, Hadassah University Medical Center, Ein Kerem, Jerusalem, Israel
- 4 The Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Ronald A Bronicki
- 5 Department of Pediatrics, Critical Care Medicine and Cardiology, Baylor College of Medicine, Houston, TX, USA
- 6 Pediatric Cardiovascular Intensive Care Unit, Texas Children's Hospital, Houston, TX, USA
| | - Barbara-Jo Achuff
- 5 Department of Pediatrics, Critical Care Medicine and Cardiology, Baylor College of Medicine, Houston, TX, USA
- 6 Pediatric Cardiovascular Intensive Care Unit, Texas Children's Hospital, Houston, TX, USA
| | - Paul A Checchia
- 5 Department of Pediatrics, Critical Care Medicine and Cardiology, Baylor College of Medicine, Houston, TX, USA
- 6 Pediatric Cardiovascular Intensive Care Unit, Texas Children's Hospital, Houston, TX, USA
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Kongkiattikul L, Dagenais M, Ruo N, Fontela P, Di Genova T, Zavalkoff S. The impact of a quality improvement project to standardize pain, agitation, and withdrawal assessments on the use of morphine and midazolam in the Pediatric Intensive Care Unit. Paediatr Anaesth 2019; 29:322-330. [PMID: 30664310 DOI: 10.1111/pan.13591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/27/2018] [Accepted: 01/14/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study aims to assess the impact of a quality improvement initiative to increase assessments of pain, agitation, and iatrogenic withdrawal syndrome, on the use of sedative and analgesic medication in a pediatric intensive care unit. METHODS This is a retrospective pre and post, observational, quality improvement study conducted in an 18-bed medical-surgical-cardiac, tertiary intensive care unit. We included patients consecutively admitted from October 1 to March 31 (pre-period 2015-2016, post-period 2016-2017) who were mechanically ventilated beyond 48 hours. A multidisciplinary team, including a family advisor, implemented the following interventions using rapid "Plan-Do-Study-Act cycles:" (a) standardized pain and sedation assessments, (b) standardized sedation goal setting, and (c) non-pharmacological strategies to manage pain and agitation. We did not implement any specific sedation protocol. We used audit and feedback to reinforce change. RESULTS The post-intervention phase started once sedation scores were documented q12h for >60% of patients. The groups (n = 45 per group) were similar regarding demographics, severity of illness, and mechanical ventilation duration, but different in length of intensive care stay. The cumulative dose of midazolam equivalent was significantly lower in the post-intervention period (3.71 vs 2.65 mg/kg/mechanical ventilation day, P = 0.009, 95% CI: -1.12 (-1.89, -0.31)). Morphine equivalent usage went from 3.51 to 2.57 mg/kg/mechanical ventilation day (P = 0.066, 95% CI: -0.67 [-1.44, 0.05]). There were no significant pre-post-differences in the use of other sedative agents, rates of iatrogenic withdrawal syndrome or severe pain, nor medication cost. CONCLUSION Implementation of a multifaceted QI project was successful at increasing standardized assessments of pain and agitation, and was associated with a significant reduction in midazolam use. We also observed a decrease in morphine use without increasing rates of severe pain. Incidence of iatrogenic withdrawal syndrome and cost were unchanged.
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Affiliation(s)
- Lalida Kongkiattikul
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, Quebec, Canada.,Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Maryse Dagenais
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Ni Ruo
- Department of Pharmacy, McGill University Health Centre, Montreal, Quebec, Canada
| | - Patricia Fontela
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Tanya Di Genova
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Samara Zavalkoff
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
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Bichaff P, Setani KT, Motta EHG, Delgado AF, Carvalho WB, Luglio M. Opioid tapering and weaning protocols in pediatric critical care units: a systematic review. ACTA ACUST UNITED AC 2019; 64:909-915. [PMID: 30517238 DOI: 10.1590/1806-9282.64.10.909] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 01/20/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Opioid abstinence syndrome is common in the pediatric intensive care environment because sedation is often needed during the children's treatment. There is no specific guideline regarding the management of these patients; and lately, methadone is an important drug for the prevention of abstinence symptoms during the weaning of opioids. This study gathers the available research to establish the initial dose of methadone, the rate of taper and tools to recognize this syndrome and act promptly. METHODS A systematic review was made from data of four different databases. Forty-nine articles of observational and experimental studies were selected based on the inclusion criteria (critical pediatric patients in acute use of opioids) and exclusion criteria (previous chronic use of opioids, other medications). The data regarding specific themes were separated in sections: initial dose of methadone, use of protocols in clinical practice, abstinence scales and adjuvant drugs. RESULTS The articles showed a great heterogeneity of ways to calculate the initial dose of methadone. The pediatric intensive care units of the study had different weaning protocols, with a lower incidence of abstinence when a pre-defined sequence of tapering was used. The Withdrawal Assessment Tool - 1 was the most used scale for tapering the opioids, with good sensitivity and specificity for signs and symptoms. CONCLUSION There is still little evidence of other medications that can help prevent the abstinence syndrome of opioids. This study tries to promote a better practice during opioid weaning.
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Affiliation(s)
- Pedro Bichaff
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo (SP), Brasil
| | - Karina T Setani
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo (SP), Brasil
| | - Emiliana H G Motta
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo (SP), Brasil
| | - Artur F Delgado
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo (SP), Brasil
| | - Werther B Carvalho
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo (SP), Brasil
| | - Michele Luglio
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo (SP), Brasil
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Muirhead R, Kynoch K. Safety and effectiveness of parent/nurse controlled analgesia on patient outcomes in the neonatal intensive care unit: a systematic review protocol. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2018; 16:1959-1964. [PMID: 29912720 DOI: 10.11124/jbisrir-2017-003711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION The review question is: How safe is parent/nurse controlled analgesia and what is its effectiveness on patient outcomes in the neonatal intensive care unit?
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Affiliation(s)
- Renee Muirhead
- The Queensland Centre for Evidence Based Nursing and Midwifery: a Joanna Briggs Institute Centre of Excellence
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38
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van der Vossen AC, van Nuland M, Ista EG, de Wildt SN, Hanff LM. Oral lorazepam can be substituted for intravenous midazolam when weaning paediatric intensive care patients off sedation. Acta Paediatr 2018; 107:1594-1600. [PMID: 29570859 PMCID: PMC6120549 DOI: 10.1111/apa.14327] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 03/04/2018] [Accepted: 03/15/2018] [Indexed: 11/27/2022]
Abstract
AIM Intravenous sedatives used in the paediatric intensive care unit (PICU) need to be tapered after prolonged use to prevent iatrogenic withdrawal syndrome (IWS). We evaluated the occurrence of IWS and the levels of sedation before and after conversion from intravenous midazolam to oral lorazepam. METHODS This was a retrospective, observational, single cohort study of children under the age of 18 admitted to the PICU of the Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands, between January 2013 and December 2014. The outcome parameters were the Sophia Observation withdrawal Symptoms (SOS) scale scores and COMFORT Behaviour scale scores before and after conversion. RESULTS Of the 79 patients who were weaned, 32 and 39 had before and after SOS scores and 77 had COMFORT-B scores. IWS was reported in 15 of 79 patients (19.0%) during the 48 hours before the start of lorazepam and 17 of 79 patients (21.5%) during the 48 hours after treatment started. Oversedation was seen in 16 of 79 patients (20.3%) during the 24 hours before substitution and in 30 of 79 patients (38.0%) during the 24 hours after substitution. CONCLUSION The weaning protocol was not able to prevent IWS in all patients, but converting from intravenous midazolam to oral lorazepam did not increase the incidence.
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Affiliation(s)
- Anna C. van der Vossen
- Department of Hospital PharmacyErasmus MCUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Merel van Nuland
- Department of Hospital PharmacyErasmus MCUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Erwin G. Ista
- Intensive Care and Pediatric SurgeryErasmus MC‐Sophia Children's HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Saskia N. de Wildt
- Intensive Care and Pediatric SurgeryErasmus MC‐Sophia Children's HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
- Department of Pharmacology and ToxicologyRadboud UniversityNijmegenthe Netherlands
| | - Lidwien M. Hanff
- Department of Hospital PharmacyErasmus MCUniversity Medical Center RotterdamRotterdamthe Netherlands
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Staveski SL, Wu M, Tesoro TM, Roth SJ, Cisco MJ. Interprofessional Team's Perception of Care Delivery After Implementation of a Pediatric Pain and Sedation Protocol. Crit Care Nurse 2018; 37:66-76. [PMID: 28572103 DOI: 10.4037/ccn2017538] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Pain and agitation are common experiences of patients in pediatric cardiac intensive care units. Variability in assessments by health care providers, communication, and treatment of pain and agitation creates challenges in management of pain and sedation. OBJECTIVES To develop guidelines for assessment and treatment of pain, agitation, and delirium in the pediatric cardiac intensive unit in an academic children's hospital and to document the effects of implementation of the guidelines on the interprofessional team's perception of care delivery and team function. METHODS Before and after implementation of the guidelines, interprofessional team members were surveyed about the members' perception of analgesia, sedation, and delirium management RESULTS: Members of the interprofessional team felt more comfortable with pain and sedation management after implementation of the guidelines. Team members reported improvements in team communication on patients' comfort. Members thought that important information was less likely to be lost during transfer of care. They also noted that the team carried out comfort management plans and used pharmacological and nonpharmacological therapies better after implementation of the guidelines than they did before implementation. CONCLUSIONS Guidelines for pain and sedation management were associated with perceived improvements in team function and patient care by members of the interprofessional team.
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Affiliation(s)
- Sandra L Staveski
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio. .,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California. .,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California. .,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford. .,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California.
| | - May Wu
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
| | - Tiffany M Tesoro
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
| | - Stephen J Roth
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
| | - Michael J Cisco
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
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Nurse titrated analgesia and sedation in intensive care increases the frequency of comfort assessment and reduces midazolam use in paediatric patients following cardiac surgery. Aust Crit Care 2018; 31:31-36. [DOI: 10.1016/j.aucc.2017.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 02/08/2017] [Accepted: 02/11/2017] [Indexed: 12/24/2022] Open
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Michel J, Hofbeck M, Gerbig I, Icheva V, Heimberg E, Jost W, Schlensak C, Kumpf M, Blumenstock G, Neunhoeffer F. Nurse-driven analgesia and sedation in pediatric patients with univentricular hearts requiring extracorporeal life support after first-stage palliation surgery: A pilot study. Paediatr Anaesth 2017; 27:1261-1270. [PMID: 29063727 DOI: 10.1111/pan.13274] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Few data are available regarding requirements of sedation and analgesia in children during extracorporeal life support. AIMS The aim of this study was to evaluate if children with functionally univentricular hearts on extracorporeal life support after first-stage palliation surgery have higher requirement of analgesics and sedatives compared with children without extracorporeal life support using a goal-directed nurse-driven analgesia and sedation protocol. METHODS This prospective observational matched case-control pilot study was conducted at a cardiac pediatric intensive care unit of a tertiary referral center. Seventeen patients with functionally univentricular hearts including hypoplastic left heart syndrome who were on extracorporeal life support after first-stage palliation surgery were enrolled from July 2012 to January 2017. Seventeen matched patients served as controls. Doses of morphine, midazolam, clonidine, and muscle relaxants as well as sedation scores (COMFORT behavior scale and the nurse interpretation of sedation scale) were assessed according to a nurse-driven protocol every 8 hours up to 120 hours after first-stage palliation surgery. RESULTS Sedation scores were equal in the extracorporeal life support group and in the control group at most points in time. There was no significant difference in cumulative doses of morphine and midazolam. However, children of the extracorporeal life support group received higher doses of midazolam and morphine at some points in time. CONCLUSION A nurse-driven protocol for analgesia and sedation of children with extracorporeal life support is feasible. Patients with extracorporeal life support do not need deeper sedation levels and have not higher cumulative sedation requirements than children without extracorporeal life support.
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Affiliation(s)
- Jörg Michel
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Ines Gerbig
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Vanya Icheva
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Ellen Heimberg
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Walter Jost
- Department of Thoracic, Cardiac and Vascular Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Christian Schlensak
- Department of Thoracic, Cardiac and Vascular Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Gunnar Blumenstock
- Institute for Clinical Epidemiology and Applied Biometry, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital Tuebingen, Tuebingen, Germany
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Factors Associated With Pediatric Ventilator-Associated Conditions in Six U.S. Hospitals: A Nested Case-Control Study. Pediatr Crit Care Med 2017; 18:e536-e545. [PMID: 28914722 DOI: 10.1097/pcc.0000000000001328] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES A newly proposed surveillance definition for ventilator-associated conditions among neonatal and pediatric patients has been associated with increased morbidity and mortality among ventilated patients in cardiac ICU, neonatal ICU, and PICU. This study aimed to identify potential risk factors associated with pediatric ventilator-associated conditions. DESIGN Retrospective cohort. SETTING Six U.S. hospitals PATIENTS:: Children less than or equal to 18 years old ventilated for greater than or equal to 1 day. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified children with pediatric ventilator-associated conditions and matched them to children without ventilator-associated conditions. Medical records were reviewed for comorbidities and acute care factors. We used bivariate and multivariate conditional logistic regression models to identify factors associated with ventilator-associated conditions. We studied 192 pairs of ventilator-associated conditions cases and matched controls (113 in the PICU and cardiac ICU combined; 79 in the neonatal ICU). In the PICU/cardiac ICU, potential risk factors for ventilator-associated conditions included neuromuscular blockade (odds ratio, 2.29; 95% CI, 1.08-4.87), positive fluid balance (highest quartile compared with the lowest, odds ratio, 7.76; 95% CI, 2.10-28.6), and blood product use (odds ratio, 1.52; 95% CI, 0.70-3.28). Weaning from sedation (i.e., decreasing sedation) or interruption of sedation may be protective (odds ratio, 0.44; 95% CI, 0.18-1.11). In the neonatal ICU, potential risk factors included blood product use (odds ratio, 2.99; 95% CI, 1.02-8.78), neuromuscular blockade use (odds ratio, 3.96; 95% CI, 0.93-16.9), and recent surgical procedures (odds ratio, 2.19; 95% CI, 0.77-6.28). Weaning or interrupting sedation was protective (odds ratio, 0.07; 95% CI, 0.01-0.79). CONCLUSIONS In mechanically ventilated neonates and children, we identified several possible risk factors associated with ventilator-associated conditions. Next steps include studying propensity-matched cohorts and prospectively testing whether changes in sedation management, transfusion thresholds, and fluid management can decrease pediatric ventilator-associated conditions rates and improve patient outcomes.
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Sedating Children on Extracorporeal Membrane Oxygenation: Achieving More With Less. Crit Care Med 2017; 45:1794-1796. [PMID: 28915181 DOI: 10.1097/ccm.0000000000002560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Differentiating Delirium From Sedative/Hypnotic-Related Iatrogenic Withdrawal Syndrome: Lack of Specificity in Pediatric Critical Care Assessment Tools. Pediatr Crit Care Med 2017; 18:580-588. [PMID: 28430755 DOI: 10.1097/pcc.0000000000001153] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To identify available assessment tools for sedative/hypnotic iatrogenic withdrawal syndrome and delirium in PICU patients, the evidence supporting their use, and describe areas of overlap between the components of these tools and the symptoms of anticholinergic burden in children. DATA SOURCES Studies were identified using PubMed and EMBASE from the earliest available date until July 3, 2016, using a combination of MeSH terms "delirium," "substance withdrawal syndrome," and key words "opioids," "benzodiazepines," "critical illness," "ICU," and "intensive care." Review article references were also searched. STUDY SELECTION Human studies reporting assessment of delirium or iatrogenic withdrawal syndrome in children 0-18 years undergoing critical care. Non-English language, exclusively adult, and neonatal intensive care studies were excluded. DATA EXTRACTION References cataloged by study type, population, and screening process. DATA SYNTHESIS Iatrogenic withdrawal syndrome and delirium are both prevalent in the PICU population. Commonly used scales for delirium and iatrogenic withdrawal syndrome assess signs and symptoms in the motor, behavior, and state domains, and exhibit considerable overlap. In addition, signs and symptoms of an anticholinergic toxidrome (a risk associated with some common PICU medications) overlap with components of these scales, specifically in motor, cardiovascular, and psychiatric domains. CONCLUSIONS Although important studies have demonstrated apparent high prevalence of iatrogenic withdrawal syndrome and delirium in the PICU population, the overlap in these scoring systems presents potential difficulty in distinguishing syndromes, both clinically and for research purposes.
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Neunhoeffer F, Hanser A, Esslinger M, Icheva V, Kumpf M, Gerbig I, Hofbeck M, Michel J. Ketamine Infusion as a Counter Measure for Opioid Tolerance in Mechanically Ventilated Children: A Pilot Study. Paediatr Drugs 2017; 19:259-265. [PMID: 28299720 DOI: 10.1007/s40272-017-0218-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Drug rotation to prevent opioid tolerance is well recognized in chronic pain management. However, ketamine infusion as a counter measure for opioid tolerance is rarely described in mechanically ventilated children developing tolerance from prolonged opioid infusion. PATIENTS AND METHODS We performed a retrospective study in a 14-bed medical-surgical-cardiac pediatric intensive care unit. Thirty-two mechanically ventilated children who had developed tolerance from prolonged intravenous infusion of opioids received a continuous intravenous infusion of ketamine as an opioid substitute for more than 2 days, scheduled in a drug rotation protocol. RESULTS Thirty-two children (median age 2.5 years, range 0.1-16.0; weight 11.2 kg [3.8-62.0]) were included. Patients had received continuous intravenous infusion of opioids and benzodiazepines for 16.0 days (4.0-34.0) when drug rotation was started. The median dose of continuous intravenous infusion of ketamine was 4.0 mg·kg-1·h-1 (1.8-6.0) and the median duration was 3.0 days (2.0-6.0). After having restarted opioids, fentanyl doses were significantly lower compared with the time before the drug rotation began (after, 2.9 µg·kg-1·h-1 [0.8-4.9] vs before, 4.15 µg·kg-1·h-1 [1.2-10.0]; p < 0.001). Continuous intravenous infusion of midazolam and clonidine were unchanged during drug rotation. COMFORT-B scoring was significantly lower after having started drug rotation (after, 14.5 [8-19] vs before, 16 [11-22]; p < 0.001). CONCLUSION Drug rotation with ketamine in mechanically ventilated children with opioid tolerance is feasible and seems to reduce the rate of fentanyl infusion.
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Affiliation(s)
- Felix Neunhoeffer
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany.
| | - Anja Hanser
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany
| | - Martin Esslinger
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany
| | - Vanja Icheva
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany
| | - Matthias Kumpf
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany
| | - Ines Gerbig
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany
| | - Michael Hofbeck
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany
| | - Jörg Michel
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler Str. 1, 72076, Tübingen, Germany
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Dreyfus L, Javouhey E, Denis A, Touzet S, Bordet F. Implementation and evaluation of a paediatric nurse-driven sedation protocol in a paediatric intensive care unit. Ann Intensive Care 2017; 7:36. [PMID: 28341980 PMCID: PMC5366991 DOI: 10.1186/s13613-017-0256-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 03/08/2017] [Indexed: 12/02/2022] Open
Abstract
Background Optimal sedation and analgesia is a challenge in paediatric intensive care units (PICU) because of difficulties in scoring systems and specific metabolism inducing tolerance and withdrawal. Excessive sedation is associated with prolonged mechanical ventilation and hospitalisation. Adult and paediatric data suggest that goal-directed sedation algorithms reduce the duration of mechanical ventilation. We implemented a nurse-driven sedation protocol in a PICU and evaluated its impact. Methods We conducted a before and after protocol implementation study in a population of children aged 0–18 years who required mechanical ventilation for at least 24 h between January 2013 and March 2015. After the protocol implementation in January 2014, nurses managed analgesia and sedation following an algorithm that included the COMFORT behaviour scale (COMFORT-B). Duration of mechanical ventilation was the primary outcome; secondary outcomes were total doses and duration of medications, PICU length of stay, incidence of ventilator-associated pneumonia, and occurrence of withdrawal symptoms. Pre–post analysis followed with segmented regression analysis of interrupted time series was used to assess the effect of protocol. Results A total of 200 children were analysed, including 107 before implementation and 93 children after implementation of the protocol. After implementation of the protocol, the total number of COMFORT-B scores per day of mechanical ventilation significantly increased from 3.9 ± 2.5 times during the pre-implementation period to 6.6 ± 3.5 times during the post-implementation period (p < 10−3). Mean duration of mechanical ventilation tended to be lower in the post-implementation period (8.3 ± 7.3 vs 6.6 ± 5.6 days, p = 0.094), but changes in either the trend per trimester from pre-implementation to post-implementation (p = 0.933) or the immediate change after implementation (p = 0.923) were not significant with segmented regression analysis. No significant change between pre- and post-implementation was shown for total dose of sedatives, withdrawal symptoms, agitation episodes, or unplanned endotracheal extubations. Conclusions These results were promising and suggested that implementation of a nurse-driven sedation protocol in a PICU was feasible. Evaluation of sedation and analgesia was better after the protocol implementation; duration of mechanical ventilation and occurrence of withdrawal symptoms tended to be reduced. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0256-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lélia Dreyfus
- Service de réanimation pédiatrique, Hospices Civils de Lyon - Hôpital Femme Mère Enfant, 59, Boulevard Pinel, 69500, Bron, France.
| | - Etienne Javouhey
- Service de réanimation pédiatrique, Hospices Civils de Lyon - Hôpital Femme Mère Enfant, 59, Boulevard Pinel, 69500, Bron, France.,Université Claude-Bernard Lyon 1, 69008, Lyon, France
| | - Angélique Denis
- Pôle information médicale évaluation recherche, Hospices Civils de Lyon, 162 avenue Lacassagne Bâtiment A, 69003, Lyon, France
| | - Sandrine Touzet
- Pôle information médicale évaluation recherche, Hospices Civils de Lyon, 162 avenue Lacassagne Bâtiment A, 69003, Lyon, France.,HESPER EA 7425, Université Claude Bernard Lyon 1, 69008, Lyon, France
| | - Fabienne Bordet
- Service de réanimation pédiatrique, Hospices Civils de Lyon - Hôpital Femme Mère Enfant, 59, Boulevard Pinel, 69500, Bron, France
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Abstract
OBJECTIVES To evaluate the impact of a nurse-driven sedation protocol on the length of mechanical ventilation, total daily doses of sedatives, and complications of sedation. DESIGN A single-center prospective before and after study was conducted from October 2010 to December 2013. SETTING Twelve-bed surgical and medical PICU of the university-affiliated hospital in Nantes, France. PATIENTS A total of 235 patients, between 28 days and 18 years old, requiring mechanical ventilation for at least 24 hours were included in the study; data from 194 patients were analyzed. INTERVENTIONS During the first study phase, no protocol was used. During the second phase, patients were sedated according to a nurse-driven protocol. MEASUREMENTS AND MAIN RESULTS In the whole population, the length of mechanical ventilation did not differ between protocol and control groups (protocol, 4 [3-8] vs control, 5 [3-7.5]; p = 0.44). Analyzing age subgroups, the length of mechanical ventilation was significantly shorter in the protocol group than in the control group in children older than 12 months (4 [3-8] vs 5 [2.75-11.25] d; p = 0.04). Daily dose of midazolam decreased during the protocol phase compared with the control phase (1 [0.56-1.8] and 1.2 [0.85-2.4] mg/kg/d, respectively; p = 0.02). No differences were shown regarding other daily dose of drugs. In the control group, 68% of children had more than 20% of COMFORT-behavior scale assessment under the target (oversedation) versus 59% in the protocol group (p = 0.139). CONCLUSIONS Implementation of a nurse-driven sedation protocol in a PICU is feasible and safe, allowed a decrease in daily dose of benzodiazepines, and decreased the duration of mechanical ventilation in older patients.
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Knowing Risk Factors for Iatrogenic Withdrawal Syndrome in Children May Still Leave Us Empty-Handed*. Crit Care Med 2017; 45:141-142. [DOI: 10.1097/ccm.0000000000002160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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