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Mondardini MC, Sperotto F, Daverio M, Amigoni A. Analgesia and sedation in critically ill pediatric patients: an update from the recent guidelines and point of view. Eur J Pediatr 2023; 182:2013-2026. [PMID: 36892607 DOI: 10.1007/s00431-023-04905-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/14/2023] [Accepted: 02/26/2023] [Indexed: 03/10/2023]
Abstract
In the last decades, the advancement of knowledge in analgesia and sedation for critically ill pediatric patients has been conspicuous and relevant. Many recommendations have changed to ensure patients' comfort during their intensive care unit (ICU) stay and prevent and treat sedation-related complications, as well as improve functional recovery and clinical outcomes. The key aspects of the analgosedation management in pediatrics have been recently reviewed in two consensus-based documents. However, there remains a lot to be researched and understood. With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field. Conclusion: With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field. What is Known: • Critically ill pediatric patients receiving intensive care required analgesia and sedation to attenuate painful and stressful stimuli. •Optimal management of analgosedation is a challenge often burdened with complications such as tolerance, iatrogenic withdrawal syndrome, delirium, and possible adverse outcomes. What is New: •The new insights on the analgosedation treatment for critically ill pediatric patients delineated in the recent guidelines are summarized to identify strategies for changes in clinical practice. •Research gaps and potential for quality improvement projects are also highlighted.
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Affiliation(s)
- Maria Cristina Mondardini
- Pediatric Anesthesia and Intensive Care Unit, Department of Woman's and Child's Health, IRCCS University Hospital of Bologna Policlinico S. Orsola, Bologna, Italy
| | - Francesca Sperotto
- Cardiovascular Critical Care Unit, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy.
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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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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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van Dijk M, Ista E. Four-in-One: A Comprehensive Checklist for the Assessment of Pain, Undersedation, Iatrogenic Withdrawal and Delirium in the PICU: A Delphi Study. Front Pediatr 2022; 10:887689. [PMID: 35769214 PMCID: PMC9234388 DOI: 10.3389/fped.2022.887689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/21/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Children's pain, undersedation, iatrogenic withdrawal syndrome and delirium often have overlapping symptoms, which makes it difficult to decide why a child in the PICU is not comfortable. Validated assessment tools for these conditions are available, but regular assessment with multiple instruments may be too time-consuming. Therefore, we aimed to develop a new holistic instrument-the mosaIC checklist-that incorporates the assessment of the four conditions. MATERIALS AND METHODS We conducted a two-rounds international Delphi study among experts working in PICUs worldwide to find cues that in combination or separately are relevant for the four conditions. RESULTS In the first Delphi round, 38 of the 48 enrolled participants (79%) completed a questionnaire; in the second round 32 of 48 (67%). Eventually, 46 cues in eight categories (e.g., facial, vocal/verbal, body movements, sleep /behavioral state, posture/muscle tone, agitation, physiological and contextual) were found relevant. Thirty-three (72%) were considered relevant for pain, 24 for undersedation (52%), 35 for iatrogenic withdrawal syndrome (76%) and 28 (61%) for pediatric delirium. Thirteen cues (28%) were considered relevant for all four conditions; 11's (24%) for only one condition. CONCLUSION This Delphi study is the first step in developing a 4-in-1 comprehensive checklist to assess pain, undersedation, iatrogenic withdrawal syndrome and delirium in a holistic manner. Further validation is needed before the checklist can be applied in practice. Application of the mosaIC checklist could help determine what condition is most likely to cause a child's discomfort-and at the same time help reduce the PICU staff's registration burden.
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Affiliation(s)
- Monique van Dijk
- Pediatric Intensive Care Unit, Department of Pediatric Surgery, Erasmus University Medical Center, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Internal Medicine, Section Nursing Science, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Erwin Ista
- Pediatric Intensive Care Unit, Department of Pediatric Surgery, Erasmus University Medical Center, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Internal Medicine, Section Nursing Science, Erasmus University Medical Center, Rotterdam, Netherlands
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Di Nardo M, Boldrini F, Broccati F, Cancani F, Satta T, Stoppa F, Genuini L, Zampini G, Perdichizzi S, Bottari G, Fischer M, Gawronski O, Bonetti A, Piermarini I, Recchiuti V, Leone P, Rossi A, Tabarini P, Biasucci D, Villani A, Raponi M, Cecchetti C, Choong K. The LiberAction Project: Implementation of a Pediatric Liberation Bundle to Screen Delirium, Reduce Benzodiazepine Sedation, and Provide Early Mobilization in a Human Resource-Limited Pediatric Intensive Care Unit. Front Pediatr 2021; 9:788997. [PMID: 34956989 PMCID: PMC8692861 DOI: 10.3389/fped.2021.788997] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/08/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Delirium, bed immobilization, and heavy sedation are among the major contributors of pediatric post-intensive care syndrome. Recently, the Society of Critical Care Medicine has proposed the implementation of daily interventions to minimize the incidence of these morbidities and optimize children functional outcomes and quality of life. Unfortunately, these interventions require important clinical and economical efforts which prevent their use in many pediatric intensive care units (PICU). Aim: First, to evaluate the feasibility and safety of a PICU bundle implementation prioritizing delirium screening and treatment, early mobilization (<72 h from PICU admission) and benzodiazepine-limited sedation in a human resource-limited PICU. Second, to evaluate the incidence of delirium and describe the early mobilization practices and sedative drugs used during the pre- and post-implementation periods. Third, to describe the barriers and adverse events encountered during early mobilization. Methods: This observational study was structured in a pre- (15th November 2019-30th June 2020) and post-implementation period (1st July 2020-31st December 2020). All patients admitted in PICU for more than 72 h during the pre and post-implementation period were included in the study. Patients were excluded if early mobilization was contraindicated. During the pre-implementation period, a rehabilitation program including delirium screening and treatment, early mobilization and benzodiazepine-sparing sedation guidelines was developed and all PICU staff trained. During the post-implementation period, delirium screening with the Connell Assessment of Pediatric Delirium scale was implemented at bedside. Early mobilization was performed using a structured tiered protocol and a new sedation protocol, limiting the use of benzodiazepine, was adopted. Results: Two hundred and twenty-five children were enrolled in the study, 137 in the pre-implementation period and 88 in the post-implementation period. Adherence to delirium screening, benzodiazepine-limited sedation and early mobilization was 90.9, 81.1, and 70.4%, respectively. Incidence of delirium was 23% in the post-implementation period. The median cumulative dose of benzodiazepines corrected for the total number of sedation days (mg/kg/sedation days) was significantly lower in the post-implementation period compared with the pre-implementation period: [0.83 (IQR: 0.53-1.31) vs. 0.74 (IQR: 0.55-1.16), p = 0.0001]. The median cumulative doses of fentanyl, remifentanil, and morphine corrected for the total number of sedation days were lower in the post-implementation period, but these differences were not significant. The median number of mobilizations per patient and the duration of each mobilization significantly increased in the post-implementation period [3.00 (IQR: 2.0-4.0) vs. 7.00 (IQR: 3.0-12.0); p = 0.004 and 4 min (IQR: 3.50-4.50) vs. 5.50 min (IQR: 5.25-6.5); p < 0.0001, respectively]. Barriers to early mobilization were: disease severity and bed rest orders (55%), lack of physicians' order (20%), lack of human resources (20%), and lack of adequate devices for patient mobilization (5%). No adverse events related to early mobilization were reported in both periods. Duration of mechanical ventilation and PICU length of stay was significantly lower in the post-implementation period as well as the occurrence of iatrogenic withdrawal syndrome. Conclusion: This study showed that the implementation of a PICU liberation bundle prioritizing delirium screening and treatment, benzodiazepine-limited sedation and early mobilization was feasible and safe even in a human resource-limited PICU. Further pediatric studies are needed to evaluate the clinical impact of delirium, benzodiazepine-limited sedation and early mobilization protocols on patients' long-term functional outcomes and on hospital finances.
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Affiliation(s)
- Matteo Di Nardo
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesca Boldrini
- Unit of Clinical Psychology, Department of Neurological Sciences, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesca Broccati
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Federica Cancani
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Tiziana Satta
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesca Stoppa
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Leonardo Genuini
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Giorgio Zampini
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Salvatore Perdichizzi
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Gabriella Bottari
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Maximilian Fischer
- Pediatric Emergency Unit, Department of Medical and Surgical Sciences (DIMEC), St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Orsola Gawronski
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Annamaria Bonetti
- Functional Rehab Unit, Neurorehabilitation and Robotics Department, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Irene Piermarini
- Respiratory Physiotherapy, Pediatric Pulmonology and Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics (DPUO), Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Veronica Recchiuti
- Functional Rehab Unit, Neurorehabilitation and Robotics Department, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Paola Leone
- Respiratory Physiotherapy, Pediatric Pulmonology and Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics (DPUO), Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Angela Rossi
- Unit of Clinical Psychology, Department of Neurological Sciences, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Paola Tabarini
- Unit of Clinical Psychology, Department of Neurological Sciences, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Daniele Biasucci
- Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario "A. Gemelli" Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Alberto Villani
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Massimiliano Raponi
- Medical Directorate, Bambino Gesu' Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Corrado Cecchetti
- PICU, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Karen Choong
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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