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Zeilmaker-Roest G, de Vries-Rink C, van Rosmalen J, van Dijk M, de Wildt SN, Knibbe CAJ, Koomen E, Jansen NJG, Kneyber MCJ, Maebe S, Van den Berghe G, Haghedooren R, Vlasselaers D, Bogers AJJC, Tibboel D, Wildschut ED. Intermittent intravenous paracetamol versus continuous morphine in infants undergoing cardiothoracic surgery: a multi-center randomized controlled trial. Crit Care 2024; 28:143. [PMID: 38689310 PMCID: PMC11061924 DOI: 10.1186/s13054-024-04905-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/07/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND To determine whether intermittent intravenous (IV) paracetamol as primary analgesic would significantly reduce morphine consumption in children aged 0-3 years after cardiac surgery with cardiopulmonary bypass. METHODS Multi-center, randomized, double-blinded, controlled trial in four level-3 Pediatric Intensive Care Units (PICU) in the Netherlands and Belgium. Inclusion period; March 2016-July 2020. Children aged 0-3 years, undergoing cardiac surgery with cardiopulmonary bypass were eligible. Patients were randomized to continuous morphine or intermittent IV paracetamol as primary analgesic after a loading dose of 100 mcg/kg morphine was administered at the end of surgery. Rescue morphine was given if numeric rating scale (NRS) pain scores exceeded predetermined cutoff values. Primary outcome was median weight-adjusted cumulative morphine dose in mcg/kg in the first 48 h postoperative. For the comparison of the primary outcome between groups, the nonparametric Van Elteren test with stratification by center was used. For comparison of the proportion of patients with one or more NRS pain scores of 4 and higher between the two groups, a non-inferiority analysis was performed using a non-inferiority margin of 20%. RESULTS In total, 828 were screened and finally 208 patients were included; parents of 315 patients did not give consent and 305 were excluded for various reasons. Fourteen of the enrolled 208 children were withdrawn from the study before start of study medication leaving 194 patients for final analysis. One hundred and two patients received intermittent IV paracetamol, 106 received continuous morphine. The median weight-adjusted cumulative morphine consumption in the first 48 h postoperative in the IV paracetamol group was 5 times lower (79%) than that in the morphine group (median, 145.0 (IQR, 115.0-432.5) mcg/kg vs 692.6 (IQR, 532.7-856.1) mcg/kg; P < 0.001). The rescue morphine consumption was similar between the groups (p = 0.38). Non-inferiority of IV paracetamol administration in terms of NRS pain scores was proven; difference in proportion - 3.1% (95% CI - 16.6-10.3%). CONCLUSIONS In children aged 0-3 years undergoing cardiac surgery, use of intermittent IV paracetamol reduces the median weight-adjusted cumulative morphine consumption in the first 48 h after surgery by 79% with equal pain relief showing equipoise for IV paracetamol as primary analgesic. Trial Registration Clinicaltrials.gov, Identifier: NCT05853263; EudraCT Number: 2015-001835-20.
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MESH Headings
- Humans
- Morphine/therapeutic use
- Morphine/administration & dosage
- Acetaminophen/therapeutic use
- Acetaminophen/administration & dosage
- Male
- Female
- Infant
- Double-Blind Method
- Pain, Postoperative/drug therapy
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Belgium
- Netherlands
- Infant, Newborn
- Administration, Intravenous
- Cardiac Surgical Procedures/methods
- Child, Preschool
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Intensive Care Units, Pediatric/organization & administration
- Intensive Care Units, Pediatric/statistics & numerical data
- Pain Measurement/methods
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Affiliation(s)
- Gerdien Zeilmaker-Roest
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands.
| | - Christine de Vries-Rink
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Monique van Dijk
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Saskia N de Wildt
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Department of Clinical Pharmacy, St. Antonius Hospital Nieuwegein/Utrecht, Utrecht, The Netherlands
| | - Erik Koomen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nicolaas J G Jansen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin C J Kneyber
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Sofie Maebe
- Department of Pediatrics, Maastricht University Medical Center+, MosaKids Children's Hospital, Maastricht, The Netherlands
| | | | | | - Dirk Vlasselaers
- Department of Intensive Care Medicine, UZ Leuven, Louvain, Belgium
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Enno D Wildschut
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
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Wong JJM, Tan HL, Sultana R, Ma YJ, Aguilan AB, Goh CY, Lee WC, Kumar P, Lee JH. Respiratory Support After Extubation in Children With Pediatric ARDS. Respir Care 2024; 69:422-429. [PMID: 38538015 PMCID: PMC11108100 DOI: 10.4187/respcare.11334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
BACKGROUND Postextubation respiratory support in pediatric ARDS may be used to support the recovering respiratory system and promote timely, successful liberation from mechanical ventilation. This study's aims were to (1) describe the use of postextubation respiratory support in pediatric ARDS from the time of extubation to hospital discharge, (2) identify potential risk factors for postextubation respiratory support, and (3) provide preliminary data for future larger studies. METHODS This pilot single-center prospective cohort study recruited subjects with pediatric ARDS. Subjects' respiratory status up to hospital discharge, the use of postextubation respiratory support, and how it changed over time were recorded. Analysis was performed comparing subjects who received postextubation respiratory support versus those who did not and compared its use among pediatric ARDS severity categories. Multivariable logistic regression was used to determine variables associated with the use of postextubation respiratory support and included oxygenation index (OI), ventilator duration, and weight. RESULTS Seventy-three subjects with pediatric ARDS, with median age and OI of 4 (0.6-10.5) y and 7.3 (4.9-12.7), respectively, were analyzed. Postextubation respiratory support was provided to 54/73 (74%) subjects: 28/45 (62.2%), 19/21 (90.5%), and 7/7 (100%) for mild, moderate, and severe pediatric ARDS, respectively, (P = .01). OI and mechanical ventilation duration were higher in subjects who received postextubation respiratory support (8.7 [5.4-14] vs 4.6 [3.7-7], P < .001 and 10 [7-17] d vs 4 [2-7] d, P < .001) compared to those who did not. At hospital discharge, 12/67 (18.2%) survivors received home respiratory support (6 subjects died prior to hospital discharge). In the multivariable model, ventilator duration (adjusted odds ratio 1.3 [95% CI 1.0-1.7], P = .050) and weight (adjusted odds ratio 0.95 [95% CI 0.91-0.99], P = .02) were associated with the use of postextubation respiratory support. CONCLUSIONS The majority of intubated subjects with pediatric ARDS received respiratory support postextubation, and a substantial proportion continued to require it up to hospital discharge.
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Affiliation(s)
- Judith Ju Ming Wong
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore.
| | - Herng Lee Tan
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Rehena Sultana
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Yi-Jyun Ma
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Apollo Bugarin Aguilan
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Chen Yun Goh
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Wen Cong Lee
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Pavanish Kumar
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
| | - Jan Hau Lee
- Drs Wong and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore; and Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore. Mss Tan, Ma, and Goh and Messrs Aguilan and Lee are affiliated with Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore. Ms Sultana is affiliated with Center for Quantitative Medicine, Duke-NUS Medical School, Singapore. Dr Kumar is affiliated with Translational Immunology Institute, SingHealth/Duke-NUS Academic Medical Centre, Singapore
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Aljabari S, Keaveney S, Anderson J. Enteral Pentobarbital in the Difficult to Sedate Critically Ill Children. J Pediatr Pharmacol Ther 2024; 29:32-36. [PMID: 38332954 PMCID: PMC10849682 DOI: 10.5863/1551-6776-29.1.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 03/06/2023] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Difficult analgosedation is common and challenging in the pediatric intensive care unit (PICU). It is important to study alternative and supplemental sedatives for when the first-line agents become -insufficient. METHODS In this retrospective chart-review study, we report our center's experience in using intermittent doses of enteral pentobarbital as an adjunct sedative in 13 difficult to sedate critically ill and mechanically ventilated children. We compare the average sedation score and cumulative doses of other -sedatives (opioids, benzodiazepines and alpha-2 agonists) in the 24 hours before and 24 hours after enteral -pentobarbital initiation. RESULTS The addition of enteral pentobarbital was associated with lower State Behavioral State (SBS) scores in 8 out of the 13 patients and on average smaller doses of opioids (decreased by 11%), benzodiazepines (BZD) (decreased by 5%) and alpha-agonists (decreased by 20%). No adverse effects were noted attributable to pentobarbital administration. CONCLUSION Enteral pentobarbital seems to be safe and effective agent in the difficult to sedate critically ill child.
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Affiliation(s)
- Salim Aljabari
- Department of Pediatrics (SA), University of Arkansas for Medical Sciences/Arkansas Children’s Hospital, Little Rock, AR
| | | | - Jordan Anderson
- School of Pharmacy (JA), University of Missouri, Columbia, MO
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4
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Wyness B, Crook J, D'Silva P, McCormick D. Chloral hydrate - use as a sedative in paediatric settings. Arch Dis Child Educ Pract Ed 2023; 108:445-449. [PMID: 37495268 DOI: 10.1136/archdischild-2022-324939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/11/2023] [Indexed: 07/28/2023]
Affiliation(s)
- Benjamin Wyness
- Pharmacy Department, King's College Hospital NHS Foundation Trust, London, UK
| | - Joanne Crook
- Pharmacy Department, King's College Hospital NHS Foundation Trust, London, UK
| | - Pam D'Silva
- Paediatric Intensive Care Unit, Variety Children's Hospital, Kings College Hospital NHS Foundation Trust, London, UK
| | - David McCormick
- Paediatric Neurosciences, Variety Children's Hospital, Kings College Hospital NHS Foundation Trust, London, UK
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5
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MacDonald I, Alvarado S, Marston MT, Gomez Tovar L, Chanez V, Favre E, Gu Y, Trombert A, Perez MH, Ramelet AS. A systematic review of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal syndrome in pediatric intensive care. Front Pediatr 2023; 11:1264717. [PMID: 37868267 PMCID: PMC10587441 DOI: 10.3389/fped.2023.1264717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/12/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction This systematic review aimed to evaluate the quality of clinical practice guidelines (CPGs) and recommendations for managing pain, sedation, delirium, and iatrogenic withdrawal syndrome in pediatric intensive care (PICU). The objectives included evaluating the quality of recommendations, synthesizing recommendations, harmonizing the strength of the recommendation (SoR) and the certainty of evidence (CoE), and assessing the relevance of supporting evidence. Methods A comprehensive search in four electronic databases (Medline, Embase.com, CINAHL and JBI EBP Database), 9 guideline repositories, and 13 professional societies was conducted to identify CPGs published from January 2010 to the end of May 2023 in any language. The quality of CPGs and recommendations was assessed using the AGREE II and AGREE-REX instruments. Thematic analysis was used to synthesize recommendations, and the GRADE SoR and CoE harmonization method was used to interpret the credibility of summary recommendations. Results A total of 18 CPGs and 170 recommendations were identified. Most CPGs were of medium-quality, and three were classified as high. A total of 30 summary recommendations were synthesized across each condition, focused on common management approaches. There was inconsistency in the SoRs and CoE for summary recommendations, those for assessment showed the highest consistency, the remaining were conditional, inconsistent, inconclusive, and lacked support from evidence. Conclusion This systematic review provides an overview of the quality of CPGs for these four conditions in the PICU. While three CPGs achieved high-quality ratings, the overall findings reveal gaps in the evidence base of recommendations, patient and family involvement, and resources for implementation. The findings highlight the need for more rigorous and evidence-based approaches in the development and reporting of CPGs to enhance their trustworthiness. Further research is necessary to enhance the quality of recommendations for this setting. The results of this review can provide a valuable foundation for future CPG development. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=274364, PROSPERO (CRD42021274364).
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Affiliation(s)
- Ibo MacDonald
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Silvia Alvarado
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Mark T. Marston
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Luz Gomez Tovar
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Faculty of Health, Universidad Surcolombiana, Neiva, Colombia
| | - Vivianne Chanez
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Eva Favre
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Department Adult Intensive Care, Lausanne University Hospital, Lausanne, Switzerland
| | - Ying Gu
- Nursing Department, Children's Hospital of Fudan University, Shanghai, China
| | - Alexia Trombert
- Medical Library, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Maria-Helena Perez
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
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Shannon ML, Muhammad A, James NT, Williams ML, Breeyear J, Edwards T, Mosley JD, Choi L, Kannankeril P, Van Driest S. Variant-based heritability assessment of dexmedetomidine and fentanyl clearance in pediatric patients. Clin Transl Sci 2023; 16:1628-1638. [PMID: 37353859 PMCID: PMC10499425 DOI: 10.1111/cts.13574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/12/2023] [Accepted: 06/01/2023] [Indexed: 06/25/2023] Open
Abstract
Despite complex pathways of drug disposition, clinical pharmacogenetic predictors currently rely on only a few high effect variants. Quantification of the polygenic contribution to variability in drug disposition is necessary to prioritize target drugs for pharmacogenomic approaches and guide analytic methods. Dexmedetomidine and fentanyl, often used in postoperative care of pediatric patients, have high rates of inter-individual variability in dosing requirements. Analyzing previously generated population pharmacokinetic parameters, we used Bayesian hierarchical mixed modeling to measure narrow-sense (additive) heritability (h SNP 2 ) of dexmedetomidine and fentanyl clearance in children and identify relative contributions of small, moderate, and large effect-size variants toh SNP 2 . We used genome-wide association studies (GWAS) to identify variants contributing to variation in dexmedetomidine and fentanyl clearance, followed by functional analyses to identify associated pathways. For dexmedetomidine, median clearance was 33.0 L/h (interquartile range [IQR] 23.8-47.9 L/h) andh SNP 2 was estimated to be 0.35 (90% credible interval 0.00-0.90), with 45% ofh SNP 2 attributed to large-, 32% to moderate-, and 23% to small-effect variants. The fentanyl cohort had median clearance of 8.2 L/h (IQR 4.7-16.7 L/h), with estimatedh SNP 2 of 0.30 (90% credible interval 0.00-0.84). Large-effect variants accounted for 30% ofh SNP 2 , whereas moderate- and small-effect variants accounted for 37% and 33%, respectively. As expected, given small sample sizes, no individual variants or pathways were significantly associated with dexmedetomidine or fentanyl clearance by GWAS. We conclude that clearance of both drugs is highly polygenic, motivating the future use of polygenic risk scores to guide appropriate dosing of dexmedetomidine and fentanyl.
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Affiliation(s)
| | - Ayesha Muhammad
- School of MedicineVanderbilt UniversityNashvilleTennesseeUSA
| | - Nathan T. James
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
- Present address:
Berry Consultants, LLCAustinTexasUSA
| | - Michael L. Williams
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
- Present address:
Department of Clinical Pharmacology and Quantitative PharmacologyAstraZenecaGothenburgSweden
| | - Joseph Breeyear
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Todd Edwards
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jonathan D. Mosley
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Department of Biomedical InformaticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Leena Choi
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Prince Kannankeril
- Center for Pediatric Precision Medicine, Department of PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Sara Van Driest
- Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Center for Pediatric Precision Medicine, Department of PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
- Present address:
All of Us Research ProgramNational Institutes of HealthWashingtonDCUSA
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7
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Goldsworthy A, Chawla J, Baumann O, Birt J, Gough S. Extended Reality Use in Paediatric Intensive Care: A Scoping Review. J Intensive Care Med 2023; 38:856-877. [PMID: 37437084 PMCID: PMC10503262 DOI: 10.1177/08850666231185721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 01/06/2023] [Accepted: 06/16/2023] [Indexed: 07/14/2023]
Abstract
Background: Extended reality (XR) technology such as virtual and augmented reality is increasingly being utilised in paediatric medicine due to its role in medical education and reported positive impacts on outcomes including pain, anxiety, and sleep. To the author's knowledge, no previous reviews investigating the use of XR in paediatric intensive care have been undertaken. Objectives: To scope the use of XR in paediatric intensive care, and assess its barriers to adoption, including safety considerations, cleaning and infection control. Eligibility criteria: All articles of any methodological design discussing the use of XR within paediatric intensive and critical care were included. Sources of evidence: Four databases (EMBASE, CINAHL, PsychInfo, PubMed) and Google Scholar were searched without any limitations on publication year. Charting methods: Data was extracted into Microsoft Excel by two authors independently (AG & SF) and cross-checked for completeness. Results: One hundred and eighty-eight articles were originally identified. Following the application of eligibility criteria 16 articles utilising XR in clinical interventions (n = 7) and medical education (n = 9) were included. Articles utilised VR and AR for highly variable purposes within both medical education (eg disaster preparedness, intubation) and clinical interventions (eg decrease pain, nausea, anxiety and improve Glasgow Coma Scale). Conclusions: While research into the use of XR in paediatric intensive care is still in its infancy it has increased dramatically over the past 5 years within two key areas. Firstly, in healthcare education, to assist in the acquisition of PICU-specific knowledge and practice of skills such as intubation of difficult airways. Secondly, studies have evaluated and demonstrated that with appropriate use, VR appears to be a safe and feasible intervention to decrease pain and anxiety in PICU patients.
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Affiliation(s)
| | - Jasneek Chawla
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia
- Department of Paediatric Respiratory & Sleep Medicine, Queensland Children's Hospital, South Brisbane, Australia
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Meitner C, Feuerstein RA, Steele AM. Nursing strategies for the mechanically ventilated patient. Front Vet Sci 2023; 10:1145758. [PMID: 37576838 PMCID: PMC10421733 DOI: 10.3389/fvets.2023.1145758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/19/2023] [Indexed: 08/15/2023] Open
Abstract
The goal of this manuscript is to provide a comprehensive and multi-disciplinary review of the best nursing practices of caring for mechanically ventilated patients. By reviewing human medicine literature, the authors will extrapolate procedures that have been found to be most effective in reducing the risk of mechanical ventilation (MV) complications. Paired with review of the current standards in veterinary medicine, the authors will compile the best practice information on mechanically ventilated patient care, which will serve as a detailed resource for the veterinary nursing staff. Written from a nursing standpoint, this manuscript aims to consolidate the nursing assessment of a mechanically ventilated patient, addressing both systemic and physical changes that may be encountered during hospitalization. The goal of this review article is to present information that encourages a proactive approach to nursing care by focusing on understanding the effects of polypharmacy, hemodynamic changes associated with MV, complications of recumbent patient care, and sources of hospital acquired infections. When applied in conjunction with the more technical aspects of MV, this manuscript will allow veterinary technicians involved in these cases to understand the dynamic challenges that mechanically ventilated patients present, provide guidance to mitigate risk, address issues quickly and effectively, and create an up-to date standard of practice that can be implemented.
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Affiliation(s)
- Cassandra Meitner
- Department of Small Animal Clinical Medicine, Small Animal Emergency and Critical Care, University of Tennessee College of Veterinary Medicine, University of Tennessee, Knoxville, TN, United States
| | - Rachel A. Feuerstein
- Department of Small Animal Clinical Medicine, Small Animal Emergency and Critical Care, University of Tennessee College of Veterinary Medicine, University of Tennessee, Knoxville, TN, United States
| | - Andrea M. Steele
- Ontario Veterinary College, Health Sciences Centre, University of Guelph, Guelph, ON, Canada
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Grandjean C, Perez MH, Ramelet AS. Comparison of clinical characteristics and healthcare resource use of pediatric chronic and non-chronic critically ill patients in intensive care units: a retrospective national registry study. Front Pediatr 2023; 11:1194833. [PMID: 37435169 PMCID: PMC10331166 DOI: 10.3389/fped.2023.1194833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/12/2023] [Indexed: 07/13/2023] Open
Abstract
Introduction Chronic critically ill patients (CCI) in pediatric intensive care unit (PICU) are at risk of negative health outcomes, and account for a considerable amount of ICU resources. This study aimed to (a) describe the prevalence of CCI children, (b) compare their clinical characteristics and ICU resources use with non-CCI children, and (c) identify associated risk factors of CCI. Methods A retrospective national registry study including 2015-2017 data from the eight Swiss PICUs of five tertiary and three regional hospitals, admitting a broad case-mix of medical and surgical patients, including pre- and full-term infants. CCI patients were identified using an adapted definition: PICU length of stay (LOS) ≥8 days and dependence on ≥1 PICU technology. Results Out of the 12,375 PICU admissions, 982 (8%) were CCI children and compared to non-CCI children, they were younger (2.8 vs. 6.7 months), had more cardiac conditions (24% vs. 12%), and higher mortality rate (7% vs. 2%) (p < 0.001). Nursing workload was higher in the CCI compared to the non-CCI group (22 [17-27]; 21 [16-26] respectively p < 0.001). Factors associated with CCI were cardiac (aOR = 2.241) and neurological diagnosis (aOR = 2.062), surgery (aORs between 1.662 and 2.391), ventilation support (aOR = 2.278), high mortality risk (aOR = 1.074) and agitation (aOR = 1.867). Conclusion the results confirm the clinical vulnerability and the complexity of care of CCI children as they were defined in our study. Early identification and adequate staffing is required to provide appropriate and good quality care.
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Affiliation(s)
- Chantal Grandjean
- Pediatric Intensive and Intermediate Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Marie-Hélène Perez
- Pediatric Intensive and Intermediate Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Pediatric Intensive and Intermediate Care Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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MacDonald I, de Goumoëns V, Marston M, Alvarado S, Favre E, Trombert A, Perez MH, Ramelet AS. Effectiveness, quality and implementation of pain, sedation, delirium, and iatrogenic withdrawal syndrome algorithms in pediatric intensive care: a systematic review and meta-analysis. Front Pediatr 2023; 11:1204622. [PMID: 37397149 PMCID: PMC10313131 DOI: 10.3389/fped.2023.1204622] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/15/2023] [Indexed: 07/04/2023] Open
Abstract
Background Pain, sedation, delirium, and iatrogenic withdrawal syndrome are conditions that often coexist, algorithms can be used to assist healthcare professionals in decision making. However, a comprehensive review is lacking. This systematic review aimed to assess the effectiveness, quality, and implementation of algorithms for the management of pain, sedation, delirium, and iatrogenic withdrawal syndrome in all pediatric intensive care settings. Methods A literature search was conducted on November 29, 2022, in PubMed, Embase, CINAHL and Cochrane Library, ProQuest Dissertations & Theses, and Google Scholar to identify algorithms implemented in pediatric intensive care and published since 2005. Three reviewers independently screened the records for inclusion, verified and extracted data. Included studies were assessed for risk of bias using the JBI checklists, and algorithm quality was assessed using the PROFILE tool (higher % = higher quality). Meta-analyses were performed to compare algorithms to usual care on various outcomes (length of stay, duration and cumulative dose of analgesics and sedatives, length of mechanical ventilation, and incidence of withdrawal). Results From 6,779 records, 32 studies, including 28 algorithms, were included. The majority of algorithms (68%) focused on sedation in combination with other conditions. Risk of bias was low in 28 studies. The average overall quality score of the algorithm was 54%, with 11 (39%) scoring as high quality. Four algorithms used clinical practice guidelines during development. The use of algorithms was found to be effective in reducing length of stay (intensive care and hospital), length of mechanical ventilation, duration of analgesic and sedative medications, cumulative dose of analgesics and sedatives, and incidence of withdrawal. Implementation strategies included education and distribution of materials (95%). Supportive determinants of algorithm implementation included leadership support and buy-in, staff training, and integration into electronic health records. The fidelity to algorithm varied from 8.2% to 100%. Conclusions The review suggests that algorithm-based management of pain, sedation and withdrawal is more effective than usual care in pediatric intensive care settings. There is a need for more rigorous use of evidence in the development of algorithms and the provision of details on the implementation process. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021276053, PROSPERO [CRD42021276053].
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Affiliation(s)
- Ibo MacDonald
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
| | - Véronique de Goumoëns
- La Source School of Nursing, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
- Bureau d’Echange des Savoirs pour des praTiques exemplaires de soins (BEST) a JBI Center of Excellence, Lausanne, Switzerland
| | - Mark Marston
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Silvia Alvarado
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Eva Favre
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Department of Adult Intensive Care, Lausanne University Hospital, Lausanne, Switzerland
| | - Alexia Trombert
- Medical Library, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Maria-Helena Perez
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Bureau d’Echange des Savoirs pour des praTiques exemplaires de soins (BEST) a JBI Center of Excellence, Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
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11
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Bacha AJ, Gadisa DA, Gudeta MD, Beressa TB, Negera GZ. Survival Status and Predictors of Mortality Among Patients Admitted to Pediatric Intensive Care Unit at Selected Tertiary Care Hospitals in Ethiopia: A Prospective Observational Study. Clin Med Insights Pediatr 2023; 17:11795565231169498. [PMID: 37284002 PMCID: PMC10240865 DOI: 10.1177/11795565231169498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/27/2023] [Indexed: 06/08/2023] Open
Abstract
Background Advances in pediatric intensive care have dramatically improved the prognosis for critically ill patients. The study aimed to determine the survival status and predictors of mortality among patients admitted to the pediatric intensive care unit at selected tertiary care hospitals in Ethiopia. Methods A health facility-based prospective observational study from October 2020 to May 30, 2021, was conducted in a selected tertiary care hospital in Ethiopia. Kaplan Meier was used to compare patient survival experiences and Cox regression was used to identify independent predictors of ICU mortality. The hazard ratio was used as a measure of the strength of the association, and a P-value of <.05 was considered to declare statistical significance. Results Of 206 study participants, 59 (28.6%) patients died during follow-up time, and the incidence of mortality was 3.6 deaths per 100 person-day observation (95% CI: 2.04-5.04 deaths per 100 person-days). Respiratory failure 19 (32.2%) was the commonest cause of death followed by septic shock 11(18.6). In-ICU complications (AHR: 2.13; 95% CI: 1.02, 4.42; P = .04), sepsis diagnosis (AHR: 2.43; 95% CI: 1.24, 4.78; P = .01), GCS < 8 (AHR: 1.96; 95% CI: 1.12, 3.43; P = .02), use of sedative drugs (AHR: 2.40; 95% CI: 1.16, 4.95; P = .02) were linked with increased risk of in-ICU mortality. In contrast, the use of mechanical ventilation was associated with decreased mortality (AHR: 0.45; 95% CI: 0.21, 0.92; P = .03). Conclusion The study found a high incidence of in-ICU mortality among admitted pediatric patients in selected Ethiopian tertiary care hospitals. In-ICU complications, sepsis diagnosis, GCS < 8, and patient use of sedative drugs were independent predictors of in-ICU mortality. Prudent follow-up is warranted for those patients with the aforementioned risk factors.
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Affiliation(s)
- Amente Jorise Bacha
- Department of Pharmacy, Clinical Pharmacy Unit, Ambo University, Ambo, Ethiopia
| | | | - Mesay Dechasa Gudeta
- Department of Clinical Pharmacy, School of Pharmacy, Haramaya University, Harar, Ethiopia
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12
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Hui WF, Lam CY, Cheung WL, Ku SW. The Pitfall of Over-Sedation During Recovery From Acute Kidney Injury. Hosp Pharm 2023; 58:143-147. [PMID: 36890960 PMCID: PMC9986579 DOI: 10.1177/00185787221126336] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 14-year-old boy with movement disorder and epilepsy developed status dystonicus leading to rhabdomyolysis and subsequent acute kidney injury requiring continuous renal replacement therapy (CRRT). He was given multiple intravenous sedatives and analgesics to control his dystonia and dyskinesia. 8 days after admission, his condition had improved and a trial termination of CRRT was carried out. The sedatives and analgesics were switched to oral diazepam, morphine, clonidine, and chloral hydrate. However, his renal function did not recover fully. There was rising trend of serum creatinine level with evolving hyperphosphatemia and metabolic acidosis. He also gradually developed hypoventilation, hypercapnia and pinpoint pupils after weaning CRRT. The clinical impression was over-sedation resulting in hypoventilation and respiratory failure, contributed by the deteriorating renal function. Non-invasive ventilatory support was then started and CRRT was resumed. His condition improved over the next 24 hours. Dexmedetomidine infusion was used during CRRT and he slowly required stepping up of sedatives again. A separate set of dosage for all his oral sedative agents was prepared for his subsequent CRRT weaning challenge and no more over-sedative episode was then encountered. Our case illustrated that patients at recovery phase of AKI are susceptible to medication overdose, especially during the period of CRRT weaning. Sedatives and analgesics including morphine and benzodiazepines should be used with caution during this period and alternatives may need to be considered. Advanced planning of medication dosage adjustment is advised to reduce the risk of medication overdose.
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Affiliation(s)
- Wun Fung Hui
- Department of Paediatrics and
Adolescent Medicine, Hong Kong Children’s Hospital, Kowloon, Hong Kong
| | - Cheuk Yi Lam
- Department of Pharmacy, Hong Kong
Children’s Hospital, Kowloon, Hong Kong
| | - Wing Lum Cheung
- Department of Paediatrics and
Adolescent Medicine, Hong Kong Children’s Hospital, Kowloon, Hong Kong
| | - Shu Wing Ku
- Department of Paediatrics and
Adolescent Medicine, Hong Kong Children’s Hospital, Kowloon, Hong Kong
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13
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The Emerging Role of Virtual Reality as an Adjunct to Procedural Sedation and Anesthesia: A Narrative Review. J Clin Med 2023; 12:jcm12030843. [PMID: 36769490 PMCID: PMC9917582 DOI: 10.3390/jcm12030843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/03/2023] [Accepted: 01/08/2023] [Indexed: 01/24/2023] Open
Abstract
Over the past 20 years, there has been a significant reduction in the incidence of adverse events associated with sedation outside of the operating room. Non-pharmacologic techniques are increasingly being used as peri-operative adjuncts to facilitate and promote anxiolysis, analgesia and sedation, and to reduce adverse events. This narrative review will briefly explore the emerging role of immersive reality in the peri-procedural care of surgical patients. Immersive virtual reality (VR) is intended to distract patients with the illusion of "being present" inside the computer-generated world, drawing attention away from their anxiety, pain, and discomfort. VR has been described for a variety of procedures that include colonoscopies, venipuncture, dental procedures, and burn wound care. As VR technology develops and the production costs decrease, the role and application of VR in clinical practice will expand. It is important for medical professionals to understand that VR is now available for prime-time use and to be aware of the growing body in the literature that supports VR.
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Mencía S, Alonso C, Pallás-Alonso C, López-Herce J. Evaluation and Treatment of Pain in Fetuses, Neonates and Children. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1688. [PMID: 36360416 PMCID: PMC9689143 DOI: 10.3390/children9111688] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 10/25/2022] [Accepted: 10/28/2022] [Indexed: 08/03/2023]
Abstract
The perception of pain is individual and differs between children and adults. The structures required to feel pain are developed at 24 weeks of gestation. However, pain assessment is complicated, especially in neonates, infants and preschool-age children. Clinical scales adapted to age are the most used methods for assessing and monitoring the degree of pain in children. They evaluate several behavioral and/or physiological parameters related to pain. Some monitors detect the physiological changes that occur in association with painful stimuli, but they do not yet have a clear clinical use. Multimodal analgesia is recommended for pain treatment with non-pharmacological and pharmacological interventions. It is necessary to establish pharmacotherapeutic protocols for analgesia adjusted to the acute or chronic, type and intensity of pain, as well as age. The most used analgesics in children are paracetamol, ibuprofen, dipyrone, opioids (morphine and fentanyl) and local anesthetics. Patient-controlled analgesia is an adequate alternative for adolescent and older children in specific situations, such as after surgery. In patients with severe or persistent pain, it is very important to consult with specific pain services.
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Affiliation(s)
- Santiago Mencía
- Pediatric Intensive Care Service, Gregorio Marañón General University Hospital, Health Research Institute of Gregorio Marañón Madrid, 28029 Madrid, Spain
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Carlos III Institute, 28029 Madrid, Spain
| | - Clara Alonso
- Carlos III Institute, 28029 Madrid, Spain
- Department of Neonatology, 12 de Octubre University Hospital, 28041 Madrid, Spain
| | - Carmen Pallás-Alonso
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Carlos III Institute, 28029 Madrid, Spain
- Department of Neonatology, 12 de Octubre University Hospital, 28041 Madrid, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Service, Gregorio Marañón General University Hospital, Health Research Institute of Gregorio Marañón Madrid, 28029 Madrid, Spain
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Carlos III Institute, 28029 Madrid, Spain
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15
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Marco D, von Borell F, Ramelet AS, Sperotto F, Pokorna P, Brenner S, Mondardini MC, Tibboel D, Amigoni A, Ista E. Pain and sedation management and monitoring in pediatric intensive care units across Europe: an ESPNIC survey. Crit Care 2022; 26:88. [PMID: 35361254 PMCID: PMC8969245 DOI: 10.1186/s13054-022-03957-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/19/2022] [Indexed: 12/01/2022] Open
Abstract
Background Management and monitoring of pain and sedation to reduce discomfort as well as side effects, such as over- and under-sedation, withdrawal syndrome and delirium, is an integral part of pediatric intensive care practice. However, the current state of management and monitoring of analgosedation across European pediatric intensive care units (PICUs) remains unknown. The aim of this survey was to describe current practices across European PICUs regarding the management and monitoring of pain and sedation.
Methods An online survey was distributed among 357 European PICUs assessing demographic features, drug choices and dosing, as well as usage of instruments for monitoring pain and sedation. We also compared low- and high-volume PICUs practices. Responses were collected from January to April 2021. Results A total of 215 (60% response rate) PICUs from 27 European countries responded. Seventy-one percent of PICUs stated to use protocols for analgosedation management, more frequently in high-volume PICUs (77% vs 63%, p = 0.028). First-choice drug combination was an opioid with a benzodiazepine, namely fentanyl (51%) and midazolam (71%) being the preferred drugs. The starting doses differed between PICUs from 0.1 to 5 mcg/kg/h for fentanyl, and 0.01 to 0.5 mg/kg/h for midazolam. Daily assessment and documentation for pain (81%) and sedation (87%) was reported by most of the PICUs, using the preferred validated FLACC scale (54%) and the COMFORT Behavioural scale (48%), respectively. Both analgesia and sedation were mainly monitored by nurses (92% and 84%, respectively). Eighty-six percent of the responding PICUs stated to use neuromuscular blocking agents in some scenarios. Monitoring of paralysed patients was preferably done by observation of vital signs with electronic devices support. Conclusions This survey provides an overview of current analgosedation practices among European PICUs. Drugs of choice, dosing and assessment strategies were shown to differ widely. Further research and development of evidence-based guidelines for optimal drug dosing and analgosedation assessment are needed. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03957-7.
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Affiliation(s)
- Daverio Marco
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Florian von Borell
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany.,Department of Pediatric and Adolescent Medicine, University Clinic Carl Gustav Carus, Dresden, Germany
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland. .,Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland.
| | - Francesca Sperotto
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy.,Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paula Pokorna
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.,Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.,Intensive Care and Department of Paediatric Surgery, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Sebastian Brenner
- Department of Pediatric and Adolescent Medicine, University Clinic Carl Gustav Carus, Dresden, Germany
| | - Maria Cristina Mondardini
- Pediatric Anesthesia and Intensive Care Unit, Department of Woman's and Child's Health, IRCCS University Hospital of Bologna Policlinico S.Orsola, Bologna, Italy.,Department of Woman's and Child's Health, IRCCS University Hospital of Bologna Policlinico S.Orsola, Bologna, Italy
| | - Dick Tibboel
- Pediatric Intensive Care Unit, Department of Pediatric Surgery, • Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Erwin Ista
- Pediatric Intensive Care Unit, Department of Pediatric Surgery, • Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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16
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MacDonald I, Perez MH, Amiet V, Trombert A, Ramelet AS. Quality of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal in pediatric intensive care: a systematic review protocol. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2021-001293. [PMID: 36053608 PMCID: PMC8852722 DOI: 10.1136/bmjpo-2021-001293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/16/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Inadequate management of pain and sedation in critically ill children can cause unnecessary suffering and agitation, but also delirium and iatrogenic withdrawal. It is, therefore, important to address these four interrelated conditions together. Some clinical practice guidelines (CPGs) are available for the management of pain and sedation, and a few for delirium and iatrogenic withdrawal in the paediatric intensive care unit; none address the four conditions altogether. Critical appraisal of the quality of CPGs is necessary for their recommendations to be adopted into clinical practice. The aim of this systematic review is to identify and appraise the quality of CPGs and recommendations for management of either pain, sedation, delirium and iatrogenic withdrawal. METHODS AND ANALYSIS Researchers will conduct a systematic review in electronic databases (Medline ALL (Ovid), Embase.com, CINAHL with Full Text (EBSCO), JBI EBP Database (Ovid)), guideline repositories and websites of professional societies to identify CPGs published from 2010 to date. They will then combine index and free terms describing CPGs with pain, sedation, delirium and withdrawal. The researchers will include CPGs if they can be applied in the paediatric intensive care population (newborns to 18 years old) and include recommendation(s) for assessment of at least one of the four conditions. Two independent reviewers will screen for eligibility, complete data extraction and quality assessments using the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the AGREE Recommendation Excellence instruments. Researchers will report characteristics, content and recommendations from CPGs in tabulated forms. ETHICS AND DISSEMINATION Ethical approval is not required for this systematic review. Results will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42021274364.
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Affiliation(s)
- Ibo MacDonald
- University Institute of Higher Education and Research in Healthcare, University of Lausanne Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Marie-Hélène Perez
- Department of Woman Mother and Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Vivianne Amiet
- Department of Woman Mother and Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Alexia Trombert
- Medical Library, Lausanne University Hospital, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- University Institute of Higher Education and Research in Healthcare, University of Lausanne Faculty of Biology and Medicine, Lausanne, Switzerland .,Department of Woman Mother and Child, Lausanne University Hospital, Lausanne, Switzerland
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Egbuta C, Easley RB. Update on ventilation management in the Pediatric Intensive Care Unit. Paediatr Anaesth 2022; 32:354-362. [PMID: 34882910 DOI: 10.1111/pan.14374] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 12/22/2022]
Abstract
Studies have shown that up to 63% of pediatric intensive care unit patients admitted with acute respiratory or cardiorespiratory illness require mechanical ventilation. Mechanical ventilator support can be divided into three phases: initiation, escalation, and resolution. Noninvasive ventilation is typical during the initiation phase in the management of acute pediatric respiratory failure. The major advancements in the use of noninvasive ventilation involve the emergence of high-flow nasal cannula and how widespread the use of high-flow nasal cannula has become in pediatric critical care practice. When high-flow nasal cannula fails, escalation to continuous positive airway pressure or bi-level positive airway pressure is the next step in respiratory care progression. Careful clinical assessment is necessary to avoid delayed escalation between forms of noninvasive support or escalation to intubation and invasive mechanical ventilation. Advancements in conventional mechanical ventilation are centered on optimizing ventilator settings and customizing monitoring with the overarching goal to reduce complications of mechanical ventilation, such as ventilator-induced lung injury. New mechanical ventilator strategies integrating esophageal pressure monitoring, volumetric capnography, and neurally adjusted ventilator assist help to optimize conventional ventilator support. Nonconventional modes of ventilation in the intensive care unit are high-frequency modes and airway pressure release ventilation. Extracorporeal pulmonary support via extracorporeal membrane oxygenation or paracorporeal lung assist devices provides rescue options when conventional and nonconventional methods fail. During resolution of a course of mechanical ventilator support, reliable weaning strategies and extubation readiness testing are lacking in pediatric critical care. Further, timing of tracheostomy, risk reduction in ventilator-induced lung injury, and decreased sedation requirements in pediatric patients requiring mechanical ventilation in the pediatric intensive care unit are areas of ongoing research.
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Affiliation(s)
- Chinyere Egbuta
- Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
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Yang Y, Geva A, Madden K, Mehta NM. Implementation Science in Pediatric Critical Care - Sedation and Analgesia Practices as a Case Study. Front Pediatr 2022; 10:864029. [PMID: 35859943 PMCID: PMC9289107 DOI: 10.3389/fped.2022.864029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022] Open
Abstract
Sedation and analgesia (SA) management is essential practice in the pediatric intensive care unit (PICU). Over the past decade, there has been significant interest in optimal SA management strategy, due to reports of the adverse effects of SA medications and their relationship to ICU delirium. We reviewed 13 studies examining SA practices in the PICU over the past decade for the purposes of reporting the study design, outcomes of interest, SA protocols used, strategies for implementation, and the patient-centered outcomes. We highlighted the paucity of evidence-base for these practices and also described the existing gaps in the intersection of implementation science (IS) and SA protocols in the PICU. Future studies would benefit from a focus on effective implementation strategies to introduce and sustain evidence-based SA protocols, as well as novel quasi-experimental study designs that will help determine their impact on relevant clinical outcomes, such as the occurrence of ICU delirium. Adoption of the available evidence-based practices into routine care in the PICU remains challenging. Using SA practice as an example, we illustrated the need for a structured approach to the implementation science in pediatric critical care. Key components of the successful adoption of evidence-based best practice include the assessment of the local context, both resources and barriers, followed by a context-specific strategy for implementation and a focus on sustainability and integration of the practice into the permanent workflow.
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Affiliation(s)
- Youyang Yang
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Alon Geva
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Kate Madden
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
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