2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility

The 2023 World delirium awareness and quality Survey: A Canadian substudy

OBJECTIVE

This study aimed to evaluate the proportion of screened patients with delirium and the strategies used for its management in Canadian hospitals caring for critically ill children or adults.

METHODS

This is a secondary analysis of a cross-sectional study completed on World Delirium Awareness Day (March 15, 2023). Respondents completed a 35-question survey on the proportion of screened patients with delirium (at 8:00 am and 8:00 pm), treatment, and management strategies employed.

RESULTS

A total of 27 ICUs (22 adult and 5 pediatric) participated. Among adult ICU patients assessed for delirium, 18 % (n = 34/194) had delirium at 8:00 am and 18 % (32/181) had delirium at 8:00 pm. In pediatric ICUs, the proportion of screened patients with delirium was higher, with 50 % (n = 8/16) at 8:00 am and 44 % (n = 7/16) at 8:00 pm. Delirium management strategies varied: with non-pharmacological approaches such as multi-professional rounds (100 %), pain management (96 %), and mobilization (85 %) being most common. The most reported written delirium management protocols included spontaneous breathing trials in adult ICUs and physical restraint and sedation management in PICUs. Few ICUs reported written protocols for family engagement and empowerment.

CONCLUSIONS

Delirium remains a prevalent issue in Canadian ICUs, with variability in assessment and management strategies. Gaps in family engagement and pediatric-specific protocols persist. Addressing barriers like staff shortages and lack of training is critical to improving care.

IMPLICATIONS FOR CLINICAL PRACTICE

Improving delirium management requires standardized protocols, especially in PICUs, and better integration of family engagement in care. Addressing workforce challenges (e.g., staff shortages and educating new staff on delirium) will be crucial for enhancing delirium prevention and treatment in Canadian ICUs. Further research should focus on pediatric-specific interventions and pharmacological management.

Enhanced recovery in cardiac surgery patients with frailty through comprehensive perioperative nursing interventions: A randomized controlled trial

ObjectiveTo evaluate the effects of comprehensive perioperative nursing interventions on postoperative recovery in cardiac surgery patients with frailty, with a focus on physical activity, nutritional status, and cognitive function.DesignA prospective, randomized, single-blind, parallel-group design with a 1:1 allocation ratio.SettingCardiac surgery department in a tertiary care hospital.ParticipantsThis study included 300 patients with frailty after cardiac surgery. Using a computer-generated random number table, patients were randomly assigned to the experimental group (150 patients) and the control group (150 patients). The intervention group received preoperative psychological counseling, targeted nutritional support, skincare, and continuous hemodynamic monitoring; the control group received routine care, including postoperative vital sign monitoring, basic nutritional support, wound care, and standard cardiovascular assessments (e.g., heart rate and blood pressure).Primary outcomesPostoperative recovery was assessed through improvements in physical activity (Barthel Index), nutritional status (Mini Nutritional Assessment), cognitive function (Mini-Mental State Examination), biostatistical data and cardiopulmonary function indicators.ResultsThe intervention group showed significant improvements: Barthel Index increased by 20 points (95% CI: 15-25, p < 0.01), Mini Nutritional Assessment scores by 3 points (95% CI: 1-5, p < 0.05), and Mini-Mental State Examination scores by 4 points (95% CI: 2-6, p < 0.05). Hospital stay was reduced by 5 days (95% CI: 3-7, p < 0.01), and the 6-month survival rate was 10% higher (95% CI: 5-15%, p < 0.05) compared to the control group.ConclusionsComprehensive perioperative nursing interventions significantly improve postoperative recovery, self-care ability, nutritional status, cognitive function, and short-term survival in cardiac surgery patients with frailty.

Validity and reliability of the Critical-Care Pain Observation Tool (CPOT) for critically ill pediatric patients

INTRODUCTION

In some regions, critically ill pediatric and adult patients are cared for in the same intensive care unit, complicating pain assessment due to mixed age groups. To address this, it is essential to use pain scales that are applicable to a wide age range. The Critical-Care Pain Observation Tool (CPOT) was developed to assess pain in both intubated and non-intubated adult patients. However, its applicability in pediatric patients has not been confirmed. The purpose of this study was to evaluate CPOT for critically ill pediatric patients.

METHODS

We conducted a prospective observational study in an eight-bed open PICU from January 2022 to March 2023. Three research nurses independently assessed pain using CPOT, the Face, Legs, Activity, Cry, Consolability (FLACC) scale, and an Observational Visual Analog Scale (VAS obs). Criterion-related and construct validity were examined using Spearman's rank correlation coefficients between CPOT, VAS obs, and FLACC. Diagnostic performance was evaluated via ROC analysis using a FLACC score ≥ 4 as the reference. CPOT scores with and without medical interventions were compared using the Mann-Whitney U test, and inter-rater reliability was assessed with Cohen's weighted κ.

RESULTS

Ninety-one patients were observed 165 times. CPOT strongly correlated with VAS obs (Spearman's ρ =  0.87, p <  0.01) and FLACC (Spearman's ρ =  0.84, p <  0.01). At a CPOT cut-off score of 3, sensitivity was 100% and specificity was 96.7%. CPOT effectively reflected pain levels during medical interventions (p <  0.01), and inter-rater reliability was high (weighted κ =  0.89, 95% CI: 0.799-0.941).

CONCLUSIONS

This study suggests that CPOT may be a useful tool for pain assessment in pediatric patients.

Implementing Early Mobility Practices in a Respiratory Care Unit: A Quality Improvement Project

BACKGROUND

Early mobility (EM) is beneficial for critically ill patients, but adoption in intermediate care units remains limited.

LOCAL PROBLEM

At the project site, fewer than 10% of patients admitted to the respiratory care unit (RCU) engaged in EM due to clinical severity, lack of staff confidence, and limited collaboration with physical therapy.

METHODS

A pre- postimplementation quality improvement design was used to assess mobility outcomes.

INTERVENTIONS

A nurse-driven EM program was implemented in a 10-bed RCU at a tertiary center. A multidisciplinary team delivered staff education, introduced an evidence-based protocol, and addressed barriers.

RESULTS

Forty-eight patients were included in the project (22 preimplementation and 26 postimplementation). The number of physical therapy consultations increased from 36% to 73% (P= .01), with 69% of patients achieving higher discharge mobility postimplementation versus 59% preimplementation. Length of stay and mortality were unchanged.

CONCLUSIONS

EM practices improve mobility in intermediate care through education and collaboration.

[Environmental sustainability in intensive care medicine]

Intensive care medicine is an area with a particularly high consumption of resources. This review presents important new findings relating to the environmental sustainability of intensive care medicine. For example, the drugs used in intensive care medicine can end up in the environment and cause relevant ecotoxicity. The consumption of material items is very high in intensive care medicine and the increasing replacement of reusable items by disposable items is a major problem. Simple measures can reduce the ecological footprint of materials and introduce the recycling of waste in intensive care units. The high energy consumption of air conditioning, lighting and medical technology varies between facilities but in most cases is substantial and can be significantly reduced through appropriate measures. Ideally, the consumption should be measured and analyzed in detail. In the future, support from artificial intelligence is conceivable in this aspect. Sustainability must be given a much higher priority in the training, continued and advanced education in intensive care medicine than it has been to date and in intensive care research sustainability aspects should be given equal consideration alongside economic aspects when it comes to assessing otherwise equivalent treatments. It is particularly important to avoid the misuse and overuse of intensive care. It brings no benefit to patients and hinders needs-based treatment that is oriented towards the patient's well-being. In addition, misuse and overuse increases costs and drives up the consumption of resources and thus the ecological footprint. Sustainability in the intensive care unit can only be achieved as a team. Various approaches are presented on how a networked Green Team can promote sustainability in the intensive care unit.

A Comparison of the Effect of Two Doses of Oral Melatonin as Premedication on Orientation Score, Induction Compliance, and Emergency Agitation of Children Undergoing Elective Surgeries: A Double-Blinded Randomized Trial

Background: Following sedation or general anesthesia, emergent agitation (EA) presents as a sequence of abrupt, complicated psychomotor problems marked by perceptual abnormalities, delusions, and disorientation. Studies have proved that melatonin significantly decreases the incidence of postoperative agitation in children after anesthesia. The primary objective of this study was to compare the effectiveness of two doses of oral melatonin as a premedication for orientation score, induction compliance, and emergency agitation of children undergoing surgeries. Methods: In this double-blinded randomized controlled trial, 126 children, aged 4-14, of either sex, with an ASA I or II, scheduled for elective surgery were randomly assigned to get either melatonin 0.4 mg/kg (Group M4) or melatonin 0.2 mg/kg (Group M2), with 63 kids in each group. All children have had the same anesthetic strategy. As a primary outcome, orientation score, induction compliance to intravenous induction anesthesia, and decreased emergency agitation were assessed. Results: Both groups were comparable in terms of demographic characteristics and baseline data. Orientation scores were similar between the groups. Preoperatively, all patients were oriented in both time and place. The two groups had no statistically significant difference according to induction compliance distribution (p=0.065). There was a statistically significant difference in agitation behavior after 5, 10, and 15 min postoperatively in M 4, 2, and total participants (p < 0.001). Conclusion: In pediatric surgical patients, the melatonin dosage does not affect children's compliance with induction but impacts their postoperative behavior by reducing the likelihood of agitation. Administering oral melatonin before surgery could potentially aid in managing postoperative delirium in children.

Outcomes in early mobilisation research in critically ill children: A scoping review

OBJECTIVE

Early mobilisation in critically ill children is safe and feasible. However, the effectiveness of early mobilisation on short- and long-term outcomes is understudied. The aim of this scoping review was to generate an overview of outcomes used in previous research regarding early mobilisation in critically ill children.

DATA SOURCES

A systematic search was performed in Medline, Embase, Cochrane library, and CINAHL, without restricting on design, on April 3rd, 2023.

STUDY SELECTION

Two independent reviewers assessed titles, abstracts, and full texts. Studies were included if they described any outcomes related to early mobilisation in critically ill children.

DATA CHARTING PROCESS

One reviewer performed data extraction, which was subsequently verified by another reviewer. Seven domains were used to categorise the outcomes: mortality, physiological, life impact, resource use, adverse events, process indicators, and perception of early mobilisation.

DATA SYNTHESIS

Out of 3380 screened titles, 25 studies were included. Data extraction yielded 148 unique outcomes, which were clustered into 40 outcomes. Outcomes spanned in all seven domains, with "length of paediatric intensive care unit stay" (resource use) and "adverse events involving unintentional removal of catheters, tubes, and/or lines" (adverse events) being the most frequently reported. Process indicators such as mobilisation activities were well documented. Mortality and functionality outcomes were chosen the least.

CONCLUSIONS

This scoping review provides a categorised overview of outcomes that have been used to assess the effectiveness of early mobilisation in critically ill children. The findings show a great heterogeneity in used outcomes and are input for paediatric intensive care unit experts and parents to prioritise outcomes developing a Core Outcome Set.

Visceral Pain in Preterm Infants with Necrotizing Enterocolitis: Underlying Mechanisms and Implications for Treatment

Necrotizing enterocolitis (NEC) is a relatively rare but very severe gastrointestinal disease primarily affecting very preterm infants. NEC is characterized by excessive inflammation and ischemia in the intestines, and is associated with prolonged, severe visceral pain. Despite its recognition as a highly painful disease, current pain management for NEC is often inadequate, and research on optimal analgesic therapy for these patients is lacking. Insight into the mechanisms underlying intestinal pain in infants with NEC-visceral pain-could help identify the most effective analgesics for these vulnerable patients. Therefore, this comprehensive review aims to provide an overview of visceral nociception, including transduction, transmission, modulation, and experience, and discuss the implications for analgesic therapy in preterm infants with NEC. The transmission of visceral pain differs from that of somatic pain, contributing to the diffuse nature of visceral pain. Studies evaluating the effectiveness of analgesics for treating visceral pain in infants are scarce. However, research in visceral pain models highlights agents that may be particularly effective for treating visceral pain based on their mechanisms of action. Further research is necessary to determine whether agents that have shown promise for treating visceral pain in preclinical studies and adults are effective in infants with NEC as well.

Refractory agitation in the NICU: challenges in prevention, diagnosis, and treatment

In this paper we explore refractory agitation in the neonatal population, focusing on the limitations of existing evidence on appropriate prevention, diagnosis, and treatment options. We highlight seven patients identified in an urban single-center level IV NICU with agitation unresponsive to standard non-pharmacologic interventions and escalation of standard neurosedative medications. We analyzed baseline characteristics and clinical courses of these patients with the aim to identify the NICU subpopulation at greatest risk for development of refractory agitation and to gain insight into the potential benefits of alternative medical management of agitation on later neurodevelopment. Based on these experiences we propose a practical approach to infants at increased risk for refractory agitation including standardized screening guidelines and a clinical pathway for developmentally appropriate non-pharmacologic and pharmacologic management.

Increased sound levels in the cardiac ICU are associated with an increase in heart rate, blood pressure, and sedation

BACKGROUND

Several organizations including the Environmental Protection Agency, World Health Organization and American Academy of Pediatrics recommend that hospital sound levels not exceed 45 decibels. Yet, several studies across multiple age groups have observed higher than recommended levels in the intensive care setting. Elevated sound levels in hospitals have been associated with disturbances in sleep, patient discomfort, delayed recovery, and delirium.

METHODS

We measured sound levels in a pediatric cardiac intensive care unit and collected vital signs data, sedation dosing and delirium scores. During a 5-week study period, sound levels for 68 patients in 22 private and 4 semi-private rooms were monitored.

RESULTS

Sound levels were consistently above stated recommendations with an average daytime level of 50.6 decibels (maximum, 76.9 decibels) and an average nighttime level of 49.5 decibels (maximum, 69.6 decibels). An increase in average and maximum sound levels increased the probability of sedation administration the following hour (p-value < 0.001 and 0.01, respectively) and was predictive of an increase in heart rate and blood pressure (p-value < 0.001).

CONCLUSION

Sound levels in the CICU were consistently higher than recommended. An increase in heart rate, blood pressure and sedation utilization may suggest a stress response to persistent and sudden loud sounds. Given known negative impacts of excessive noise on stress, sleep, and brain development, as well as the similar adverse effects from the related use of sedative medications, reducing excessive and sudden noise may provide an opportunity to improve short- and long-term hemodynamic and neurodevelopmental outcomes in the pediatric cardiac intensive care unit.

Building global collaborative research networks in paediatric critical care: a roadmap

Paediatric critical care units are designed for children at a vulnerable stage of development, yet the evidence base for practice and policy in paediatric critical care remains scarce. In this Health Policy, we present a roadmap providing strategic guidance for international paediatric critical care trials. We convened a multidisciplinary group of 32 paediatric critical care experts from six continents representing paediatric critical care research networks and groups. The group identified key challenges to paediatric critical care research, including lower patient numbers than for adult critical care, heterogeneity related to cognitive development, comorbidities and illness or injury, consent challenges, disproportionately little research funding for paediatric critical care, and poor infrastructure in resource-limited settings. A seven-point roadmap was proposed: (1) formation of an international paediatric critical care research network; (2) development of a web-based toolkit library to support paediatric critical care trials; (3) establishment of a global paediatric critical care trial repository, including systematic prioritisation of topics and populations for interventional trials; (4) development of a harmonised trial minimum set of trial data elements and data dictionary; (5) building of infrastructure and capability to support platform trials; (6) funder advocacy; and (7) development of a collaborative implementation programme. Implementation of this roadmap will contribute to the successful design and conduct of trials that match the needs of globally diverse paediatric populations.

Management of severe traumatic brain injury in pediatric patients: an evidence-based approach

BACKGROUND

Traumatic brain injury (TBI) is a major cause of death and disability worldwide. The decision-making process in the management of severe TBI must be based on the best available evidence to minimize the occurrence of secondary brain injuries. However, healthcare approaches to managing TBI patients exhibit considerable variation.

METHODS

Over an 18-month period, a multidisciplinary panel consisting of medical doctors, physiotherapists, nutritional therapists, and nurses performed a comprehensive review on various subtopics concerning TBI. The panel identified primary questions to be addressed using the Population, Intervention, Control, and Outcome (PICO) format and applied the Evidence to Decision (EtD) framework criteria for evaluating interventions. Subsequently, the panel formulated recommendations for the management of severe TBI in children.

RESULTS

Fourteen evidence-based recommendations have been devised for the management of severe TBI in children, covering nine topics, including imaging studies, neuromonitoring, prophylactic anticonvulsant use, hyperosmolar therapy, sedation and analgesia, mechanical ventilation strategies, nutritional therapy, blood transfusion, and decompressive craniectomy. For each topic, the panel provided clinical recommendations and identified research priorities.

CONCLUSIONS

This review offers evidence-based strategies aimed to guide practitioners in the care of children who suffer from severe TBI.

A NICU Postoperative Pain Management Improvement Project to Reduce Uncontrolled Pain and Improve Staff Satisfaction

BACKGROUND

Postoperative pain management in the neonatal period is an area of high variability and a source of staff dissatisfaction. Pain management is a key component of high-quality care; however, pain assessment in infants is difficult and analgesics can negatively impact the developing brain.

PURPOSE

We aimed to improve postoperative pain control for infants in our neonatal intensive care unit (NICU), limit variability in the approach to pain management, and increase staff satisfaction.

METHODS

This project was completed between April 2019 and March 2022 with sustainment tracked through December 2023. Interventions took place in a 70-bed level IV NICU using quality improvement methodology. Interventions included efforts aimed at improving pain assessment as well as development and implementation of a pain management guideline. Outcome measures included frequency of uncontrolled postoperative pain and measures of staff satisfaction. Process measures included compliance with pain assessment cadence and guideline recommendations. Opioid exposure within 24 hours of surgery was included as a balancing measure.

RESULTS

Pain management was assessed in 811 infants: 392 prior to guideline implementation, 273 during implementation, and 146 during sustainment period. Uncontrolled postoperative pain decreased from 26% pre-implementation to 18% post implementation and into the sustainment period. Staff satisfaction improved from 67% to 83%. These improvements were associated with decreased variability in postoperative pain management and a decrease in postoperative opioid exposure.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The use of a postoperative pain management guideline can improve pain control, decrease drug regimen variability, decrease opioid exposure, and increase staff satisfaction.

Assessment of delirium in Indonesian pediatric intensive care unit: a psychometric evaluation of the Cornell Assessment of Pediatric Delirium

This study has the objective to translate the Cornell Assessment of Pediatric Delirium (CAPD) into Indonesian and evaluate the psychometric properties and diagnostic accuracy of the Indonesian version of the CAPD (I-CAPD) in identifying delirium in critically ill children. This prospective methodological study was conducted between January and April 2024 in a 6-bed pediatric intensive care unit (PICU). In total, 90 children aged 0-18 years hospitalized in the PICU were included. Bedside nurses administered the I-CAPD every shift, while delirium diagnoses were confirmed by a psychiatrist by using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. A receiver operating characteristic (ROC) curve analysis was conducted to examine the sensitivity and specificity of the I-CAPD. The mean age was 8 years, with 53% being girl. According to DSM-5 criteria, 55.6% of the children had PICU delirium. Cronbach's α and interclass correlation coefficient for the I-CAPD were 0.94 and 0.94, respectively. The I-CAPD exhibited a single-factor structure accounting for 72% of the total variance. The I-CAPD was significantly associated with pain assessments (r = 0.32, P < 0.001). The ROC curve analysis indicated an optimal cutoff of ≥ 9, with the sensitivity, specificity, and area under curve of 92%, 93%, and 0.96, respectively.

CONCLUSION

The I-CAPD demonstrates reliable psychometric properties and diagnostic accuracy for detecting delirium in critically ill children. Future studies should explore the impact of routine I-CAPD screening on clinical outcomes and targeted interventions for pediatric delirium.

WHAT IS KNOWN

• Delirium in pediatric intensive care units (PICUs) is prevalent and associated with adverse outcomes, yet its diagnosis remains challenging, particularly in low-resource settings. • The Cornell Assessment of Pediatric Delirium (CAPD) has been validated in multiple languages and contexts but has not been adapted for use in Indonesian-speaking populations.

WHAT IS NEW

• This study demonstrates the successful translation and psychometric evaluation of the Indonesian version of the CAPD (I-CAPD), confirming its reliability and validity in identifying delirium in critically ill Indonesian children. • The I-CAPD provides a standardized tool with high diagnostic accuracy (sensitivity: 92%; specificity: 93%) for routine delirium screening in Indonesian PICUs.

State-of-the-art anesthesia practices: a comprehensive review on optimizing patient safety and recovery

OBJECTIVE

This review explores recent advancements in anesthesia care, focusing on the integration of innovative practices to enhance patient outcomes across the perioperative period.

METHODS

Following the framework of Whitmore and Knafl, we systematically searched six databases (PubMed, Google Scholar, EMBASE, CINAHL, OVID, and Cochrane Library) for studies published from January 2020 to January 2024, relating to advancements in anesthesia care, best practice implementation, and patient outcomes. After independent screening and data extraction by two reviewers, the review focuses on innovations in anesthetic drugs, monitoring technologies, anesthesia techniques, and evidence-based practices in anesthesia and clinical guidelines.

RESULTS

Of the 25,984 studies retrieved, 26 met inclusion criteria. Recent developments in anesthetic drugs have improved safety and efficacy, reducing complications. Advanced monitoring devices, such as multiparameter and brain function monitors, have enhanced patient safety through real-time assessments. Innovations in regional anesthesia and ultrasound-guided nerve blocks have led to better pain management, reduced recovery time, and minimized morbidity. Additionally, evidence-based practices like comprehensive preoperative assessment, patient education, and multidisciplinary teamwork significantly improved patient outcomes.

CONCLUSION

Integrating the latest innovations and best practices in anesthesia care is essential for optimizing patient outcomes. Ongoing research and adoption of advanced technologies are crucial to addressing current challenges and enhancing anesthesia quality. This review emphasizes the importance of a holistic approach from preoperative preparation to postoperative recovery to achieve optimal patient outcomes.

Recognition and Management of Delirium in the Neonatal Intensive Care Unit: Case Series From a Single-Center Level 4 Intensive Care Unit

Delirium often goes unrecognized in neonates and children because of lack of experience in evaluating behavior and cognition, insufficient awareness of the prevalence, and nondistinctive symptoms in this population. Although there are increasing reports of the presence of delirium in neonates, there are few data to guide the pharmacologic treatment in this population. In this retrospective single-center case series, we present our experience using quetiapine to treat delirium in 9 medically complex neonates. Based on an extensive literature review, expert opinion, and institutional experience, we propose an approach for monitoring and treating delirium in neonates and infants.

Keep Moving: Sustainability of an Early Mobility Protocol in an Academic Pediatric ICU

Introduction

Mobilization protocols are safe and feasible for critically ill pediatric patients in the intensive care unit (ICU), but barriers exist to sustainability. This study described a focused early mobility protocol, sustained over 5 years, which is on time for therapy consults and patient mobilization at a single institution.

Methods

A formal ICU mobility protocol was implemented as part of a unit-wide ICU liberation bundle. As part of the ongoing program assessment, over a specific 3-month timeframe annually from 2017 to 2023, the number of physical and occupational therapy (PT/OT) consults, mobilization rate, and time to PT/OT consult were analyzed. In addition, in 2023, we assessed specific barriers to early PT/OT consultation.

Results

Annually, for each study timeframe, there was a sustained decrease in time to therapy consult from a mean of 3.8 days for PT and 7 days for OT in 2017 to 1.9 and 1.6 days, respectively, in 2023. Similarly, the mobilization rate increased from 20.3 sessions per 100 patient days in 2017 to 48.2 in 2023. There was a trend toward missed or delayed therapy consults at times of higher ICU census. No adverse events were associated with mobilization.

Conclusions

An ICU early mobility protocol leads to a sustained decrease in the time to therapy consultation, an increase in the number of therapy consults, and an increase in the mobilization rate. Future interventions should focus on mitigating barriers to timely consultation, specifically at times of higher ICU census.

Development and Preliminary Testing of the Withdrawal Assessment Tool-Alpha 2 Agonist: An Assessment Instrument for Monitoring Iatrogenic Withdrawal Symptoms in Children Receiving an Alpha-2 Agonist

OBJECTIVES

To develop and conduct preliminary testing of the Withdrawal Assessment Tool-Alpha 2 Agonist (WAT-A2A) to monitor dexmedetomidine and clonidine withdrawal symptoms in acutely ill children.

DESIGN

Three-phase instrument development study. Phase 1: retrospective chart review of symptoms exhibited by children with documented dexmedetomidine withdrawal; phase 2: WAT-A2A instrument construction based on phase 1 data; and phase 3: prospective testing of the WAT-A2A in children weaning from alpha 2 agonists (A2As).

SETTING

Academic free-standing children's hospital.

PATIENTS

Acutely ill children weaning from at least 5 days of dexmedetomidine. Excluded were children concurrently weaning other sedatives.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Phase 1: In 83 of 303 children weaning from at least 5 days of dexmedetomidine who had clinician documentation and were managed for A2A withdrawal, 88% ( n = 72) exhibited at least a 20% increase in heart rate (HR), 83% ( n = 69) exhibited agitation or change in usual state behavior, 46% ( n = 38) exhibited at least a 20% increase in diastolic blood pressure (DBP), and when documented, 56% (27/48) exhibited tremors during their A2A withdrawal episode. Phase 2: The WAT-A2A was constructed, based on phase 1 data, and includes four items: HR, state behavior, DBP, and tremors. Phase 3: The WAT-A2A was tested and performed well in 82 children weaning from A2A. The total WAT-A2A score correlated with clinician subjective assessment of A2A withdrawal (Spearman correlation = 0.5; p < 0.001). Inter-rater agreement, comparing paired ratings of prospectively collected WAT-A2A data, indicated moderate inter-rater reliability.

CONCLUSIONS

Acutely ill children receiving sedation with an A2A for more than 5 days may develop physiologic dependence, requiring gradual dosing reductions. While further psychometric testing is advised, the WAT-A2A provides an objective instrument to help clinicians quantify dexmedetomidine withdrawal symptoms in acutely ill children may facilitate A2A weaning and limit unnecessary variation in practice.

Using Implementation Science to Assess Barriers to Agreement on Sedation Goal Setting and Assessment

OBJECTIVES

Sedation assessment and goal setting using a validated assessment tool are key components of the ICU Liberation bundle. Appropriate integration of these bundle elements into daily practice remains challenging. Understanding barriers is an important step toward implementation of these best practice bundle elements.

DESIGN

Two-phased explanatory mixed methods assessment carried out 2022-2023.

SETTING

Forty-bed quaternary PICU.

SUBJECTS

Bedside nurses and prescribers caring for mechanically ventilated patients on sedative infusions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Forty-one nurses and 32 prescribers participated in the phase 1 pre-education assessments (2022). We identified lack of correlation between the providers' stated State Behavioral Scale (SBS) numerical goal and descriptive goal and hypothesized that this discrepancy was either due to a knowledge gap or disagreement on sedation goals. To investigate this hypothesis, we performed a phase 2 assessment (2022-2023), starting with a multipronged educational activity, followed by a repeat survey that included a qualitative interview. One hundred ninety nurses and 45 prescribers received the educational activity. Twenty-eight nurses and 22 prescribers participated in the phase 2 assessments with the qualitative interview. Although correlation of the sedation goal between providers improved, it remained poor. Subsequent qualitative interview data indicated that the reasons for persistent disagreement in the sedation goal for a given patient were related to individual providers' beliefs and attitudes toward sedation, rather than lack of understanding about using the SBS to set a target sedation goal.

CONCLUSIONS

Barriers to setting and managing daily patient sedation goal in the PICU extend beyond providers' knowledge gaps. An improved understanding of underlying barriers is essential for successful implementation of evidence-based sedation guidelines.

Planning a Phased Guideline Implementation Strategy Across the Multicenter Ventilation Liberation for Kids (VentLib4Kids) Collaborative

OBJECTIVES

To evaluate contextual factors relevant to implementing pediatric ventilator liberation guidelines and to develop an implementation strategy for a multicenter collaborative.

DESIGN

Cross-sectional qualitative analysis of a 2023/2024 survey.

SETTING

International, multicenter Ventilation Liberation for Kids (VentLib4Kids) collaborative.

SUBJECTS

Physicians, advanced practice providers, respiratory therapists, and nurses.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The survey was distributed to 26 PICUs representing 18 unique centers (17 in North American)-14 general medical/surgical, eight cardiac, and four mixed (1935 solicitations). All 409 responses were analyzed (prescribers 39.8%, nursing 32.8%, and respiratory therapists 27.4%). Three implementation tiers were identified based on perceptions of evidence, feasibility, positive impact, and favorability constructs. Tier A (≥ 80% agreement for all constructs) included extubation readiness testing (ERT) screening, ERT bundle, spontaneous breathing trials (SBTs), upper airway obstruction (UAO) risk mitigation, and risk stratified noninvasive respiratory support (NRS). Tier B (50-79% agreement) included standard risk SBT method, risk stratified SBT duration, and UAO risk assessment. Tier C (< 50% agreement) included high-risk SBT method, respiratory muscle strength testing, and infant NRS. The smallest perceived practice gaps were noted in tier A and the largest in tier C. The smallest practice gap was risk stratified NRS (88% agreement). The largest practice gap was respiratory muscle strength (18% agreement). In regression analysis, independently significant differences in perceptions based on role and unit type for multiple constructs were identified for UAO risk assessment, UAO risk mitigation, risk stratified NRS, and infant NRS.

CONCLUSIONS

This survey study of the VentLib4Kids collaborative lays the foundation for phased implementation of the 2023 pediatric ventilator liberation guidelines. Early phases should focus on the best implementation profiles and smallest practice gaps. Later phases should address those that are more challenging. Unit- and role-based tailoring of differences should be considered for some recommendations more than others.

Neonatal delirium

Delirium is a common and serious complication of critical illness that has been increasingly recognized in pediatric patients. There have been several published cases of delirium in newborns and infants over the last decade, though research on neonatal delirium is severely lacking. The true prevalence of delirium and its associated consequences in this population remain unknown, although the risk of delirium in this population appears to be elevated compared to older youth. The current approach to management of delirium in neonates is extrapolated from older children. In the present review, the pathophysiology and clinical presentation of delirium are outlined. Strategies for prevention, evaluation, and management of delirium in neonates are explored.

Altered Mental Status and Delirium in Pediatric Patients

Mental status is the collection of an individual's consciousness, perception, emotion, memory, and cognition at a particular point in time, which is inferred by the clinician through careful observation and interaction. The pediatric mental status assessment must be approached with an understanding of cognitive, language, and psychosocial development. Alterations must then be comprehensively and clearly described. Delirium is a phenotypic diagnosis with a specific set of criteria in the DSM and is a serious neurocognitive disorder caused by physiologic changes due to illness, injury, toxins, medications, and/or substances. Recognition of delirium in children is improved by monitoring of predisposing risks and precipitating factors, as well as the regular use of validated pediatric screening tools. Management of delirium is focused on treatment of the underlying etiology, prevention of iatrogenic deliriogenic factors, and patient safety.

Prolonged magnesium sulfate infusion as adjuvant analgesia in postoperative transplant patients in the pediatric ICU: Preliminary results of a feasibility study

The opioid crisis has emphasized identification of opioid-sparing analgesics. This study was designed as a prospective trial with retrospective control group to determine feasibility for implementing a high-dose prolonged magnesium sulfate infusion for adjuvant analgesia in the pediatric intensive care unit. Approval was granted for study of children receiving total pancreatectomy with islet cell autotransplantation and liver transplantation ages 3-18 years. Study exclusions were pregnancy, neuromuscular disease, hypersensitivity, preoperative creatinine >1.5 times upper limit normal, arrhythmia or pacemaker presence, and clinician concern. Eleven patients were enrolled between January 2020 and December 2022. Magnesium sulfate bolus (50 mg/kg) followed by intravenous infusion (15 mg/kg/h) was initiated in the operating room and extended postoperatively (maximum 48 h). Serum magnesium levels were monitored serially. To prioritize safety, infusion dose was decreased by 5 mg/kg/h for levels greater than 3.5 mg/dL. Clinical team otherwise followed standard multimodal pain practice. Primary outcome was oral morphine equivalent per kg per day during intensive care course (maximum 7 days). Secondary outcomes focused primarily on magnesium safety, including hemodynamic variables, electrolyte variables, respiratory support, and opioid-related side effects. There were no serious adverse events. Treatment group trended toward slightly higher intravenous fluid requirement (~1 bolus), however no increase in blood product. Treatment and control groups were otherwise comparable in targeted outcomes and overall adverse event profile. Use of a high-dose magnesium sulfate infusion protocol for analgesic postoperative use in select transplant recipients appears feasible for continued optimization of study in the PICU.

Delirium in the ICU: how much do we know? A narrative review

Delirium in critical ill patients is a complex and common neurological syndrome in the intensive care unit (ICU) that is caused by a range of structural or functional abnormalities. ICU Delirium is associated with reduced compliance, prolonged hospital stays, greater use or delayed withdrawal of sedatives, higher rates and durations of mechanical ventilation, and higher rates of mortality. The aetiology and pathogenesis of ICU delirium are unclear, and the lack of better prediction, prevention, and treatment measures leads to a non-standardized control of delirium. By searching the relevant literature, we aim in this narrative review to describe progress in the pathogenesis, predictive biomarkers, diagnosis, and treatment of ICU delirium.

Current Evidence Regarding the Evaluation and Management of Neonatal Delirium

PURPOSE OF REVIEW

Newborns and infants in the neonatal intensive care unit (NICU) may be at uniquely high risk of developing delirium. Because there is a dearth of NICU-focused literature, providers must rely on evidence derived from older children and infants in other care settings to guide management. The literature was rigorously reviewed to highlight evidence specific to newborns and infants and is summarized here.

RECENT FINDINGS

Delirium likely occurs in newborns and infants at similar or higher rates than what is seen in other care settings. Recent literature calls particular attention to the lack of assessment tools validated in a NICU setting. Evidence for the evaluation and management of delirium in the NICU is lacking. More study specific to the NICU is needed to build consensus toward best practice.

Moral Distress and Pain Management: Implications for Critical Care Nurses

Nurses have an ethical responsibility to manage pain and the suffering derived from it. Given the complexity of patients in the critical care setting and the high incidence of pain experienced by critically ill patients, critical care nurses may experience moral distress when pain is inadequately managed. To address moral distress associated with pain management, critical care nurses should be provided with education on evidence-based pain management practices and encouraged to evaluate their personal biases and beliefs regarding pain management. Furthermore, organizations should consider the implementation of programs to address moral distress stemming from pain management and other precipitating factors.

Sedation - analgesia - muscle relaxant - withdrawal and delirium practices in pediatric intensive care units in Türkiye

BACKGROUND

Pain and sedation management is an integral part of pediatric intensive care practice. Sedoanalgesia management must be balanced in order to optimize comfort and avoid complications. In order to achieve this balance, sedoanalgesia management needs to be clarified in pediatric intensive care units (PICU). With this study, we aimed to investigate sedation, analgesia, withdrawal and delirium practices, pharmacologic agent preferences, and current experiences and practices in scoring systems in PICUs in Türkiye.

METHOD

A questionnaire consisting of 57 questions was sent via e-mail to the 'Pediatric Intensive Care and Emergency' group, which includes all intensive care specialists, subspecialty students and lecturers in Türkiye.

RESULTS

Our study involved 36 pediatric intensive care physicians working in PICUs in Türkiye. Among the PICU specialists who participated in the study, 83.3% stated that they performed routine assessments of sedation efficacy. While dexmedetomidine was the most commonly used sedative agent in patients undergoing noninvasive mechanical ventilation, benzodiazepines were the most preferred pharmacologic agent for sedation during mechanical ventilation. Of the pediatric intensivists who participated in the study, 94.4% stated that they performed routine pain assessments in their units. Of the PICU specialists who participated in the study, 69.4% stated that muscle relaxants were most commonly used to prevent patient-ventilator incompatibility during mechanical ventilation. Of the participants, 88.8% made withdrawal assessments when discontinuing sedo-analgesic agents. Delirium assessment was routinely performed by 58.3% of the participants.

CONCLUSIONS

This study showed that the practices in sedoanalgesia management in PICUs in Türkiye are in parallel with recommendations of the sedation guideline. Despite the increased sensitivity in sedoanalgesia management, awareness in the management of delirium and withdrawal syndrome is not at the desired level. Therefore, there is a need to develop guidelines, raise awareness and increase training on these issues in our Türkiye.

Early progressive mobility to improve neurodevelopment of infants with severe bronchopulmonary dysplasia at a level IV neonatal intensive care unit: a prospective cohort study

OBJECTIVE

To measure the feasibility of early progressive mobility (EPM) in intubated infants with severe bronchopulmonary dysplasia (BPD) and compare neurodevelopmental skill acquisition of these infants before and after implementation of a clinical EPM program.

STUDY DESIGN

Single-center pre-post intervention prospective cohort study in a level IV Neonatal Intensive Care Unit (NICU) from 2019-2022. Bivariate tests compared EPM interventions and results of serial Test of Infant Motor Performance (TIMP) assessments in 32 intubated infants with severe BPD cared for during two epochs, before and after NICU-wide EPM implementation.

RESULTS

Infants in epoch 2 experienced significantly more EPM interventions than infants in epoch 1. Infants in epoch 2 also had more advanced motor skills on the TIMP than infants in epoch 1. There were no unplanned extubations.

CONCLUSIONS

We demonstrated successful implementation of EPM in this high-risk population with evidence of beneficial impacts on early motor development.

The roles and patterns of critical care pharmacists: a literature review and practical operation model in China

Drug-related problems (DRPs) are prevalent in critically ill patients and may significantly increase mortality risks. The participation of critical care pharmacists (CCPs) in the medical team has demonstrated a benefit to healthcare quality. Research indicates that CCP medication order evaluations can reduce DRPs, while their participation in rounds can reduce adverse drug events and shorten hospital stays. Pharmacist medication reconciliation often proves more effective than physicians, and CCPs play a crucial role in antimicrobial management and reducing treatment costs. Despite these benefits, there is a noticeable lack of practical guidance for implementing CCP roles effectively. Their workflow heavily influences the efficiency of CCPs. Integrating results from the literature with our practical experience, we have detailed workflows and critical entry points that CCPs can refer to. Pharmacists should be proactive rather than passive consultants. Pre-round medication order evaluations are crucial for determining the depth of a pharmacist's involvement in patient care. These evaluations should cover the following aspects: medication indication, dosage, treatment duration, detection of DRPs, implementation of therapeutic drug monitoring, dosing of sedatives and analgesics, and pharmaceutical cost containment. Beyond identifying medication issues, a primary task during rounds is gathering additional information and building trust with the medical team. Post-round responsibilities for CCPs include patient and caregiver education on medication, medication reconciliation for transitioning patients, and follow-up care for post-ICU patients. Establishing a rationalized and standardized workflow is essential to minimize daily work omissions and maximize the pharmacist's value. A multidisciplinary pharmacist-led team can significantly promote the rational use of antibiotics. Participation in post-ICU outpatient follow-ups can reduce drug-induced injuries after discharge. This review provides a detailed overview of the tasks performed by CCPs before, during, and after medical rounds, serving as a valuable reference for establishing an efficient workflow for CCPs.

A deep learning model for estimating sedation levels using heart rate variability and vital signs: a retrospective cross-sectional study at a center in South Korea

BACKGROUND

Optimal sedation assessment in critically ill children remains challenging due to the subjective nature of behavioral scales and intermittent evaluation schedules. This study aimed to develop a deep learning model based on heart rate variability (HRV) parameters and vital signs to predict effective and safe sedation levels in pediatric patients.

METHODS

This retrospective cross-sectional study was conducted in a pediatric intensive care unit at a tertiary children's hospital. We developed deep learning models incorporating HRV parameters extracted from electrocardiogram waveforms and vital signs to predict Richmond Agitation-Sedation Scale (RASS) scores. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve (AUPRC). The data were split into training, validation, and test sets (6:2:2), and the models were developed using a 1D ResNet architecture.

RESULTS

Analysis of 4,193 feature sets from 324 patients achieved excellent discrimination ability, with AUROC values of 0.867, 0.868, 0.858, 0.851, and 0.811 for whole number RASS thresholds of -5 to -1, respectively. AUPRC values ranged from 0.928 to 0.623, showing superior performance in deeper sedation levels. The HRV metric SDANN2 showed the highest feature importance, followed by systolic blood pressure and heart rate.

CONCLUSIONS

A combination of HRV parameters and vital signs can effectively predict sedation levels in pediatric patients, offering the potential for automated and continuous sedation monitoring in pediatric intensive care settings. Future multi-center validation studies are needed to establish broader applicability.

Assessment of intensive care unit delirium in developmentally delayed children

Pediatric intensive care unit (ICU) delirium is an increasingly common diagnosis with negative impacts on morbidity and mortality. Patients with developmental delay are particularly susceptible to developing ICU delirium due to possible cerebral disease, sensory loss, unfamiliar environment, or use of deliriogenic medications. Of the existing scoring tools to assess for ICU delirium, few have been evaluated for patients with developmental delay. This review highlights the literature investigating measures of accuracy of ICU delirium scoring tools in pediatric patients, potential impact of developmental delay on successfully diagnosing delirium, and future directions for this area of care. IMPACT: This article summarizes pediatric intensive care unit (ICU) delirium, delirium screening tools, and developmental delay. This article highlights the limitations to current ICU delirium screening tools in patients with developmental delay and highlights future directions for the field.

Framework for Research Gaps in Pediatric Ventilator Liberation

BACKGROUND

The 2023 International Pediatric Ventilator Liberation Clinical Practice Guidelines provided evidence-based recommendations to guide pediatric critical care providers on how to perform daily aspects of ventilator liberation. However, because of the lack of high-quality pediatric studies, most recommendations were conditional based on very low to low certainty of evidence.

RESEARCH QUESTION

What are the research gaps related to pediatric ventilator liberation that can be studied to strengthen the evidence for future updates of the guidelines?

STUDY DESIGN AND METHODS

We conducted systematic reviews of the literature in eight predefined Population, Intervention, Comparator, Outcome (PICO) areas related to pediatric ventilator liberation to generate recommendations. Subgroups responsible for each PICO question subsequently identified major research gaps by synthesizing the literature. These gaps were presented at an international symposium at the Pediatric Acute Lung Injury and Sepsis Investigators meeting in spring 2022 for open discussion. Feedback was incorporated, and final evaluation of research gaps are summarized herein. Although randomized controlled trials (RCTs) represent the highest level of evidence, the panel sought to highlight areas where alternative study designs also may be appropriate, given challenges with conducting large multicenter RCTs in children.

RESULTS

Significant research gaps were identified in six broad areas related to pediatric ventilator liberation. Several of these areas necessitate multicenter RCTs to provide definitive results, whereas other gaps can be addressed with multicenter observational studies or quality improvement initiatives. Furthermore, a need for some physiologic studies in several areas remains, particularly regarding newer diagnostic methods to improve identification of patients at high risk of extubation failure.

INTERPRETATION

Although pediatric ventilator liberation guidelines have been created, the certainty of evidence remains low and multiple research gaps exist that should be bridged through high-quality RCTs, multicenter observational studies, and quality improvement initiatives.

Weaning-associated interventions for ventilated intensive care patients: A scoping review

BACKGROUND

Mechanical ventilation is a core intervention in critical care, but may also lead to negative consequences. Therefore, ventilator weaning is crucial for patient recovery. Numerous weaning interventions have been investigated, but an overview of interventions to evaluate different foci on weaning research is still missing.

AIM

To provide an overview of interventions associated with ventilator weaning.

STUDY DESIGN

We conducted a scoping review. A systematic search of the Medline, CINAHL and Cochrane Library databases was carried out in May 2023. Interventions from studies or reviews that aimed to extubate or decannulate mechanically ventilated patients in intensive care units were included. Studies concerning children, outpatients or non-invasive ventilation were excluded. Screening and data extraction were conducted independently by three reviewers. Identified interventions were thematically analysed and clustered.

RESULTS

Of the 7175 records identified, 193 studies were included. A total of six clusters were formed: entitled enteral nutrition (three studies), tracheostomy (17 studies), physical treatment (13 studies), ventilation modes and settings (47 studies), intervention bundles (42 studies), and pharmacological interventions including analgesic agents (8 studies), sedative agents (53 studies) and other agents (15 studies).

CONCLUSIONS

Ventilator weaning is widely researched with a special focus on ventilation modes and pharmacological agents. Some aspects remain poorly researched or unaddressed (e.g. nutrition, delirium treatment, sleep promotion).

RELEVANCE TO CLINICAL PRACTICE

This review compiles studies on ventilator weaning interventions in thematic clusters, highlighting the need for multidisciplinary care and consideration of various interventions. Future research should combine different interventions and investigate their interconnection.

A qualitative needs assessment of early participants in an Enhanced Recovery After Surgery program in CHD

Although medical advancements have improved the mortality of CHD, morbidity still exists, impacting patient quality of life. Returning to baseline in the early surgical recovery phase is an area of potential improvement. This preliminary project aims to qualitatively understand CHD family perspectives concerning the immediate postoperative recovery phase. The participating patients enrolled in the Enhanced Recovery After Surgery program, a postsurgical symptom management tool utilised in adult centres and broadening into pediatrics. Twenty-three of 27 contacted families answered open-ended questions 1 to 3 months postoperatively regarding difficulties experienced during their first week home. They reviewed a list of symptoms including: difficulties with pain, nausea, activity, sleep, appetite, bowel or urinary systems, and taking medications. A qualitative thematic analysis was performed with the open responses, as well as a quantitative assessment of the types of issues that made recovery challenging. Participants struggled most with sleep (78%), returning to activity (70%), and pain (57%). Open-ended responses suggested that an inability to do daily activities, sleep (frequently impacted by pain), and inadequate resources most negatively impacted recovery. Given these findings, investigating postoperative sleep regimens and effective pain plan components may prove useful, in addition to the further development of early mobility programs. The positive and negative experiences highlighting the desire for readily available medical guidance enforce the need for open communication between families and team members, potentially aided by digital tools. Ultimately, further data could support the development of a standardised protocol to better the immediate postoperative quality of life for CHD families.

World delirium awareness and quality survey in 2023-a worldwide point prevalence study

BACKGROUND

Delirium, an acute brain dysfunction, is proposed to be highly prevalent in clinical care and shown to significantly increase the risk of mortality and dementia.

OBJECTIVES

To report on the global prevalence of clinically documented delirium and delirium-related clinical practices in wards caring for paediatric and adult patients in healthcare facilities.

DESIGN

A prospective, cross-sectional, 39-question survey completed on World Delirium Awareness Day, 15 March 2023.

PARTICIPANTS

Clinicians or researchers with access to clinical data.

MAIN OUTCOME AND MEASURE

The primary outcome was the prevalence of clinically documented delirium at 8:00 a.m. (4 h) and 8:00 p.m. (±4 h). Secondary outcomes included delirium-related care practices and barriers to use. Descriptive statistics were calculated and multilevel modelling was completed.

RESULTS

1664 wards submitted surveys from 44 countries, reporting on delirium assessments at 8:00 a.m. (n = 36 048) and 8:00 p.m. (n = 32 867); 61% reported use of validated delirium assessment tools. At 8:00 a.m., 18% (n = 2788/15 458) and at 8:00 p.m., 17.7% (n = 2454/13 860) were delirium positive. Top prevention measures were pain management (86.7%), mobilisation (81.4%) and adequate fluids (80.4%). Frequently reported pharmacologic interventions were benzodiazepines (52.7%) and haloperidol (46.2%). Top barriers included the shortage of staff (54.3%), lack of time to educate staff (48.6%) and missing knowledge about delirium (38%).

CONCLUSION AND RELEVANCE

In this study, approximately one out of five patients were reported as delirious. The reported high use of benzodiazepines needs further evaluation as it is not aligned with best-practice recommendations. Findings provide a benchmark for future quality improvement projects and research.

Development and feasibility of a sex- and gender-sensitive primary care intervention for patients with chronic non-cancer pain receiving long-term opioid therapy (GESCO): a study protocol

BACKGROUND

Chronic non-cancer pain (CNCP) is a common condition worldwide. The disease burden is influenced not only by pain itself, but also by psychiatric co-morbidities, which aggravate symptoms, generally negatively influence therapies, and may thereby lead to frustration, resignation, or withdrawal. A growing body of evidence suggests that sex and gender aspects influence CNCP management as the experience of pain, the emotions associated with it, and the expression of pain may differ between women and men. In addition, doctor-patient communication is known to be influenced by gender stereotypes. Despite there being evidence on such differences, current guidelines do not consider sex- and gender-sensitive approaches. In order to examine how to adequately address the diversity of the experience and processing of pain in patients of differing sex and gender, the GESCO study aims at developing and pilot testing a sex- and gender-sensitive intervention for patients with CNCP receiving long-term opioid therapy (LTOT) in primary care.

METHODS

The development process is designed in accordance with the first two phases of the UK Medical Research Council. Phase I will iteratively explore, develop, and pilot the intervention's modules using literature searches, interviews, and workshops involving stakeholders and experts. Phase II will pilot-test the novel intervention in a sample of 40 patients with CNCP under LTOT from ten general practices using an effectiveness-implementation hybrid design including a mixed-methods process evaluation focusing on implementation strategy criteria and a single-arm, pre-post comparison to determine preliminary effects in preparation for a larger effectiveness trial. The intervention will combine in-person educational sessions for general practitioners and tools to be used in patient care.

DISCUSSION

The intervention aims to improve CNCP management in primary care by empowering practitioners to reflect on their attitudes towards pain and stereotypes. Besides sex and gender aspects, awareness of other factors that might affect the care process, such as age, social conditions, or culture, is also promoted. The intention is to develop a comprehensive care concept for CNCP that considers aspects relevant for sex- and gender-sensitive care which are transferrable to other health care fields as well.

TRIAL REGISTRATION

German Clinical Trial Register DRKS00029980.

Sedation Management in the Intubated Pediatric Patient as a Method to Reduce Neuromuscular Blockade Utilization Rate During Transport: A Quality Improvement Project

OBJECTIVE

Models recommending continuous sedation combined with specific tools to assess sedation depth during pediatric transport do not exist. Published studies demonstrate that nurse-driven sedation protocols yield more consistent levels of appropriate sedation.

METHODS

A retrospective review in 2020 of mechanically ventilated pediatric transport patients at this institution demonstrated that 60.7% received neuromuscular blockade. This higher than anticipated neuromuscular blockade usage indicated an opportunity to improve sedation management. The primary aim of this quality improvement project is to decrease neuromuscular blockade use to < 30% of intubated pediatric patients cared for by our critical care transport team. To achieve this, we aimed to improve patient sedation by increasing the use of continuous sedation medication infusions to > 75% of patients by the first quarter of 2022. The initiative took place with a hospital-based pediatric/neonatal critical care transport team.

RESULTS

Continuous sedation infusions increased using protocolized sedation from 10.7% at baseline to a sustained rate of 88% with dexmedetomidine (76.3%) and propofol (13.6%) as primary medications. The percentage of patients receiving neuromuscular blockade decreased in stepwise fashion from the initial 60.7% to 8.3%.

CONCLUSION

This project demonstrated sustained improvement in continuous sedation and decrease in neuromuscular blockade use through the initiation of a continuous sedation protocol in transport.

The Nurse-Implemented Chronotherapeutic Bundle in Critically Ill Children, RESTORE Resilience (R 2 ): Pilot Testing in a Two-Phase Cohort Study, 2017-2021

OBJECTIVES

Pilot test the nurse-led chronotherapeutic bundle in critically ill children, RESTORE Resilience (R 2 ).

DESIGN

A two-phase cohort study was carried out from 2017 to 2021.

SETTING

Two similarly sized and organized PICUs in the United States.

PATIENTS

Children 6 months to 17 years old who were mechanically ventilated for acute respiratory failure.

INTERVENTIONS

R 2 seven-item chronotherapeutic bundle, including: 1) replication of child's pre-hospital daily routine (i.e., sleep/wake, feeding, activity patterns); 2) cycled day-night light/sound modulation; 3) minimal effective sedation; 4) night fasting with bolus enteral daytime feedings; 5) early progressive mobility; 6) nursing care continuity; and 7) parent diaries.

MEASUREMENTS AND MAIN RESULTS

Children underwent environmental (light, sound) and patient (actigraphy, activity log, salivary melatonin, electroencephalogram) monitoring. Parents completed the Child's Daily Routine and Sleep Survey (CDRSS) and Family-Centered Care Scale. The primary outcome was post-extubation daytime activity consolidation (Daytime Activity Ratio Estimate [DARE]). Twenty baseline-phase (2017-2019) and 36 intervention-phase (2019-2021) participants were enrolled. During the intervention phase, nurses used the CDRSS to construct children's PICU schedules. Overall compliance with nurse-implemented R 2 elements 1-5 increased from 18% (interquartile range, 13-30%) at baseline to 63% (53-68%) during the intervention phase ( p < 0.001). Intervention participants were exposed to their pre-hospitalization daily routine ( p = 0.002), cycled day-night light/sound modulation ( p < 0.001), and early progressive mobility on more PICU days ( p = 0.02). Sedation target identification, enteral feeding schedules, and nursing care continuity did not differ between phases. Parent diaries were seldom used. DARE improved during the intervention phase and was higher pre-extubation (median 62% vs. 53%; p = 0.04) but not post-extubation (62% vs. 57%; p = 0.56).

CONCLUSIONS

In the PICU, implementation of an individualized nurse-implemented chronotherapeutic bundle is feasible. Children who received the R 2 bundle had increased pre-extubation daytime activity consolidation compared to children receiving usual care. Given variation in protocol adherence, further R 2 testing should include interprofessional collaboration, pragmatic trial design, and implementation science strategies.

The effects of maternal voice on pain during placement of peripherally inserted central catheter in neonates

Background

Peripherally inserted central catheter (PICC) are a necessary procedure for preterm newborns care. Despite the use of analgesic treatments, its insertion can be painful. Our objective was to study the effect of maternal voice on pain during PICC insertion.

Method

We conducted a pre post study for 2 years. Pain was compared between the two groups (with/without maternal presence) using a neonatal pain scale (FANS). Infection rate, procedure time, number of failures, mothers' anxiety and caregivers'anxiety were compared between the two groups.

Results

Ninety neonates were eligible. Finally, 63 neonates were included. Thirty-four placements were realized without maternal voice (first period) and 29 with maternal voice (second period). Mean FANS during PICC placement was lower in the maternal voice group than in the control group (1.15 ± 1.27 vs. 1.41 ± 1.49, p = 0.033). The FANS was also lower in the maternal voice group during the time of the first cutaneous effraction (p = 0.032). There was no significant difference between the two groups concerning the other outcomes.

Conclusion

Maternal voice added to conventional care decreased acute pain during PICC insertion without increasing infection rate, number of failures or procedure time.

Trends in analgesia-sedation of pediatric patients receiving I-131 MIBG in the pediatric intensive care unit: A report from the Pediatric Health Information System database

BACKGROUND

Children with neuroblastoma receiving I-131 metaiodobenzylguanidine (MIBG) therapy require sedation-analgesia for strict radiation safety precautions during MIBG infusion and clearance. We evaluated the sedation-analgesia trends of patients undergoing MIBG therapy using the Pediatric Health Information System (PHIS) database.

MATERIALS AND METHODS

Retrospective data from 476 patient encounters from the PHIS from 2010 to 2019.

RESULTS

Total 240/476 (50.45%) children evaluated were under 6 years of age. Compared to 2010, in 2018 there was a decrease in benzodiazepine infusion use (60% vs. 40%, p < .04), as well as a decrease in use of opiate infusion (35% vs. 25%, p < .001). Compared to 2010, in 2018 we report an increase in the use of ketamine (from 5% to 10%, p < .002), as well as an increase in dexmedetomidine use (0% vs. 30%, p < .001). Dexmedetomidine was the most used medication in the 0-3 years age group compared to children older than 3 years of age (14.19% vs. 5.80%, p < .001). Opiate was the most used medication in children greater than 3 years compared to the 0-3-year age group (36.23 vs. 23.87, p < .05).

CONCLUSION

Using PHIS data, we discovered considerable variability in the medications used for sedation in patients undergoing MIBG therapy. Although benzodiazepines and opioids were the most used agents, there was a trend toward decreasing use of benzodiazepines and opioids in these patients. Furthermore, there has been an increasing trend in the use of dexmedetomidine and ketamine.

Cost-Benefit Analysis of a Pediatric ICU Sedation Weaning Protocol

OBJECTIVE

A risk stratified sedation weaning protocol improved patient outcomes in a pediatric intensive care unit (PICU). We sought to determine the protocol effect on medication costs.

METHODS

This was a retrospective observational cohort study in an academic tertiary care children's hospital PICU (2018-2020) comparing the cost when weaning benzodiazepine, alpha agonist, and/or opioid infusions in intubated children <18 years of age.

RESULTS

There were 84 total sedation weaning instances (pre-protocol n = 41 and post-protocol n = 41); 2 patients had 2 encounters, 1 in each phase. The total cost (in 2022 United States Dollars) of sedation weaning was $400,328.87 ($15,994.44/kg) pre-protocol compared with $170,458.85 ($11,227.52/kg) post-protocol. The median cost of sedation wean per patient for pre-protocol patients was $3197.42 (IQR: $322.66-$12,643.29) and post-protocol patients was $1851.44 (IQR: $425.05-$5355.85; p = 0.275). A linear regression model estimated the expected cost of sedation wean for post-protocol patients to be $5173.20 lower than for pre-protocol patients of the same weight and overall drug risk (p = 0.036). The proportion of withdrawal symptoms in the pre-protocol patients (16%) was not significantly different from the proportion in the post-protocol patients (14%; p = 0.435).

CONCLUSIONS

Implementation of a PICU sedation weaning protocol in a single-center conferred cost benefit without negatively impacting patient outcomes. A larger multicenter study would provide insight to the applicability to PICUs in varied settings with differing patient populations.