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Valadkhani S, Hejazi S, Farahani AS. Translation and validation of the Comfort Behaviors Checklist in hospitalized children with chronic diseases. BMC Pediatr 2023; 23:622. [PMID: 38066455 PMCID: PMC10709840 DOI: 10.1186/s12887-023-04451-x] [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: 06/26/2022] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Different tools have been developed to measure patients' comfort. This study aims to translate, validate, and apply the Comfort Behaviors Checklist to hospitalized children with chronic diseases. METHODS Validity and reliability are assessed using face and content validity, construct validity (known-groups technique and Principal Component Analysis), internal consistency, and inter-rater reliability. The study takes place in a children's hospital in Iran, involving 220 children aged 4 to 6. RESULTS The Comfort Behaviors Checklist demonstrates acceptable face and content validity. Construct validity is supported by the lack of correlation between behavioral comfort scores in known groups. The Principal Component analysis results in five components, explaining 70.39% of the total variation. The checklist exhibits acceptable reliability, with a total Cronbach's alpha coefficient of 0.86 and an intraclass correlation coefficient of 0.835. CONCLUSION The Comfort Behavior Checklist is a valid and reliable tool for assessing the level of comfort in Iranian children with chronic diseases.
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Affiliation(s)
- Sara Valadkhani
- Department of Pediatric Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sima Hejazi
- Department of Nursing, Bojnurd Faculty of Nursing, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Azam Shirinabadi Farahani
- Department of Pediatric Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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IJland MM, Lemson J, van der Hoeven JG, Heunks LMA. The impact of critical illness on the expiratory muscles and the diaphragm assessed by ultrasound in mechanical ventilated children. Ann Intensive Care 2020; 10:115. [PMID: 32852710 PMCID: PMC7450159 DOI: 10.1186/s13613-020-00731-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 08/17/2020] [Indexed: 12/26/2022] Open
Abstract
Background Critical illness has detrimental effects on the diaphragm, but the impact of critical illness on other major muscles of the respiratory pump has been largely neglected. This study aimed to determine the impact of critical illness on the most important muscles of the respiratory muscle pump, especially on the expiratory muscles in children during mechanical ventilation. In addition, the correlation between changes in thickness of the expiratory muscles and the diaphragm was assessed. Methods This longitudinal observational cohort study performed at a tertiary pediatric intensive care unit included 34 mechanical ventilated children (> 1 month– < 18 years). Thickness of the diaphragm and expiratory muscles (obliquus interna, obliquus externa, transversus abdominis and rectus abdominis) was assessed daily using ultrasound. Contractile activity was estimated from muscle thickening fraction during the respiratory cycle. Results Over the first 4 days, both diaphragm and expiratory muscles thickness decreased (> 10%) in 44% of the children. Diaphragm and expiratory muscle thickness increased (> 10%) in 26% and 20% of the children, respectively. No correlation was found between contractile activity of the muscles and the development of atrophy. Furthermore, no correlation was found between changes in thickness of the diaphragm and the expiratory muscles (P = 0.537). Decrease in expiratory muscle thickness was significantly higher in patients failing extubation compared to successful extubation (− 34% vs − 4%, P = 0.014). Conclusions Changes in diaphragm and expiratory muscles thickness develop rapidly after the initiation of mechanical ventilation. Changes in thickness of the diaphragm and expiratory muscles were not significantly correlated. These data provide a unique insight in the effects of critical illness on the respiratory muscle pump in children.
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Affiliation(s)
- Marloes M IJland
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Joris Lemson
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Johannes G van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Postbox 7057, 1007MB, Amsterdam, The Netherlands.
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Abstract
INTRODUCTION The use of mechanical ventilation is an invaluable tool in caring for critically ill patients. Enhancing our capabilities in mechanical ventilation has been instrumental in the ability to support clinical conditions and diseases which were once associated with high mortality. Areas covered: Within this manuscript, we will look to discuss emerging approaches to improving the care of pediatric patients who require mechanical ventilation. After an extensive literature search, we will provide a brief review of the history and pathophysiology of acute respiratory distress syndrome, an assessment of several ventilator settings, a discussion on assisted ventilation, review of therapy used to rescue in severe respiratory failure, methods of monitoring the effects of mechanical ventilation, and nutrition. Expert opinion: As we have advanced in our care, we are seeing children survive illnesses that would have once claimed their lives. Given this knowledge, we must continue to advance the research in pediatric critical care to understand the means in which we can tailor the therapy to the patient in efforts to efficiently liberate them from mechanical ventilation once their illness has resolved.
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Affiliation(s)
- Duane C Williams
- a Division of Pediatric Critical Care Medicine, Department of Pediatrics , Penn State Hershey Children's Hospital , Hershey , PA , USA
| | - Ira M Cheifetz
- b Division of Pediatric Critical Care Medicine, Department of Pediatrics , Duke Children's Hospital , Durham , NC , USA
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Lee B, Park JD, Choi YH, Han YJ, Suh DI. Efficacy and Safety of Fentanyl in Combination with Midazolam in Children on Mechanical Ventilation. J Korean Med Sci 2019; 34:e21. [PMID: 30662387 PMCID: PMC6335121 DOI: 10.3346/jkms.2019.34.e21] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 11/08/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND To evaluate the efficacy and safety of fentanyl for sedation therapy in mechanically ventilated children. METHODS This was a double-blind, randomized controlled trial of mechanically ventilated patients between 2 months and 18 years of age. Patients were randomly divided into two groups; the control group with midazolam alone, and the combination group with both fentanyl and midazolam. The sedation level was evaluated using the Comfort Behavior Scale (CBS), and the infusion rates were adjusted according to the difference between the measured and the target CBS score. RESULTS Forty-four patients were recruited and randomly allocated, with 22 patients in both groups. The time ratio of cumulative hours with a difference in CBS score (measured CBS-target CBS) of ≥ 4 points (i.e., under-sedation) was lower in the combination group (median, 0.06; interquartile range [IQR], 0-0.2) than in the control group (median, 0.15; IQR, 0.04-0.29) (P < 0.001). The time ratio of cumulative hours with a difference in CBS score of ≥ 8 points (serious under-sedation) was also lower in the combination group (P < 0.001). The cumulative amount of midazolam used in the control group (0.11 mg/kg/hr; 0.07-0.14 mg/kg/hr) was greater than in the combination group (0.07 mg/kg/hr; 0.06-0.11 mg/kg/hr) (P < 0.001). Two cases of hypotension in each group were detected but coma and ileus, the major known adverse reactions to fentanyl, did not occur. CONCLUSION Fentanyl combined with midazolam is safe and more effective than midazolam alone for sedation therapy in mechanically ventilated children. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02172014.
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Affiliation(s)
- Bongjin Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Yu Hyeon Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Young Joo Han
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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A Pilot Randomized Controlled Trial of an Intervention to Promote Psychological Well-Being in Critically Ill Children: Soothing Through Touch, Reading, and Music. Pediatr Crit Care Med 2018; 19:e358-e366. [PMID: 29659416 DOI: 10.1097/pcc.0000000000001556] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine the feasibility and acceptability of a PICU Soothing intervention using touch, reading, and music. DESIGN Nonblinded, pilot randomized controlled trial. SETTING The PICU and medical-surgical wards of one Canadian pediatric hospital. PATIENTS Twenty PICU patients age 2-14 years old and their parents, randomized to an intervention group (n = 10) or control group (n = 10). INTERVENTION PICU Soothing consisted of: 1) parental comforting (touch and reading), followed by 2) a quiet period with music via soft headbands, administered once daily throughout hospitalization. MEASUREMENTS AND MAIN RESULTS Acceptability and feasibility of the intervention and methods were assessed via participation rates, observation, measurement completion rates, semistructured interviews, and telephone calls. Psychological well-being was assessed using measures of distress, sleep, and child and parent anxiety in the PICU, on the wards and 3 months post discharge. Forty-four percent of parents agreed to participate. Seventy percent and 100% of intervention group parents responded positively to comforting and music, respectively. Most intervention group parents (70%) and all nurses felt children responded positively. All nurses found the intervention acceptable and feasible. Measurement completion rates ranged from 70% to 100%. Pilot data suggested lower intervention group child and parent anxiety after transfer to hospital wards. CONCLUSIONS PICU Soothing is acceptable and feasible to conduct. Results support the implementation of a full-scale randomized controlled trial to evaluate intervention effectiveness.
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Cravero JP, Askins N, Sriswasdi P, Tsze DS, Zurakowski D, Sinnott S. Validation of the Pediatric Sedation State Scale. Pediatrics 2017; 139:peds.2016-2897. [PMID: 28557732 PMCID: PMC5404726 DOI: 10.1542/peds.2016-2897] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Development and validation of the Pediatric Sedation State Scale (PSSS) is intended to specifically meet the needs of pediatric procedural sedation providers to measure effectiveness and quality of care. METHODS The PSSS content was developed through Delphi methods utilizing leading pediatric sedation experts and published guidelines on procedural sedation in children. Video clips were created and presented to study participants, who graded the state of patients during procedures by using the PSSS to evaluate inter- and intrarater reliability by determining the intraclass correlation coefficient. We also compared the PSSS to the Observational Scale of Behavioral Distress-revised during 4 clinically relevant phases of a laceration repair procedure. RESULTS Six sedation states were defined for the PSSS. Each state was assigned a numerical value with higher numbers for increasing activity states. We included behaviors associated with adequate and inadequate sedation and adverse events associated with excessive sedation. Analysis of interrater and intrarater reliability revealed an intraclass correlation coefficient of 0.994 (95% confidence interval: 0.986-0.998) and 0.986 (95% confidence interval: 0.970-0.995), respectively. Criterion validity was confirmed with respect to the Observational Scale of Behavioral Distress-revised (Spearman r = 0.96). Construct validity was indicated by significant differences in PSSS scores (P < .001) between 4 phases of a procedure, each having a different degree of painful or distressing stimuli. CONCLUSIONS The PSSS is a 6-point scale that is a valid measure of the effectiveness and quality of procedural sedation in children within the limits of the testing method used in this study.
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Affiliation(s)
- Joseph P. Cravero
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Nissa Askins
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Patcharee Sriswasdi
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Daniel S. Tsze
- Columbia University College of Physicians and Surgeons, New York, New York; and
| | - David Zurakowski
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Sean Sinnott
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
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Ng E, Taddio A, Ohlsson A. Intravenous midazolam infusion for sedation of infants in the neonatal intensive care unit. Cochrane Database Syst Rev 2017; 1:CD002052. [PMID: 28141899 PMCID: PMC6464963 DOI: 10.1002/14651858.cd002052.pub3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Proper sedation for neonates undergoing uncomfortable procedures may reduce stress and avoid complications. Midazolam is a short-acting benzodiazepine that is used increasingly in neonatal intensive care units (NICUs). However, its effectiveness as a sedative in neonates has not been systematically evaluated. OBJECTIVES Primary objeciveTo assess the effectiveness of intravenous midazolam infusion for sedation, as evaluated by behavioural and/or physiological measurements of sedation levels, in critically ill neonates in the NICU. Secondary objectivesTo assess effects of intravenous midazolam infusion for sedation on complications including the following.1. Incidence of intraventricular haemorrhage (IVH)/periventricular leukomalacia (PVL).2. Mortality.3. Occurrence of adverse effects associated with the use of midazolam (hypotension, neurological abnormalities).4. Days of ventilation.5. Days of supplemental oxygen.6. Incidence of pneumothorax.7. Length of NICU stay (days).8. Long-term neurodevelopmental outcomes. SELECTION CRITERIA We selected for review randomised and quasi-randomised controlled trials of intravenous midazolam infusion for sedation in infants aged 28 days or younger. DATA COLLECTION AND ANALYSIS We abstracted data regarding the primary outcome of level of sedation. We assessed secondary outcomes such as intraventricular haemorrhage, periventricular leukomalacia, death, length of NICU stay and adverse effects associated with midazolam. When appropriate, we performed meta-analyses using risk ratios (RRs) and risk differences (RDs), and if the RD was statistically significant, we calculated the number needed to treat for an additional beneficial outcome (NNTB) or an additional harmful outcome (NNTH), along with their 95% confidence intervals (95% CIs) for categorical variables, and weighted mean differences (WMDs) for continuous variables. We assessed heterogeneity by performing the I-squared (I2) test. MAIN RESULTS We included in the review three trials enrolling 148 neonates. We identified no new trials for this update. Using different sedation scales, each study showed a statistically significantly higher sedation level in the midazolam group compared with the placebo group. However, none of the sedation scales used have been validated in preterm infants; therefore, we could not ascertain the effectiveness of midazolam in this population. Duration of NICU stay was significantly longer in the midazolam group than in the placebo group (WMD 5.4 days, 95% CI 0.40 to 10.5; I2 = 0%; two studies, 89 infants). One study (43 infants) reported significantly lower Premature Infant Pain Profile (PIPP) scores during midazolam infusion than during dextrose (placebo) infusion (MD -3.80, 95% CI -5.93 to -1.67). Another study (46 infants) observed a higher incidence of adverse neurological events at 28 days' postnatal age (death, grade III or IV IVH or PVL) in the midazolam group compared with the morphine group (RR 7.64, 95% CI 1.02 to 57.21; RD 0.28, 95% CI 0.07 to 0.49; NNTH 4, 95% CI 2 to 14) (tests for heterogeneity not applicable). We considered these trials to be of moderate quality according to GRADE assessment based on the following outcomes: mortality during hospital stay, length of NICU stay, adequacy of analgesia according to PIPP scores and poor neurological outcomes by 28 days' postnatal age. AUTHORS' CONCLUSIONS Data are insufficient to promote the use of intravenous midazolam infusion as a sedative for neonates undergoing intensive care. This review raises concerns about the safety of midazolam in neonates. Further research on the effectiveness and safety of midazolam in neonates is needed.
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Affiliation(s)
- Eugene Ng
- Sunnybrook Health Sciences CentreAubrey and Marla Dan Program for High Risk Mothers and BabiesRoom M4‐230ATorontoONCanadaM5S 1B2
| | - Anna Taddio
- Hospital for Sick Children Research InstituteGraduate Department of Pharmaceutical Sciences555 University AvenueTorontoONCanadaM5G 1X8
| | - Arne Ohlsson
- University of TorontoDepartments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and EvaluationTorontoCanada
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Alveolar formation is dysregulated by restricted nutrition but not excess sedation in preterm lambs managed by noninvasive support. Pediatr Res 2016; 80:719-728. [PMID: 27429203 PMCID: PMC5683895 DOI: 10.1038/pr.2016.143] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 05/02/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preterm birth and respiratory support with invasive mechanical ventilation frequently leads to bronchopulmonary dysplasia (BPD). A hallmark feature of BPD is alveolar simplification. For our preterm lamb model of BPD, invasive mechanical ventilation is associated with postnatal feeding intolerance (reduced nutrition) and sedation. In contrast, preterm lambs managed by noninvasive support (NIS) have normal alveolar formation, appropriate postnatal nutrition, and require little sedation. We used the latter, positive-outcome group to discriminate the contribution of reduced nutrition vs. sedation on alveolar simplification. We hypothesized that, restricted nutrition, but not sedation with pentobarbital, contributes to impaired indices of alveolar formation in preterm lambs managed by NIS. METHODS Preterm lambs managed by NIS for 21d were randomized into three groups: NIS control, NIS plus restricted nutrition, and NIS plus excess sedation with pentobarbital. We quantified morphological and biochemical indices of alveolar formation, as well as mesenchymal cell apoptosis and proliferation. RESULTS Restricted nutrition impaired morphological and biochemical indices of alveolar formation, and reduced mesenchymal cell apoptosis and proliferation. Excess sedation with pentobarbital did not alter these indices, although mesenchymal cell apoptosis was less. CONCLUSION Our results demonstrate that restricted nutrition, but not excess sedation, contributes to impaired alveolar formation during the evolution of BPD in chronically ventilated preterm lambs.
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De Luca D, Costa R, Visconti F, Piastra M, Conti G. Oscillation transmission and volume delivery during face mask-delivered HFOV in infants: Bench and in vivo study. Pediatr Pulmonol 2016; 51:705-12. [PMID: 26918535 DOI: 10.1002/ppul.23403] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/06/2016] [Accepted: 01/21/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Noninvasive high frequency oscillatory ventilation (NHFOV) has not been studied beyond neonatal age and with interfaces other than nasal prongs. We set up a preliminary study to investigate feasibility, oscillation transmission, and volume delivery of face mask-delivered NHFOV in a bench model mimicking a normal 1-year infant without any lung disease and then in vivo in a series of infants with same characteristics. DESIGN A mannequin with upper airways was connected to an electronic active lung simulator ventilated through NHFOV with varying parameters. Volume delivered by oscillations (oTv), oscillatory pressure ratio, and estimation of ventilation (DCO2) were measured at the lung simulator. Four infants were ventilated with face mask-delivered NHFOV for 2 hr and monitored with respiratory inductance plethismography. Vital parameters, oscillatory pressure ratio, oscillatory (RIPo), and spontaneous cage/abdomen displacement (RIPs) were recorded. RESULTS There was a dampening of oscillation amplitude both on the bench model and in vivo: oscillatory pressure ratios at the mask were 80% and 17%, respectively. Significant correlations exist between oscillatory pressure ratio (only when this latter was <0.038) and oTv (r = 0.48; P < 0.001) or DCO2 (r = 0.47; P < 0.001). At multivariate analysis, oscillatory pressure ratio was a main determinant of oTv and DCO2. Oscillations were slightly visible on the chest in vivo and RIPo was about 5% of RIPs. NHFOV did not change vital parameters and did not cause discomfort. CONCLUSIONS Face mask-delivered NHFOV is feasible in a model of 1-year infant. No major complications occurred in vivo. Oscillations are superimposed to the spontaneous breathing and are significantly dampened. Pediatr Pulmonol. Pediatr Pulmonol. 2016;51:705-712. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Daniele De Luca
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, University Hospital "A.Gemelli", Catholic University of the Sacred Heart, Rome, Italy.,Division of Pediatrics and Neonatal Critical Care, South Paris University Hospitals, "A.Béclère" Medical Center-APHP, Paris, France
| | - Roberta Costa
- VentiLab, Department of Anesthesia and Intensive Care, University Hospital "A.Gemelli", Catholic University of the Sacred Heart, Rome, Italy
| | - Federico Visconti
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, University Hospital "A.Gemelli", Catholic University of the Sacred Heart, Rome, Italy
| | - Marco Piastra
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, University Hospital "A.Gemelli", Catholic University of the Sacred Heart, Rome, Italy
| | - Giorgio Conti
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, University Hospital "A.Gemelli", Catholic University of the Sacred Heart, Rome, Italy.,VentiLab, Department of Anesthesia and Intensive Care, University Hospital "A.Gemelli", Catholic University of the Sacred Heart, Rome, Italy
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Maaskant J, Raymakers-Janssen P, Veldhoen E, Ista E, Lucas C, Vermeulen H. The clinimetric properties of the COMFORT scale: A systematic review. Eur J Pain 2016; 20:1587-1611. [PMID: 27161119 DOI: 10.1002/ejp.880] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2016] [Indexed: 11/08/2022]
Abstract
The COMFORT scale is a measurement tool to assess distress, sedation and pain in nonverbal paediatric patients. Several studies have described the COMFORT scale, but no formal assessment of the methodological quality has been undertaken. Therefore, we performed a systematic review to study the clinimetric properties of the (modified) COMFORT scale in children up to 18 years. We searched Central, CINAHL, Embase, Medline, PsycInfo and Web of Science until December 2014. The selection, data extraction and quality assessment were performed independently by two reviewers. Quality of the included studies was appraised using the COSMIN checklist. We found 30 studies that met the inclusion criteria. Most participants were ventilated children up to 4 years without neurological disorders. The results on internal consistency and interrater reliability showed values of >0.70 in most studies, indicating an adequate reliability. Construct validity resulted in correlations between 0.68 and 0.84 for distress, between 0.42 and 0.94 for sedation and between 0.31 and 0.96 for pain. The responsiveness of the (modified) COMFORT scale seems to be adequate. The quality of the included studies ranged from poor to excellent. The COMFORT scale shows overall an adequate reliability in providing information on distress, sedation and pain. Construct validity varies from good to excellent for distress, from moderate to excellent for sedation, and from poor to excellent for pain. The included studies were clinically and methodologically heterogeneous, hampering firm conclusions. WHAT DOES THIS REVIEW ADD?: An in-depth assessment of the clinimetric properties of the COMFORT scale. The COMFORT scale shows overall an adequate reliability in providing information on distress, sedation and pain. Construct validity varies from good to excellent for distress, from moderate to excellent for sedation, and from poor to excellent for pain.
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Affiliation(s)
- J Maaskant
- Emma Children's Hospital, Academic Medical Center Amsterdam, The Netherlands. .,Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam, The Netherlands.
| | - P Raymakers-Janssen
- Pediatric Intensive Care Unit, Wilhelmina Children's Hospital, University Medical Center Utrecht, The Netherlands
| | - E Veldhoen
- Pediatric Intensive Care Unit, Wilhelmina Children's Hospital, University Medical Center Utrecht, The Netherlands
| | - E Ista
- Intensive Care Unit, Department of Pediatrics and Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - C Lucas
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam, The Netherlands
| | - H Vermeulen
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.,Amsterdam School of Health Professions, Amsterdam, The Netherlands
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Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals. Intensive Care Med 2016; 42:972-86. [PMID: 27084344 PMCID: PMC4846705 DOI: 10.1007/s00134-016-4344-1] [Citation(s) in RCA: 241] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 03/23/2016] [Indexed: 01/12/2023]
Abstract
Background This position statement provides clinical recommendations for the assessment of pain, level of sedation, iatrogenic withdrawal syndrome and delirium in critically ill infants and children. Admission to a neonatal or paediatric intensive care unit (NICU, PICU) exposes a child to a series of painful and stressful events. Accurate assessment of the presence of pain and non-pain-related distress (adequacy of sedation, iatrogenic withdrawal syndrome and delirium) is essential to good clinical management and to monitoring the effectiveness of interventions to relieve or prevent pain and distress in the individual patient. Methods A multidisciplinary group of experts was recruited from the members of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). The group formulated clinical questions regarding assessment of pain and non-pain-related distress in critically ill and nonverbal children, and searched the PubMed/Medline, CINAHL and Embase databases for studies describing the psychometric properties of assessment instruments. Furthermore, level of evidence of selected studies was assigned and recommendations were formulated, and grade or recommendations were added on the basis of the level of evidence. Results An ESPNIC position statement was drafted which provides clinical recommendations on assessment of pain (n = 5), distress and/or level of sedation (n = 4), iatrogenic withdrawal syndrome (n = 3) and delirium (n = 3). These recommendations were based on the available evidence and consensus amongst the experts and other members of ESPNIC. Conclusions This multidisciplinary ESPNIC position statement guides professionals in the assessment and reassessment of the effectiveness of treatment interventions for pain, distress, inadequate sedation, withdrawal syndrome and delirium. Electronic supplementary material The online version of this article (doi:10.1007/s00134-016-4344-1) contains supplementary material, which is available to authorized users.
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Vet NJ, Kleiber N, Ista E, de Hoog M, de Wildt SN. Sedation in Critically Ill Children with Respiratory Failure. Front Pediatr 2016; 4:89. [PMID: 27606309 PMCID: PMC4995367 DOI: 10.3389/fped.2016.00089] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 08/09/2016] [Indexed: 01/08/2023] Open
Abstract
This article discusses the rationale of sedation in respiratory failure, sedation goals, how to assess the need for sedation as well as effectiveness of interventions in critically ill children, with validated observational sedation scales. The drugs and non-pharmacological approaches used for optimal sedation in ventilated children are reviewed, and specifically the rationale for drug selection, including short- and long-term efficacy and safety aspects of the selected drugs. The specific pharmacokinetic and pharmacodynamic aspects of sedative drugs in the critically ill child and consequences for dosing are presented. Furthermore, we discuss different sedation strategies and their adverse events, such as iatrogenic withdrawal syndrome and delirium. These principles can guide clinicians in the choice of sedative drugs in pediatric respiratory failure.
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Affiliation(s)
- Nienke J Vet
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Niina Kleiber
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Erwin Ista
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Matthijs de Hoog
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Saskia N de Wildt
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pharmacology and Toxicology, Radboud University, Nijmegen, Netherlands
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Nonpulmonary treatments for pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015; 16:S73-85. [PMID: 26035367 DOI: 10.1097/pcc.0000000000000435] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To describe the recommendations from the Pediatric Acute Lung Injury Consensus Conference on nonpulmonary treatments in pediatric acute respiratory distress syndrome. DESIGN Consensus conference of experts in pediatric acute lung injury. METHODS A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The nonpulmonary subgroup comprised three experts. When published data were lacking, a modified Delphi approach emphasizing strong professional agreement was utilized. RESULTS The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 30 of which related to nonpulmonary treatment. All 30 recommendations had strong agreement. Patients with pediatric acute respiratory distress syndrome should receive 1) minimal yet effective targeted sedation to facilitate mechanical ventilation; 2) neuromuscular blockade, if sedation alone is inadequate to achieve effective mechanical ventilation; 3) a nutrition plan to facilitate their recovery, maintain their growth, and meet their metabolic needs; 4) goal-directed fluid management to maintain adequate intravascular volume, end-organ perfusion, and optimal delivery of oxygen; and 5) goal-directed RBC transfusion to maintain adequate oxygen delivery. Future clinical trials in pediatric acute respiratory distress syndrome should report sedation, neuromuscular blockade, nutrition, fluid management, and transfusion exposures to allow comparison across studies. CONCLUSIONS The Consensus Conference developed pediatric-specific definitions for pediatric acute respiratory distress syndrome and recommendations regarding treatment and future research priorities. These recommendations for nonpulmonary treatment in pediatric acute respiratory distress syndrome are intended to promote optimization and consistency of care for patients with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.
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Abstract
Neonates are exposed to repetitive pain and stress during their stay in a NICU, which can lead to chronic complications related to their neurodevelopment and neurobehavior. Approximately 20 percent of all neonates in a NICU are intubated, mechanically ventilated, and require suctioning, which can cause both acute and chronic pain. Pain management in the neonate can be challenging. Nurses and other caregivers need to be well trained to assess pain in the neonate to effectively identify and provide appropriate pain management strategies. There is a lack of evidence to support routine administration of opiates in the neonate. As with any medication, the possibility of short- and long-term adverse reactions must be considered. Nonpharmacologic therapy should be used as much as possible.
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Cultural adaptation of patient and observational outcome measures: A methodological example using the COMFORT behavioral rating scale. Int J Nurs Stud 2014; 51:934-42. [DOI: 10.1016/j.ijnurstu.2013.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 09/27/2013] [Accepted: 10/04/2013] [Indexed: 11/19/2022]
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Piastra M, De Luca D, Costa R, Pizza A, De Sanctis R, Marzano L, Biasucci D, Visconti F, Conti G. Neurally adjusted ventilatory assist vs pressure support ventilation in infants recovering from severe acute respiratory distress syndrome: Nested study. J Crit Care 2014; 29:312.e1-5. [DOI: 10.1016/j.jcrc.2013.08.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 08/06/2013] [Accepted: 08/06/2013] [Indexed: 11/15/2022]
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Clinical pharmacology of midazolam in neonates and children: effect of disease-a review. Int J Pediatr 2014; 2014:309342. [PMID: 24696691 PMCID: PMC3948203 DOI: 10.1155/2014/309342] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 12/26/2013] [Indexed: 12/04/2022] Open
Abstract
Midazolam is a benzodiazepine with rapid onset of action and short duration of effect. In healthy neonates the half-life (t1/2) and the clearance (Cl) are 3.3-fold longer and 3.7-fold smaller, respectively, than in adults. The volume of distribution (Vd) is 1.1 L/kg both in neonates and adults. Midazolam is hydroxylated by CYP3A4 and CYP3A5; the activities of these enzymes surge in the liver in the first weeks of life and thus the metabolic rate of midazolam is lower in neonates than in adults. Midazolam acts as a sedative, as an antiepileptic, for those infants who are refractory to standard antiepileptic therapy, and as an anaesthetic. Information of midazolam as an anaesthetic in infants are very little. Midazolam is usually administered intravenously; when minimal sedation is required, intranasal administration of midazolam is employed. Disease affects the pharmacokinetics of midazolam in neonates; multiple organ failure reduces the Cl of midazolam and mechanical ventilation prolongs the t1/2 of this drug. ECMO therapy increases t1/2, Cl, and Vd of midazolam several times. The adverse effects of midazolam in neonates are scarce: pain, tenderness, and thrombophlebitis may occur. Respiratory depression and hypotension appear in a limited percentage of infants following intravenous infusion of midazolam. In conclusion, midazolam is a safe and effective drug which is employed as a sedative, as antiepileptic agent, for infants who are refractory to standard antiepileptic therapy, and as an anaesthetic.
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Cruces P, Donoso A, Valenzuela J, Díaz F. Respiratory and hemodynamic effects of a stepwise lung recruitment maneuver in pediatric ARDS: a feasibility study. Pediatr Pulmonol 2013; 48:1135-43. [PMID: 23255291 DOI: 10.1002/ppul.22729] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 10/17/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND Little is known about the efficacy and safety of recruitment maneuvers (RMs) in pediatric patients with acute respiratory distress syndrome (ARDS). We therefore assessed the effects on gas exchange and lung mechanics and the possible detrimental effects of a sequential lung RMs and decremental positive end-expiratory pressure (PEEP) titration in pediatric ARDS patients. METHODS We enrolled patients <15 years of age with ARDS, progressive hypoxemia, <72 hr of mechanical ventilation, and hemodynamic stability. A step-wise RM and decremental PEEP trial were performed. Safety was evaluated as the occurrence of hypotension and low pulse oxymeter oxygen saturation during the maneuver and development of airleaks after. Efficacy was evaluated as changes in lung compliance (Cdyn ) and gas exchange 1, 12, and 24 hr after the RM. RESULTS We included 25 patients, of median age 5 (1-16) months, median weight 7.0 (4.1-9.2) kg, median PaO2 /FIO2 117 (96-139), and median Cdyn 0.48 (0.41-0.68) ml/cmH2 O/kg at baseline. Thirty RM were performed, with all completed successfully. No airleaks developed. Mild hypotension was detected during four procedures. Following RM, Cdyn , and PaO2 /FIO2 increased significantly (P < 0.01 each), without changes in PaCO2 (P = 0.4). A >25% improvement in lung function (Cdyn or PaO2 /FIO2 ) was observed after 90% of the RM procedures. Gas exchange worsening over the next 24 hr resulted in HFOV use in 36% of patients, while the remaining subjects sustained improvements in oxygenation at 12 and 24 hr. The 28-day mortality rate was 16%. CONCLUSIONS Sequential RMs were safe and well tolerated in hemodynamically stable children with ARDS. RMs and a decremental PEEP trial may improve lung function in pediatric patients with ARDS and severe hypoxemia.
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Affiliation(s)
- Pablo Cruces
- Área de Cuidados Críticos, Hospital Padre Hurtado, Santiago, Chile; Department of Pediatrics, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
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Dorfman TL, Sumamo Schellenberg E, Rempel GR, Scott SD, Hartling L. An evaluation of instruments for scoring physiological and behavioral cues of pain, non-pain related distress, and adequacy of analgesia and sedation in pediatric mechanically ventilated patients: A systematic review. Int J Nurs Stud 2013; 51:654-76. [PMID: 23987802 DOI: 10.1016/j.ijnurstu.2013.07.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 06/03/2013] [Accepted: 07/19/2013] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Advancing technology allows for successful treatment of children with life-threatening illnesses. Effectively assessing and optimally treating a child's distress during their stay in the Pediatric Intensive Care Unit (PICU) is paramount. Objective measures of distress in mechanically ventilated pediatric patients are increasingly available but few have been evaluated. The objectives of this systematic review were to identify available instruments appropriate for measuring physiological and behavioral cues of pain, non-pain related distress, and adequacy of analgesia and sedation in mechanically ventilated pediatric patients, and evaluate these instruments in terms of their psychometric properties. DESIGN A systematic review of original and validation reports of objective instruments to measure pain and non-pain related distress, and adequacy of analgesia and sedation in mechanically ventilated PICU patients was undertaken. DATA SOURCES A comprehensive search was conducted in 10 databases from January 1970 to June 2011. Reference lists of relevant articles were reviewed to identify additional articles. REVIEW METHODS Studies were included in the review if they met pre-established eligibility criteria. Two independent reviewers reviewed studies for inclusion, assessed quality, and extracted data. RESULTS Twenty-five articles were included, identifying 15 instruments. The instruments had different foci including: assessing pain, non-pain related distress, and sedation (n=2); assessing pain exclusively (n=4); assessing sedation exclusively (n=7), assessing sedation in mechanically ventilated muscle relaxed PICU patients (n=1); and assessing delirium in mechanically ventilated PICU patients (n=1). The Comfort Scale demonstrated the greatest clinical utility in the assessment of pain, non-pain related distress, and sedation in mechanically ventilated pediatric patients. Modified FLACC and the MAPS are more appropriate, however, for the assessment of procedural pain and other brief painful events. More work is required on instruments for the assessment of distress in mechanically ventilated muscle relaxed PICU patients, and the assessment of delirium in PICU patients. CONCLUSIONS This review provides essential information to guide PICU clinicians in choosing instruments to assess pain, non-pain related distress, and adequacy of analgesia and sedation in mechanically ventilated pediatric patients. Effective knowledge translation is essential in the implementation, adoption, and successful use of these instruments.
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Affiliation(s)
| | | | - Gwen R Rempel
- University of Alberta, Edmonton, Canada; Associate Professor, Faculty of Nursing, Canada; Alberta Heritage Foundation for Health Research (AHFMR), Canada.
| | - Shannon D Scott
- University of Alberta, Edmonton, Canada; Associate Professor, Faculty of Nursing, Canada; Alberta Heritage Foundation for Health Research (AHFMR), Canada; Canadian Institutes of Health Research, Canada.
| | - Lisa Hartling
- University of Alberta, Edmonton, Canada; Canadian Institutes of Health Research, Canada; ARCHE, Canada; University of Alberta Evidence-based Practice Center, Canada; Department of Pediatrics, Canada.
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Optimal sedation in pediatric intensive care patients: a systematic review. Intensive Care Med 2013; 39:1524-34. [PMID: 23778830 DOI: 10.1007/s00134-013-2971-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 05/18/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Sedatives administered to critically ill children should be titrated to effect, because both under- and oversedation may have negative effects. We conducted a systematic review to examine reported incidences of under-, optimal, and oversedation in critically ill children receiving intensive care. METHODS A systematic literature search using predefined criteria was performed in PubMed and Embase to identify all articles evaluating level of sedation in PICU patients receiving continuous sedation. Two authors independently recorded: study objective, study design, sample size, age range, details of study intervention (if applicable), sedatives used, length of sedation, sedation scale used, and incidences of optimal, under-, and oversedation as defined in the studies. RESULTS Twenty-five studies were included. Two studies evaluated sedation level as primary study outcome; the other 23 as secondary outcomes. Together, these studies investigated 1,163 children; age range, 0-18 years. Across studies, children received many different sedative agents and sedation level was assessed with 12 different sedation scales. Optimal sedation was ascertained in 57.6 % of the observations, under sedation in 10.6 %, and oversedation in 31.8 %. CONCLUSIONS This study suggests that sedation in the PICU is often suboptimal and seldom systematically evaluated. Oversedation is more common than undersedation. As oversedation may lead to longer hospitalization, tolerance, and withdrawal, preventing oversedation in pediatric intensive care deserves greater attention.
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McPherson C. Sedation and analgesia in mechanically ventilated preterm neonates: continue standard of care or experiment? J Pediatr Pharmacol Ther 2013; 17:351-64. [PMID: 23413121 DOI: 10.5863/1551-6776-17.4.351] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Attention to comfort and pain control are essential components of neonatal intensive care. Preterm neonates are uniquely susceptible to pain and agitation, and these exposures have a negative impact on brain development. In preterm neonates, chronic pain and agitation are common adverse effects of mechanical ventilation, and opiates or benzodiazepines are the pharmacologic agents most often used for treatment. Questions remain regarding the efficacy, safety, and neurodevelopmental impact of these therapies. Both preclinical and clinical data suggest troubling adverse drug reactions and the potential for adverse longterm neurodevelopmental impact. The negative impacts of standard pharmacologic agents suggest that alternative agents should be investigated. Dexmedetomidine is a promising alternative therapy that requires further interprofessional and multidisciplinary research in this population.
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Nievas IFF, Spentzas T, Bogue CW. SNAP II index: an alternative to the COMFORT scale in assessing the level of sedation in mechanically ventilated pediatric patients. J Intensive Care Med 2013; 29:225-8. [PMID: 23753227 DOI: 10.1177/0885066613475422] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 09/11/2012] [Indexed: 11/17/2022]
Abstract
Sedation monitoring is essential in pediatric patients on ventilatory support to achieve comfort and safety. The COMFORT scale was designed and validated to assess the level of sedation in intubated pediatric patients. However, it remains unreliable in pharmacologically paralyzed patients. The SNAP II index is calculated using an algorithm that incorporates high-frequency (80-420 Hz) electroencephalogram (EEG) components, known to be useful in discriminating between awake and unconscious states, unlike other measurements that only include low-frequency EEG segments such as the bispectral index score. Previous studies suggested that the SNAP II index is a reliable and sensitive indicator of the level of consciousness in adult patients. Despite its potential, no data are currently available in the pediatric critically ill population on ventilatory support. This is the first pilot study assessing the potential application of the SNAP II index in critically ill pediatric patients by comparing it to the commonly used COMFORT scale.
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Affiliation(s)
| | - Thomas Spentzas
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Clifford W Bogue
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
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Mazars N, Milési C, Carbajal R, Mesnage R, Combes C, Rideau Batista Novais A, Cambonie G. Implementation of a neonatal pain management module in the computerized physician order entry system. Ann Intensive Care 2012; 2:38. [PMID: 22913821 PMCID: PMC3526504 DOI: 10.1186/2110-5820-2-38] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 07/02/2012] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED BACKGROUND Despite the recommended guidelines, the neonatal management of pain and discomfort often remains inadequate. The purpose of the present study was to determine whether adding a pain and discomfort module to a computerized physician order entry (CPOE) system would improve pain and discomfort evaluation in premature newborns under invasive ventilation. METHODS All newborns <37 weeks gestational age (GA) and requiring invasive ventilation were included in a prospective study during two 6-month periods: before and after the inclusion of the pain and discomfort evaluation module. The main outcome measure was the percentage of patients having at least one assessment of pain and discomfort per day of invasive ventilation using the COMFORT scale. RESULTS A total of 122 patients were included: 53 before and 69 after the incorporation of the module. The mean age was 30 (3) weeks GA. After the module was included, the percentage of patients who benefited from at least one pain and discomfort assessment per day increased from 64% to 88% (p < 0.01), and the mean number (SD) of scores recorded per day increased from 1 (1) to 3 (1) (p < 0.01). When the score was not within the established range, the nursing staff adapted analgesia/sedation doses more frequently after module inclusion (53% vs. 34%, p < 0.001). Despite higher mean doses of midazolam after module introduction [47 (45) vs. 31 (18) μg/kg/hr, p < 0.05], the durations of invasive ventilation and hospital stay, and the number of nosocomial infections, were not significantly modified. CONCLUSIONS Adding a pain and discomfort tool to the CPOE system was a simple and effective way to improve the systematic evaluation of premature newborns who required ventilatory assistance.
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Affiliation(s)
- Nathalie Mazars
- Neonatology Department, Arnaud de Villeneuve Hospital, CHU Montpellier, Montpellier, F-34000, France.
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Have a couple of minutes? Probably not. Pediatr Crit Care Med 2012; 13:246-7. [PMID: 22391846 DOI: 10.1097/pcc.0b013e31822314a8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Smith HAB, Fuchs DC, Pandharipande PP, Barr FE, Ely EW. Delirium: an emerging frontier in the management of critically ill children. Anesthesiol Clin 2011; 29:729-50. [PMID: 22078920 DOI: 10.1016/j.anclin.2011.09.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Delirium is a syndrome of acute brain dysfunction that commonly occurs in critically ill adults and most certainly is prevalent in critically ill children all over the world. The dearth of information about the incidence, prevalence, and severity of pediatric delirium stems from the simple fact that there have not been well-validated instruments for routine delirium diagnosis at the bedside. This article reviewed the emerging solutions to this problem, including description of a new pediatric tool called the pCAM-ICU. In adults, delirium is responsible for significant increases in both morbidity and mortality in critically ill patients. The advent of new tools for use in critically ill children will allow the epidemiology of this form of acute brain dysfunction to be studied adequately, will allow clinical management algorithms to be developed and implemented following testing, and will present the necessary incorporation of delirium as an outcome measure for future clinical trials in pediatric critical care medicine.
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Affiliation(s)
- Heidi A B Smith
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
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26
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VENN R, CUSACK RJ, RHODES A, GROUNDS RM. Monitoring of the depth of sedation in the intensive care unit. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/tcic.10.3.81.90] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Jácomo ADN, Carmona F, Matsuno AK, Manso PH, Carlotti APCP. Effect of oral hygiene with 0.12% chlorhexidine gluconate on the incidence of nosocomial pneumonia in children undergoing cardiac surgery. Infect Control Hosp Epidemiol 2011; 32:591-6. [PMID: 21558772 DOI: 10.1086/660018] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the effect of oral hygiene with 0.12% chlorhexidine gluconate on the incidence of nosocomial pneumonia and ventilator-associated pneumonia (VAP) in children undergoing cardiac surgery. DESIGN Prospective, randomized, double-blind, placebo-controlled trial. SETTING Pediatric intensive care unit (PICU) at a tertiary care hospital. PATIENTS One hundred sixty children undergoing surgery for congenital heart disease, randomized into 2 groups: chlorhexidine (n = 87) and control (n = 73). INTERVENTIONS Oral hygiene with 0.12% chlorhexidine gluconate or placebo preoperatively and twice a day postoperatively until PICU discharge or death. RESULTS Patients in experimental and control groups had similar ages (median, 12.2 vs 10.8 months; P = .72) and risk adjustment for congenital heart surgery 1 score distribution (66% in category 1 or 2 in both groups; P = .17). The incidence of nosocomial pneumonia was 29.8% versus 24.6% (P = .46) and the incidence of VAP was 18.3% versus 15% (P = .57) in the chlorhexidine and the control group, respectively. There was no difference in intubation time (P = .34), need for reintubation (P = .37), time interval between hospitalization and nosocomial pneumonia diagnosis (P = .63), time interval between surgery and nosocomial pneumonia diagnosis (P = .10), and time on antibiotics (P = .77) and vasoactive drugs (P = .16) between groups. Median length of PICU stay (3 vs 4 days; P = .53), median length of hospital stay (12 vs 11 days; P = .67), and 28-day mortality (5.7% vs 6.8%; P = .77) were also similar in the chlorhexidine and the control group. CONCLUSIONS Oral hygiene with 0.12% chlorhexidine gluconate did not reduce the incidence of nosocomial pneumonia and VAP in children undergoing cardiac surgery. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00829842 .
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Affiliation(s)
- Andréa D N Jácomo
- Department of Pediatrics, Hospital das Clínicas, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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The COMFORT-Behavior scale is useful to assess pain and distress in 0- to 3-year-old children with Down syndrome. Pain 2011; 152:2059-2064. [DOI: 10.1016/j.pain.2011.05.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Revised: 04/22/2011] [Accepted: 05/02/2011] [Indexed: 11/18/2022]
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Use of dexmedetomidine for sedation in critically ill mechanically ventilated pediatric burn patients. J Burn Care Res 2011; 32:98-103. [PMID: 21088616 DOI: 10.1097/bcr.0b013e318203332d] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Dexmedetomidine has previously been used only for short-term, procedural sedation in children. The purpose of this review was to describe the dosing, safety, and efficacy of dexmedetomidine for sustained sedation in intubated pediatric burn patients. The authors reviewed acutely burned children treated between 2005 and 2008 who were intubated during their course of care and who received dexmedetomidine for sedation. Patients served as their own controls using the time periods when they received sedatives other than dexmedetomidine. Eleven patients with 17 dexmedetomidine treatment courses were identified. The median patient age was 7 years (range 1.6-17 years), and median burn size was 30.5% TBSA (range 6-59%). Patients were ventilated for a median of 9 days (range 4-46 days). The median initial dose of dexmedetomidine was 0.39 μg/kg/hr (range 0.10-1.16 μg/kg/hr), with a median infusion dose of 0.57 μg/kg/hr (range 0.11-1.17 μg/kg/hr) and median treatment duration of 40 hours (range 1-356 hours). None of the patients received dexmedetomidine loading dose. Patients achieved more appropriate Riker scores while treated with dexmedetomidine than while being treated with other sedatives (3.8 vs 3.3, P = .003). The incidence of hypotension and/or bradycardia while on dexmedetomidine was not greater than when it was not being used. Clinically significant rebound hypertension and tachycardia were absent on discontinuation of dexmedetomidine. No unplanned extubations were observed. Median length of hospital stay was 49 days (range 7-118 days). Dexmedetomidine seems to be safe and effective for sedation of pediatric burn patients on mechanical ventilation with close cardiovascular monitoring.
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Sury MRJ, Bould MD. Defining awakening from anesthesia in infants: a narrative review of published descriptions and scales of behavior. Paediatr Anaesth 2011; 21:364-72. [PMID: 21324047 DOI: 10.1111/j.1460-9592.2011.03538.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES A descriptive tool or validated scale of consciousness is desirable in infants to test the value of any depth of anesthesia monitor. METHODS We have reviewed published descriptions and scales of observed behavior that may be applicable to the study of infants during the transition from anesthesia to wakefulness. RESULTS Potentially useful scales were found that had been developed for the assessment and study of natural sleep, neurological state, arousal, anesthesia, sedation, coma, and pain. Scales or criteria of behavior had been developed for anesthetised children, but there were no agreed definitions or criteria specifically for anesthetised infants or neonates. CONCLUSION Criteria for awakening of infants from anesthesia need to be developed and agreed.
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Affiliation(s)
- Michael R J Sury
- Portex Unit of Anaesthesia, University College London Institute of Child Health, London, UK.
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Abstract
The pharmacokinetics of propofol are relatively well described in the pediatric population. Recent work has confirmed the validity of allometric scaling for predicting propofol disposition across different species and for describing pediatric ontogenesis. In the first year of life, allometric models require adjustment to reflect ontogeny of maturation. Pharmacodynamic data for propofol in children are scarcer, because of practical difficulties in data collection and the limitations of currently available depth of anesthesia monitors for pediatric use. Hence, questions relating to the comparative sensitivity of children to propofol, and differences in time to peak effect relative to adults, remain unanswered. K(eo) half-lives have been determined for pediatric kinetic models using time to peak effect techniques but are not currently incorporated into commercially available target-controlled infusion pumps.
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Affiliation(s)
- Ann E Rigby-Jones
- Anaesthesia Research Group, Peninsula Medical School, Peninsula College of Medicine & Dentistry, University of Plymouth, Plymouth, UK.
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Ashkenazy S, DeKeyser-Ganz F. Assessment of the reliability and validity of the Comfort Scale for adult intensive care patients. Heart Lung 2010; 40:e44-51. [PMID: 20561865 DOI: 10.1016/j.hrtlng.2009.12.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Revised: 12/27/2009] [Accepted: 12/29/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study sought to evaluate the use of the Comfort Scale (CS), originally developed for children, in sedated adults at intensive care units. METHODS Comfort and sedation were assessed in a convenience sample of 88 adult intensive-care patients receiving mechanical ventilation, using 5 instruments (the Ramsay Scale, Sedation Agitation Scale, Richmond Agitation Sedation Scale, Glasgow Coma Scale, and CS). RESULTS Reliability (internal consistency according to Cronbach's α, .60 to .66; inter-rater reliability, r = .81; test-retest, r = .21 to .31) and validity (criterion validity with other scales, κ = .49 to .74, for construct validity and sensitivity) were determined. The range of children's comfort (i.e., 17 to 26) was different from that in adults (i.e., 16 to 20). CONCLUSIONS Results partially support the use of the CS among adults in intensive care units, with some minor adjustments.
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Affiliation(s)
- Shelly Ashkenazy
- Department of Anesthesiology and Critical Care Medicine, Hadassah Medical Organization, Jerusalem, Israel.
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Reducing unplanned extubations in a pediatric intensive care unit: a systematic approach. Int J Pediatr 2009; 2009:820495. [PMID: 20069114 PMCID: PMC2804049 DOI: 10.1155/2009/820495] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Accepted: 11/20/2009] [Indexed: 12/26/2022] Open
Abstract
Objective. To prospectively determine the rate of unplanned extubations and contributing factors and determine whether a targeted intervention program would be successful in decreasing the rate of unplanned extubations. Design. Prospective, observational study. Setting. A 10-bed Pediatric Intensive Care Unit (PICU). Patients. All intubated pediatric patients during two time periods: September 1, 2000–March 31, 2001 and November 1, 2001–April 30, 2002. Interventions. After determining the rate and causes of unplanned extubation, a program was developed consisting of education and a formalized endotracheal tube taping policy. Data were then collected after implementation of the program. Measurements and Main Results. Prior to the implementation of the program, there were 10 (14.7%) unplanned extubations for a rate of 6.4 unplanned extubations per 100 ventilated days. Of the ten unplanned extubations, reintubation was required in 2 (20%). Inadequate sedation, poor taping, and improper position of the endotracheal tube were the items most frequently cited as causing an unplanned extubation. Following the program, there were two (3.4%) unplanned extubations for 1.0 unplanned extubations per 100 ventilated days. Neither patient required reintubation. There were no significant differences (P > .05) in age, weight, endotracheal tube size, or duration of intubation in the two time periods. However, there was a significant decrease in both the number (P = .03) and the rate (P = .04) of unplanned extubations after the implementation of the quality improvement program. Conclusions. The rate of unplanned extubation in a PICU can be decreased with a quality improvement program that targets the institution's specific needs.
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Ista E, de Hoog M, Tibboel D, van Dijk M. Implementation of standard sedation management in paediatric intensive care: effective and feasible? J Clin Nurs 2009; 18:2511-20. [DOI: 10.1111/j.1365-2702.2009.02836.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Hammer GB. Sedation and analgesia in the pediatric intensive care unit following laryngotracheal reconstruction. Paediatr Anaesth 2009; 19 Suppl 1:166-79. [PMID: 19572854 DOI: 10.1111/j.1460-9592.2009.03000.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Children undergoing laryngotracheal reconstruction (LTR) may remain electively intubated in the pediatric intensive care unit (PICU) for several days following surgery to facilitate wound healing. These patients require sedation and analgesia with or without neuromuscular blockade in order to prevent excessive head and neck movement with resultant tension on the tracheal anastomosis. Achieving this level of immobility features in caring for these children. AIM The aims of this article are to describe a variety of commonly used sedation and analgesic agents and to provide guidance as to their optimal use following LTR.
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Affiliation(s)
- Gregory B Hammer
- Anesthesiology and Pediatrics, Department of Anesthesia, Stanford University School of Medicine, University Medical Center, 300 Pasteur Drive, Stanford, CA 94305-5640, USA.
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Smith HAB, Fuchs DC, Pandharipande PP, Barr FE, Ely EW. Delirium: an emerging frontier in the management of critically ill children. Crit Care Clin 2009; 25:593-614, x. [PMID: 19576533 PMCID: PMC2793079 DOI: 10.1016/j.ccc.2009.05.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The objectives of this article are (1) to introduce pediatric delirium and provide understanding of acute brain dysfunction with its classification and clinical presentations (2) to understand how delirium is diagnosed and discuss current modes of delirium diagnosis in the critically ill adult population and translation to pediatrics (3) to understand the prevalence and prognostic significance of delirium in the adult and pediatric critically ill population (4) to discuss the pathophysiology of delirium as currently understood, and (5) to provide general management guidelines for delirium.
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Affiliation(s)
- Heidi A B Smith
- Pediatrics and Anesthesiology Division of Critical Care, Department of Pediatrics, 5121 Doctor's Office Tower, 2200 Children's Way, Nashville, TN 37232-9075, USA.
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Johansson M, Kokinsky E. The COMFORT behavioural scale and the modified FLACC scale in paediatric intensive care. Nurs Crit Care 2009; 14:122-30. [DOI: 10.1111/j.1478-5153.2009.00323.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hartman ME, McCrory DC, Schulman SR. Efficacy of sedation regimens to facilitate mechanical ventilation in the pediatric intensive care unit: a systematic review. Pediatr Crit Care Med 2009; 10:246-55. [PMID: 19188867 DOI: 10.1097/pcc.0b013e31819a3bb9] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Children admitted to pediatric intensive care units (PICUs) often receive sedatives to facilitate mechanical ventilation. However, despite their widespread use, data supporting appropriate dosing, safety, and optimal regimens for sedation during mechanical ventilation are lacking. Therefore, we conducted a systematic review of published data regarding efficacy of sedation to facilitate mechanical ventilation in PICU patients. Our primary objective was to identify and evaluate the quality of evidence supporting sedatives used in PICUs for this purpose. DATA SOURCES We searched MEDLINE, EMBASE, and The Cochrane Registry of Clinical Trials from 1966 to June 2008 to identify published articles evaluating sedation regimens to facilitate mechanical ventilation in PICU patients. STUDY SELECTION We included only those studies of intubated PICU or pediatric cardiac intensive care unit patients receiving pharmacologic agents to facilitate mechanical ventilation that reported quality of sedation as an outcome. DATA EXTRACTION We analyzed studies separately for study type and by agents being studied. Studies were appraised using criteria of particular importance for reviews evaluating sedatives. DATA SYNTHESIS Our search strategy yielded 39 studies, including 3 randomized trials, 15 cohort studies, and 21 cases series or reports. The 39 studies evaluated a total of 39 different sedation regimens, with 21 different scoring systems, in a total of 901 PICU/cardiac intensive care unit patients ranging in age from 3 days to 19 years old. Most of the studies were small (<30 patients), and only four studies compared one or more agents to another. Few studies thoroughly evaluated drug safety, and only one study met all quality criteria. CONCLUSIONS Despite the widespread use of sedatives to facilitate mechanical ventilation in the PICU, we found that high-quality evidence to guide clinical practice is still limited. Pediatric randomized, controlled trials with reproducible methods and assessment of drug safety are needed.
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Affiliation(s)
- Mary E Hartman
- Department of Pediatric Critical Care Medicine, Duke University, Durham, NC, USA.
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Hammer GB. Sedation and analgesia in the pediatric Intensive Care Unit following laryngotracheal reconstruction. Otolaryngol Clin North Am 2008; 41:1023-44, x-xi. [PMID: 18775348 DOI: 10.1016/j.otc.2008.04.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Deep levels of sedation and analgesia are needed in the majority of children who require prolonged tracheal intubation after laryngotracheal reconstruction (LTR). Drug doses may be determined most appropriately using validated scoring tools for sedation and analgesia; these scales continue to evolve and are used with increasing regularity in the pediatric intensive care unit (PICU). In this presentation, the validated scoring tools used to assess sedation and analgesia are reviewed, and specific agents used to manage sedation, analgesia, and neuromuscular blockade in the PICU after LTR are discussed.
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Affiliation(s)
- Gregory B Hammer
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA 94305, USA.
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The effect of neuromuscular blockade on oxygen consumption in sedated and mechanically ventilated pediatric patients after cardiac surgery. Intensive Care Med 2008; 34:2268-72. [DOI: 10.1007/s00134-008-1252-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 08/02/2008] [Indexed: 12/19/2022]
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Withdrawal symptoms in critically ill children after long-term administration of sedatives and/or analgesics: a first evaluation. Crit Care Med 2008; 36:2427-32. [PMID: 18596622 DOI: 10.1097/ccm.0b013e318181600d] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To establish frequencies of benzodiazepine and opioid withdrawal symptoms, and correlations with total doses and duration of administration. DESIGN A prospective, repeated-measures design. SETTING Two pediatric intensive care units in a university children's hospital. PATIENTS Seventy-nine children, aged 0 days to 16 yrs, who received intravenous midazolam and/or opioids for >5 days. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pediatric intensive care unit nurses assessed withdrawal symptoms using the Sophia Benzodiazepine and Opioid Withdrawal Checklist, which includes all withdrawal symptoms (n = 24) described in the pediatric literature. Over 6 months, 2188 observations in 79 children were recorded. Forty-two percent of observations were performed within 24 hrs after tapering off or discontinuation of medication. Symptoms representing overstimulation of the central nervous system, such as anxiety, agitation, grimacing, sleep disturbance, increased muscle tension, and movement disorder, were observed in >10% of observations. Of symptoms reflecting gastrointestinal dysfunction, diarrhea and gastric retention were most frequently observed. Tachypnea, fever, sweating, and hypertension as manifestations of autonomic dysfunction were observed in >13% of observations. The Spearman's rank-correlation coefficient between total doses of midazolam and maximum sum score (of the Sophia Benzodiazepine and Opioid Withdrawal Checklist) was .51 (p < 0.001). The correlation between total doses of opioids and the maximum sum score was .39 (p < 0.01). A significant correlation (.52; p < 0.001) was also found between duration of use and maximum sum score. CONCLUSIONS This is the first study to report frequencies of all 24 withdrawal symptoms observed in children after decrease or discontinuation of benzodiazepines and/or opioids. Agitation, anxiety, muscle tension, sleeping <1 hr, diarrhea, fever, sweating, and tachypnea were observed most frequently. Longer duration of use and high dosing are risk factors for development of withdrawal symptoms in children.
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Nolent P, Laudenbach V. Sédation et analgésie en réanimation – Aspects pédiatriques. ACTA ACUST UNITED AC 2008; 27:623-32. [DOI: 10.1016/j.annfar.2008.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Froom SR, Malan CA, Mecklenburgh JS, Price M, Chawathe MS, Hall JE, Goodwin N. Bispectral Index asymmetry and COMFORT score in paediatric intensive care patients. Br J Anaesth 2008; 100:690-6. [PMID: 18337270 DOI: 10.1093/bja/aen035] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The Bispectral Index (BIS) monitor has been suggested as a potential tool to measure depth of sedation in paediatric intensive care unit (PICU) patients. The primary aim of our observational study was to assess the difference in BIS values between the left and right sides of the brain. Secondary aims were to compare BIS and COMFORT score and to assess change in BIS with tracheal suctioning. METHODS Nineteen ventilated and sedated PICU patients had paediatric BIS sensors applied to either side of their forehead. Each patient underwent physiotherapy involving tracheal suctioning. Their BIS data and corresponding COMFORT score, assessment as by their respective nurses, were recorded before, during, and after physiotherapy. RESULTS Seven patients underwent more than one physiotherapy session; therefore, 28 sets of data were collected. The mean BIS difference values (and 95% CI) between left BIS and right BIS for pre-, during, and post-physiotherapy periods were 9.2 (5.9-12.5), 15.8 (11.9-19.7), and 7.5 (5.2-9.7), respectively. Correlation between mean BIS, left brain BIS, and right brain BIS to COMFORT score was highly significant (P<0.001 for all three) during the pre- and post-physiotherapy period, but less so during the stimulated physiotherapy period (P=0.044, P=0.014, and P=0.253, respectively). CONCLUSIONS A discrepancy between left and right brain BIS exists, especially when the patient is stimulated. COMFORT score and BIS correlate well between light and moderate sedation.
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Affiliation(s)
- S R Froom
- Department of Anaesthetics and Intensive Care Medicine, University Hospital of Wales, Cardiff CF14 4XW, UK.
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Abstract
BACKGROUND Mechanical ventilation is a potentially painful and discomforting intervention widely used in neonatal intensive care units. Newborn babies (neonates) demonstrate increased sensitivity to pain, which may affect clinical and neurodevelopmental outcomes. The use of drugs that reduce pain might be important in improving survival and neurodevelopmental outcomes. OBJECTIVES To determine the effect of opioid analgesics (pain-killing drugs derived from opium e.g. morphine), compared to placebo, no drug, or other non-opioid analgesics or sedatives, on pain, duration of mechanical ventilation, mortality, growth and neurodevelopmental outcomes in newborn infants on mechanical ventilation. SEARCH STRATEGY Electronic searches included: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007); MEDLINE (1966 to June 2007); EMBASE (1974 to June 2007); and CINAHL (1982 to 2007). Previous reviews and lists of relevant articles were cross-referenced. SELECTION CRITERIA Randomised controlled trials or quasi-randomised controlled trials comparing opioids to a control, or to other analgesics or sedatives in newborn infants on mechanical ventilation. DATA COLLECTION AND ANALYSIS Data were extracted independently by two review authors. Categorical outcomes were analysed using relative risk and risk difference; and continuous outcomes with weighted mean difference or standardised mean difference. A fixed effect model was used for meta-analysis except where heterogeneity existed, in which case a random effects model was used. MAIN RESULTS Thirteen studies on 1505 infants were included. Infants given opioids showed reduced premature infant pain profile (PIPP) scores compared to the control group (weighted mean difference -1.71; 95% confidence interval -3.18 to -0.24). Differences in execution and reporting of trials mean that this meta-analysis should be interpreted with caution. Heterogeneity was significantly high in all analyses of pain, even when lower quality studies were excluded and analysis limited to very preterm newborns. Meta-analyses of mortality, duration of mechanical ventilation, and long and short-term neurodevelopmental outcomes showed no statistically significant differences. Very preterm infants given morphine took significantly longer to reach full enteral feeding than those in control groups (weighted mean difference 2.10 days; 95% confidence interval 0.35 to 3.85). One study compared morphine with a sedative: the treatments showed similar pain scores, but morphine had fewer adverse effects. AUTHORS' CONCLUSIONS There is insufficient evidence to recommend routine use of opioids in mechanically ventilated newborns. Opioids should be used selectively, when indicated by clinical judgment and evaluation of pain indicators. If sedation is required, morphine is safer than midazolam. Further research is needed.
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Affiliation(s)
- R Bellù
- Ospedale "Manzoni" -Lecco, Neonatal Intensive Care Unit, Via Eremo 9, Lecco, Italy, 23900.
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Jin HS, Yum MS, Kim SL, Shin HY, Lee EH, Ha EJ, Hong SJ, Park SJ. The efficacy of the COMFORT scale in assessing optimal sedation in critically ill children requiring mechanical ventilation. J Korean Med Sci 2007; 22:693-7. [PMID: 17728512 PMCID: PMC2693822 DOI: 10.3346/jkms.2007.22.4.693] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Sedation is often necessary to optimize care for critically ill children requiring mechanical ventilation. If too light or too deep, however, sedation can cause significant adverse reactions, making it important to assess the degree of sedation and maintain its optimal level. We evaluated the efficacy of the COMFORT scale in assessing optimal sedation in critically ill children requiring mechanical ventilation. We compared 12 month data in 21 patients (intervention group), for whom we used the pediatric intensive care unit (PICU) sedation protocol of Asan Medical Center (Seoul, Korea) and the COMFORT scale to maintain optimal sedation, with the data in 20 patients (control group) assessed before using the sedation protocol and the COMPORT scale. Compared with the control group, the intervention group showed significant decreases in the total usage of sedatives and analgesics, the duration of mechanical ventilation (11.0 days vs. 12.5 days) and PICU stay (15.0 days vs. 19.5 days), and the development of withdrawal symptoms (1 case vs. 7 cases). The total duration of sedation (8.0 days vs. 11.5 days) also tended to decrease. These findings suggest that application of protocol-based sedation with the COMPORT scale may benefit children requiring mechanical ventilation.
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Affiliation(s)
- Hyun-Seung Jin
- Department of Pediatrics, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Mi-sun Yum
- Department of Pediatrics, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Seoung-lan Kim
- Department of Pharmacology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Hye Young Shin
- Department of Pharmacology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Eun-hee Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Eun-Ju Ha
- Department of Pediatrics, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Soo Jong Hong
- Department of Pediatrics, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Seong Jong Park
- Department of Pediatrics, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
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Abstract
The goal of critical care medicine is to support organ function and maintain homeostasis until healing can occur. Sedation and analgesia may blunt the physiologic and psychologic sequelae of intensive care unit stress, and support homeostasis. Although a wide variety of agents have been used empirically, the recognition of analgesia, amnesia, and hypnosis as discrete elements comprising the sedated state has facilitated an individualized approach to therapy. Because intensive care unit patients are a highly heterogeneous population with varying levels of end-organ compromise, the development of specific, easily titratable, parenteral agents has made intensive care unit sedation safer. A trend toward refining dosage regimens in order to minimize the total dose of drug administered and to reduce the occurrence of residual sedation is driven by utilization and cost concerns. The capability for simple bedside electrophysiologic monitoring of the level of sedation is expected to improve the ability to provide optimal therapy.
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Affiliation(s)
- J E Szalados
- Department of Anesthesiology, Division of Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA.
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Ramelet AS, Rees N, McDonald S, Bulsara M, Abu-Saad HH. Development and preliminary psychometric testing of the Multidimensional Assessment of Pain Scale: MAPS. Paediatr Anaesth 2007; 17:333-40. [PMID: 17359401 DOI: 10.1111/j.1460-9592.2006.02115.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND This study aimed to test the preliminary psychometric properties of the Multidimensional Assessment Pain Scale (MAPS), a clinical instrument developed for assessing postoperative pain in critically ill preverbal children. METHODS The MAPS was developed using pain indicators observed in postoperative critically ill infants. Content validity was established by a panel of experts. The scale was tested for validity and reliability in 43 postoperative children aged 0-31 months admitted to the pediatric intensive care units of two tertiary referral hospitals. Pain was measured concurrently by three independent assessors using the MAPS, the Face, Leg, Activity, Cry, and Consolability scale (FLACC) and the Visual Analog Scale (VAS) to assess concurrent and convergent validity. RESULTS Internal consistency was moderate (r = 0.68). Interrater reliability of the MAPS was good (kappa: 0.68-0.84) for all categories and moderate for breathing pattern (kappa = 0.54). Excellent interrater reliability was shown for total MAPS (intraclass correlation 0.91). Agreement measurements between MAPS and FLACC, and MAPS and VAS showed that the risk of measurement error was small. CONCLUSION Although initial psychometric testing of the MAPS shows promising results, the tool requires further psychometric testing, including responsiveness to analgesic effect (currently in progress).
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Abdel-Rahman SM, Reed MD, Wells TG, Kearns GL. Considerations in the rational design and conduct of phase I/II pediatric clinical trials: avoiding the problems and pitfalls. Clin Pharmacol Ther 2007; 81:483-94. [PMID: 17329988 DOI: 10.1038/sj.clpt.6100134] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Over the past decade, there has been a heightened awareness of the need to include children in the drug development process. With this awareness has come an expansion of the infrastructure for conducting studies in children and an increase in the sponsorship of pediatric clinical trials. However, the growth in pediatric research has, in many cases, not been accompanied by an increase in the involvement of trained pediatric investigators when it comes to trial design and/or interpretation. Pediatric phase I/II protocols continue to span a spectrum from those that are carefully constructed to those that are poorly designed. This paper highlights the basic elements of phase I/II protocols that merit unique consideration when the clinical trial involves children. Illustrations are provided from our experience, which highlight problems that may arise when trials are not designed with the pediatric patient in mind.
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Affiliation(s)
- S M Abdel-Rahman
- Division of Pediatric Clinical Pharmacology and Medical Toxicology, The Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA.
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Lamas Ferreiro A, López-Herce J, Sánchez Pérez L, Mencía Bartolomé S, Borrego Domínguez R, Carrillo Alvarez A. [Middle latency auditory evoked potentials in critical care children: preliminary study]. An Pediatr (Barc) 2006; 64:354-9. [PMID: 16606573 DOI: 10.1157/13086524] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Middle latency auditory evoked potentials (MLAEP) reflect changes in electroencephalogram waves after an auditory signal and represent the earliest cortical response to acoustic stimulus. They are therefore used to measure variations in the level of consciousness. MLEAP have been used to measure the depth of anesthesia during surgical procedures, but experience in critical care patients is very limited. OBJECTIVE To analyze the utility of MLAEP for monitoring the level of sedation in critically ill children. METHODS Level of consciousness was monitored through MLAEP by placing special headphones and three sensors situated in the frontal and preauricular regions. Simultaneously, the level of sedation was measured using the COMFORT scale and the Bispectral Index (BIS) in distinct clinical situations. RESULTS We studied six critically ill children in whom MLAEP helped us to evaluate the level of consciousness: light sedation, natural sleep, deep sedation, sedation in a paralyzed child, and brain death. MLAEP showed a good correlation with the COMFORT scale and BIS in light and deep sedation and were effective in the early detection of brain death in one patient. In the paralyzed patient, MLAEP was able to detect undersedation. In one patient, a pacemaker interfered with the MLAEP signal. CONCLUSIONS MLAEP can be useful in evaluating the level of consciousness and sedation in critically ill children. Further studies with larger samples are required to analyze the limitations and reproducibility of this type of monitoring in children of different ages.
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Affiliation(s)
- A Lamas Ferreiro
- Sección de cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Giacoia GP, Mattison DR. Newborns and drug studies: the NICHD/FDA newborn drug development initiative. Clin Ther 2006; 27:796-813. [PMID: 16117987 DOI: 10.1016/j.clinthera.2005.06.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Progress has been made in research on the effects of drug therapy on pediatric patients, but neonates are still an understudied population. Those most likely to receive drug therapy (eg, preterm infants) are least likely to be studied. OBJECTIVES The purposes of this article are to summarize an initiative developed jointly by the National Institute of Child Health and Human Development (NICHD) and the US Food and Drug Administration (FDA) and to introduce a series of articles developed as a result of this initiative. METHODS Information for this article was gathered from the proceedings of a workshop cosponsored by the NICHD and the FDA that took place March 29 and 30, 2004, in Rockville, Maryland. RESULTS : Dosing based on use in adults and older children has resulted in adverse events among newborn infants, and may have long-term effects. Moreover, formulations appropriate for use in neonates are often unavailable, and compensatory efforts such as mixing crushed tablets into formula may interfere with accurate dose delivery. Under the Best Pharmaceuticals for Children Act of 2002, government agencies work with experts in pediatrics and pediatric research to develop and prioritize a list of off-patent drugs for which pediatric studies are urgently needed. Four such listings were published in the Federal Register from January 2003 through January 2005. The NICHD and FDA have also initiated the Newborn Drug Development Initiative (NDDI), a multiphase program to determine gaps in knowledge concerning neonatal pharmacology and clinical trial design and to explore novel study designs for use in newborns, with the ultimate goal of increasing our knowledge about the safety and efficacy of drugs used to treat newborns. CONCLUSIONS Most drugs used to treat newborns still lack appropriate dosing, efficacy, and safety studies in this vulnerable population. The NICHD and FDA developed the NDDI as an ongoing process to identify and suggest strategies for addressing obstacles to conducting drug trials in the newborn.
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Affiliation(s)
- George P Giacoia
- Obstetric and Pediatric Pharmacology Branch, Center for Research for Mothers and Children, National Institute of Child Health and Human Development, National Institutes of Health, Rockville, MD, USA.
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