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MacDonald I, Alvarado S, Marston MT, Gomez Tovar L, Chanez V, Favre E, Gu Y, Trombert A, Perez MH, Ramelet AS. A systematic review of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal syndrome in pediatric intensive care. Front Pediatr 2023; 11:1264717. [PMID: 37868267 PMCID: PMC10587441 DOI: 10.3389/fped.2023.1264717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/12/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction This systematic review aimed to evaluate the quality of clinical practice guidelines (CPGs) and recommendations for managing pain, sedation, delirium, and iatrogenic withdrawal syndrome in pediatric intensive care (PICU). The objectives included evaluating the quality of recommendations, synthesizing recommendations, harmonizing the strength of the recommendation (SoR) and the certainty of evidence (CoE), and assessing the relevance of supporting evidence. Methods A comprehensive search in four electronic databases (Medline, Embase.com, CINAHL and JBI EBP Database), 9 guideline repositories, and 13 professional societies was conducted to identify CPGs published from January 2010 to the end of May 2023 in any language. The quality of CPGs and recommendations was assessed using the AGREE II and AGREE-REX instruments. Thematic analysis was used to synthesize recommendations, and the GRADE SoR and CoE harmonization method was used to interpret the credibility of summary recommendations. Results A total of 18 CPGs and 170 recommendations were identified. Most CPGs were of medium-quality, and three were classified as high. A total of 30 summary recommendations were synthesized across each condition, focused on common management approaches. There was inconsistency in the SoRs and CoE for summary recommendations, those for assessment showed the highest consistency, the remaining were conditional, inconsistent, inconclusive, and lacked support from evidence. Conclusion This systematic review provides an overview of the quality of CPGs for these four conditions in the PICU. While three CPGs achieved high-quality ratings, the overall findings reveal gaps in the evidence base of recommendations, patient and family involvement, and resources for implementation. The findings highlight the need for more rigorous and evidence-based approaches in the development and reporting of CPGs to enhance their trustworthiness. Further research is necessary to enhance the quality of recommendations for this setting. The results of this review can provide a valuable foundation for future CPG development. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=274364, PROSPERO (CRD42021274364).
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Affiliation(s)
- Ibo MacDonald
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Silvia Alvarado
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Mark T. Marston
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Luz Gomez Tovar
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Faculty of Health, Universidad Surcolombiana, Neiva, Colombia
| | - Vivianne Chanez
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Eva Favre
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Department Adult Intensive Care, Lausanne University Hospital, Lausanne, Switzerland
| | - Ying Gu
- Nursing Department, Children's Hospital of Fudan University, Shanghai, China
| | - Alexia Trombert
- Medical Library, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Maria-Helena Perez
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
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[Pain management during pregnancy : An expert-based interdisciplinary consensus recommendation]. Schmerz 2021; 35:382-390. [PMID: 34324048 PMCID: PMC8613155 DOI: 10.1007/s00482-021-00571-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
Hintergrund Schwangerschaft und Schmerzen unterschiedlicher Herkunft sind eine ungünstige Kombination, die alle BehandlerInnen vor besondere Herausforderungen stellt. Schmerzen beeinflussen die Homöostase des Menschen negativ. Compliance der Patientin und fundiertes Wissen über Fetotoxizität und Teratogenität von Analgetika sind nötig, um die Balance zwischen Therapie der Mutter und Sicherheit des Ungeborenen zu wahren. Ziel der Arbeit ExpertInnen verschiedener Disziplinen, die mit der Betreuung von schwangeren Schmerzpatientinnen betraut sind, haben sich zusammengeschlossen, um medikamentöse und nichtmedikamentöse Therapiekonzepte zu erstellen, mit dem Ziel, eine suffiziente Analgesie von schwangeren Schmerzpatientinnen zu ermöglichen. Material und Methode Relevante Fragestellungen wurden durch ExpertInnen formuliert und einer Literatursuche unterzogen. Kombiniert mit weiteren nationalen und internationalen Empfehlungen wurden Behandlungskonzepte entwickelt, interdisziplinär diskutiert und im Anschluss Kernaussagen erstellt, die mit Empfehlungsgraden abgestuft wurden. Ergebnisse Abhängig vom Trimenon können bei Schmerzen Paracetamol, Ibuprofen, Diclofenac, Metamizol und Opioide wohlüberlegt verabreicht werden, besondere Vorsicht ist bei nichtsteroidalen Antirheumatika (NSAR) im letzten Trimenon geboten. COX-2-Hemmer werden nicht empfohlen. Bei neuropathischen Schmerzen gelten Amitriptylin, Duloxetin, Venlafaxin als sicher. Bei starker Migräne kann Sumatriptan zum Einsatz kommen. Nichtmedikamentöse Therapien wie transkutane elektrische Nervenstimulation (TENS-Therapie), Kinesio-Tapes und Akupunktur gelten als sicher. Lymphdrainagen werden bei Ödemen empfohlen, sofern sie nicht durch eine Präeklampsie bedingt sind. Schlussfolgerung Die Therapie sollte mit einer nichtmedikamentösen Behandlung beginnen und eskalierend in einer Kombination aus medikamentösen und nichtmedikamentösen Konzepten enden.
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Vittinghoff M, Lönnqvist PA, Mossetti V, Heschl S, Simic D, Colovic V, Dmytriiev D, Hölzle M, Zielinska M, Kubica-Cielinska A, Lorraine-Lichtenstein E, Budić I, Karisik M, Maria BDJ, Smedile F, Morton NS. Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative). Paediatr Anaesth 2018; 28:493-506. [PMID: 29635764 DOI: 10.1111/pan.13373] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 12/21/2022]
Abstract
The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.
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Affiliation(s)
- Maria Vittinghoff
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Per-Arne Lönnqvist
- Paediatric Anaesthesia & Intensive Care, Section of Anaesthesiology & Intensive Care, Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Valeria Mossetti
- Department of Anesthesia and Intensive Care, Regina Margherita Children's Hospital, Torino, Italy
| | - Stefan Heschl
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Dusica Simic
- University Children's Hospital, Medical Faculty University of Belgrade, Serbia
| | - Vesna Colovic
- Royal Manchester Children's Hospital, Central Manchester University Hospitals, Manchester, UK
| | - Dmytro Dmytriiev
- Department of Anesthesiology and Intensive Care, Vinnitsa National Medical University, Vinnitsa, Ukraine
| | - Martin Hölzle
- Section of Paediatric Anaesthesia, Department of Anaesthesia, Luzerner Kantonsspital, Luzern, Switzerland
| | - Marzena Zielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Anna Kubica-Cielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | | | - Ivana Budić
- Centre for Anesthesiology and Resuscitation, Clinical Centre Nis Department of Anesthesiology, Medical Faculty, University of Nis, Nis, Serbia
| | - Marijana Karisik
- Institute for Children Diseases, Department of Anaesthesiology, Clinical Centre of Montenegro, Podgorica, Montenegro
| | - Belen De Josè Maria
- Department of Pediatric Anesthesia, Hospital Sant Joan de Deu, University of Barcelona, Barcelona, Spain
| | - Francesco Smedile
- Department of Pediatric Anesthesiology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Neil S Morton
- Paediatric Anaesthesia and Pain Management, University of Glasgow, Glasgow, UK
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Scheiermann P, Herzog F, Siebenhofer A, Strametz R, Weberschock T. Intravenous versus inhalational anesthesia for pediatric inpatient surgery - A systematic review and meta-analysis. J Clin Anesth 2018; 49:19-25. [PMID: 29860223 DOI: 10.1016/j.jclinane.2018.05.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 05/09/2018] [Accepted: 05/18/2018] [Indexed: 01/29/2023]
Abstract
STUDY OBJECTIVE General anesthesia is commonly used in pediatric inpatient surgery. It can be induced and maintained by either intravenous or volatile anesthetic agents. We aimed to elucidate whether intravenous or volatile anesthetic agents are superior with regards to preventing anesthesia-related complications. DESIGN Using a predefined standardized study protocol we conducted a systematic review of randomized controlled trials (RCTs) with meta-analysis where appropriate searching the following data bases: CENTRAL, MEDLINE, EMBASE, metaRegister of Controlled Trials (until June 2016). SETTING AND PATIENTS We included any RCT comparing the adverse effects of intravenous or volatile anesthetic agents in pediatric inpatients. More specifically, primary endpoints were the appearance of cardiopulmonary complications or postoperative nausea and vomiting (PONV) or any cognitive dysfunction within 24 h following general anesthesia. Secondary endpoints were any other complication besides the aforementioned primary endpoints. MEASUREMENTS AND MAIN RESULTS In total, nine RCTs (762 children) were analyzed. Regarding primary endpoints, the use of propofol during strabismus surgery significantly increased the relative risk (RR) of oculocardiac reflex (RR 4.96, 95% confidence interval [CI]: 3.13-7.87, p < 0.00001; two studies, 257 children). PONV was significantly less frequent after general anesthesia with intravenous than with volatile anesthetic agents (RR 0.68, 95% CI: 0.48-0.98, p = 0.04; five studies, 563 children). We did not find identify any further difference with regards to the predefined primary or secondary endpoints due to clinical or statistical heterogeneity. CONCLUSIONS Taken together, propofol increased the risk of oculocardiac reflex whereas PONV was less frequent following intravenous anesthetics compared to volatile anesthetics. The study results may help tailoring the use of either intravenous of volatile anesthetics onto the needs of pediatric inpatients. Given the clinical or statistical heterogeneity among the studies, we call for a scientific effort to increase the body of evidence on anesthetic agents in pediatric general anesthesia.
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Affiliation(s)
- Patrick Scheiermann
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany.
| | - Friederike Herzog
- Institute for General Practice, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590 Frankfurt/Main, Germany.
| | - Andrea Siebenhofer
- Institute for General Practice, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590 Frankfurt/Main, Germany; Evidence-based medicine working group, Institute for General Medicine and Evidence-based Health Services Research, Medical University of Graz, Auenbruggerplatz 2/9, 8036 Graz, Austria.
| | - Reinhard Strametz
- Wiesbaden Business School of RheinMain University of Applied Sciences, Bleichstr. 44, 65183 Wiesbaden, Germany.
| | - Tobias Weberschock
- Institute for General Practice, Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590 Frankfurt/Main, Germany; Department for Dermatology, University Hospital Goethe University Frankfurt/Main, Theodor-Stern-Kai 7, 60590 Frankfurt/Main, Germany.
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