Heidi A B Smith1,2, James B Besunder3,4, Kristina A Betters1, Peter N Johnson5,6, Vijay Srinivasan7,8, Anne Stormorken9,10, Elizabeth Farrington11, Brenda Golianu12,13, Aaron J Godshall14, Larkin Acinelli15, Christina Almgren16, Christine H Bailey17, Jenny M Boyd18,19, Michael J Cisco20, Mihaela Damian21,22, Mary L deAlmeida23,24, James Fehr13,25, Kimberly E Fenton14, Frances Gilliland26,27, Mary Jo C Grant28, Joy Howell29, Cassandra A Ruggles30, Shari Simone31,32, Felice Su21,22, Janice E Sullivan33,34, Ken Tegtmeyer35,36, Chani Traube29, Stacey Williams37, John W Berkenbosch33,34. 1. Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN. 2. Division of Pediatric Cardiac Anesthesiology, Vanderbilt University Medical Center, Department of Anesthesiology, Nashville, TN. 3. Division of Pediatric Critical Care, Akron Children's Hospital, Akron, OH. 4. Department of Pediatrics, Northeast Ohio Medical University, Akron, OH. 5. University of Oklahoma College of Pharmacy, Oklahoma City, OK. 6. The Children's Hospital at OU Medical Center, Oklahoma City, OK. 7. Departments of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 8. Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA. 9. Pediatric Critical Care, Rainbow Babies Children's Hospital, Cleveland, OH. 10. Department of Pediatrics, Case Western Reserve University, Cleveland, OH. 11. Betty H. Cameron Women's and Children's Hospital at New Hanover Regional Medical Center, Wilmington, NC. 12. Division of Pediatric Anesthesia and Pain Management, Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA. 13. Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA. 14. Department of Pediatrics, AdventHealth For Children, Orlando, FL. 15. Division of Critical Care Medicine, Johns Hopkins All Children's Hospital, St Petersburg, FL. 16. Lucile Packard Children's Hospital Stanford Pain Management, Palo Alto, CA. 17. Pediatric Critical Care, Moses Cone Hospital, Greensboro, NC. 18. Division of Pediatric Critical Care, N.C. Children's Hospital, Chapel Hill, NC. 19. Division of Pediatric Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC. 20. Division of Pediatric Critical Care Medicine, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA. 21. Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA. 22. Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA. 23. Children's Healthcare of Atlanta at Egleston, Atlanta, GA. 24. Division of Pediatric Critical Care, Emory University School of Medicine, Atlanta, GA. 25. Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA. 26. Division of Cardiac Critical Care, Johns Hopkins All Children's Hospital, St Petersburg, FL. 27. College of Nursing, University of South Florida, Tampa, FL. 28. Primary Children's Hospital, Pediatric Critical Care Services, Salt Lake City, UT. 29. Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY. 30. Department of Pharmacy, Akron Children's Hospital, Akron, OH. 31. University of Maryland School of Nursing, Baltimore, MD. 32. Pediatric Intensive Care Unit, University of Maryland Medical Center, Baltimore, MD. 33. "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY. 34. Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY. 35. Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH. 36. Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH. 37. Division of Pediatric Critical Care, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN.
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.
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.
Authors: Kate L Brown; Shruti Agrawal; Matthew P Kirschen; Chani Traube; Alexis Topjian; Ronit Pressler; Cecil D Hahn; Barnaby R Scholefield; Hari Krishnan Kanthimathinathan; Aparna Hoskote; Felice D'Arco; Melania Bembea; Joseph C Manning; Maayke Hunfeld; Corinne Buysse; Robert C Tasker Journal: Intensive Care Med Date: 2022-04-21 Impact factor: 17.440
Authors: Marco Daverio; Florian von Borell; Angela Amigoni; Erwin Ista; Anne-Sylvie Ramelet; Francesca Sperotto; Paula Pokorna; Sebastian Brenner; Maria Cristina Mondardini; Dick Tibboel Journal: Crit Care Date: 2022-03-31 Impact factor: 9.097
Authors: Carmen Flores-Pérez; Luis Alfonso Moreno-Rocha; Juan Luis Chávez-Pacheco; Norma Angélica Noguez-Méndez; Janett Flores-Pérez; María Fernanda Alcántara-Morales; Luz Cortés-Vásquez; Lina Sarmiento-Argüello Journal: Saudi Pharm J Date: 2022-05-23 Impact factor: 4.562
Authors: Roberta Esteves Vieira de Castro; Miguel Rodríguez-Rubio; Maria Clara de Magalhães-Barbosa; Arnaldo Prata-Barbosa; Jaimee Holbrook; Pradip Kamat; Anne Stormorken Journal: Front Pediatr Date: 2022-08-30 Impact factor: 3.569