Practice Guideline

. 2022 Feb 1;23(2):e74-e110.

doi: 10.1097/PCC.0000000000002873.

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

Heidi A B Smith^{1

2}, James B Besunder^{3

4}, Kristina A Betters¹, Peter N Johnson^{5

6}, Vijay Srinivasan^{7

8}, Anne Stormorken^{9

10}, Elizabeth Farrington¹¹, Brenda Golianu^{12

13}, Aaron J Godshall¹⁴, Larkin Acinelli¹⁵, Christina Almgren¹⁶, Christine H Bailey¹⁷, Jenny M Boyd^{18

19}, Michael J Cisco²⁰, Mihaela Damian^{21

22}, Mary L deAlmeida^{23

24}, James Fehr^{13

25}, Kimberly E Fenton¹⁴, Frances Gilliland^{26

27}, Mary Jo C Grant²⁸, Joy Howell²⁹, Cassandra A Ruggles³⁰, Shari Simone^{31

32}, Felice Su^{21

22}, Janice E Sullivan^{33

34}, Ken Tegtmeyer^{35

36}, Chani Traube²⁹, Stacey Williams³⁷, John W Berkenbosch^{33

34}

Affiliations

¹ Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN.
² Division of Pediatric Cardiac Anesthesiology, Vanderbilt University Medical Center, Department of Anesthesiology, Nashville, TN.
³ Division of Pediatric Critical Care, Akron Children's Hospital, Akron, OH.
⁴ Department of Pediatrics, Northeast Ohio Medical University, Akron, OH.
⁵ University of Oklahoma College of Pharmacy, Oklahoma City, OK.
⁶ The Children's Hospital at OU Medical Center, Oklahoma City, OK.
⁷ Departments of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
⁸ Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.
⁹ Pediatric Critical Care, Rainbow Babies Children's Hospital, Cleveland, OH.
¹⁰ Department of Pediatrics, Case Western Reserve University, Cleveland, OH.
¹¹ Betty H. Cameron Women's and Children's Hospital at New Hanover Regional Medical Center, Wilmington, NC.
¹² Division of Pediatric Anesthesia and Pain Management, Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA.
¹³ Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA.
¹⁴ Department of Pediatrics, AdventHealth For Children, Orlando, FL.
¹⁵ Division of Critical Care Medicine, Johns Hopkins All Children's Hospital, St Petersburg, FL.
¹⁶ Lucile Packard Children's Hospital Stanford Pain Management, Palo Alto, CA.
¹⁷ Pediatric Critical Care, Moses Cone Hospital, Greensboro, NC.
¹⁸ Division of Pediatric Critical Care, N.C. Children's Hospital, Chapel Hill, NC.
¹⁹ Division of Pediatric Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC.
²⁰ Division of Pediatric Critical Care Medicine, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA.
²¹ Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA.
²² Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA.
²³ Children's Healthcare of Atlanta at Egleston, Atlanta, GA.
²⁴ Division of Pediatric Critical Care, Emory University School of Medicine, Atlanta, GA.
²⁵ Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA.
²⁶ Division of Cardiac Critical Care, Johns Hopkins All Children's Hospital, St Petersburg, FL.
²⁷ College of Nursing, University of South Florida, Tampa, FL.
²⁸ Primary Children's Hospital, Pediatric Critical Care Services, Salt Lake City, UT.
²⁹ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY.
³⁰ Department of Pharmacy, Akron Children's Hospital, Akron, OH.
³¹ University of Maryland School of Nursing, Baltimore, MD.
³² Pediatric Intensive Care Unit, University of Maryland Medical Center, Baltimore, MD.
³³ "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY.
³⁴ Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY.
³⁵ Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
³⁶ Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
³⁷ Division of Pediatric Critical Care, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN.

PMID: 35119438
DOI: 10.1097/PCC.0000000000002873

Practice Guideline

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

Heidi A B Smith et al. Pediatr Crit Care Med. 2022.

. 2022 Feb 1;23(2):e74-e110.

doi: 10.1097/PCC.0000000000002873.

Authors

Affiliations

¹ Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN.
² Division of Pediatric Cardiac Anesthesiology, Vanderbilt University Medical Center, Department of Anesthesiology, Nashville, TN.
³ Division of Pediatric Critical Care, Akron Children's Hospital, Akron, OH.
⁴ Department of Pediatrics, Northeast Ohio Medical University, Akron, OH.
⁵ University of Oklahoma College of Pharmacy, Oklahoma City, OK.
⁶ The Children's Hospital at OU Medical Center, Oklahoma City, OK.
⁷ Departments of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
⁸ Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.
⁹ Pediatric Critical Care, Rainbow Babies Children's Hospital, Cleveland, OH.
¹⁰ Department of Pediatrics, Case Western Reserve University, Cleveland, OH.
¹¹ Betty H. Cameron Women's and Children's Hospital at New Hanover Regional Medical Center, Wilmington, NC.
¹² Division of Pediatric Anesthesia and Pain Management, Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA.
¹³ Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA.
¹⁴ Department of Pediatrics, AdventHealth For Children, Orlando, FL.
¹⁵ Division of Critical Care Medicine, Johns Hopkins All Children's Hospital, St Petersburg, FL.
¹⁶ Lucile Packard Children's Hospital Stanford Pain Management, Palo Alto, CA.
¹⁷ Pediatric Critical Care, Moses Cone Hospital, Greensboro, NC.
¹⁸ Division of Pediatric Critical Care, N.C. Children's Hospital, Chapel Hill, NC.
¹⁹ Division of Pediatric Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC.
²⁰ Division of Pediatric Critical Care Medicine, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA.
²¹ Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA.
²² Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA.
²³ Children's Healthcare of Atlanta at Egleston, Atlanta, GA.
²⁴ Division of Pediatric Critical Care, Emory University School of Medicine, Atlanta, GA.
²⁵ Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA.
²⁶ Division of Cardiac Critical Care, Johns Hopkins All Children's Hospital, St Petersburg, FL.
²⁷ College of Nursing, University of South Florida, Tampa, FL.
²⁸ Primary Children's Hospital, Pediatric Critical Care Services, Salt Lake City, UT.
²⁹ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY.
³⁰ Department of Pharmacy, Akron Children's Hospital, Akron, OH.
³¹ University of Maryland School of Nursing, Baltimore, MD.
³² Pediatric Intensive Care Unit, University of Maryland Medical Center, Baltimore, MD.
³³ "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY.
³⁴ Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY.
³⁵ Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
³⁶ Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
³⁷ Division of Pediatric Critical Care, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN.

PMID: 35119438
DOI: 10.1097/PCC.0000000000002873

Abstract

Rationale: A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available.

Objective: To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility.

Design: The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to.

Methods: Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence.

Results: The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements.

Conclusions: The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.

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Conflict of interest statement

Drs. Smith and Berkenbosch were responsible for the adjudication of any conflicts of interest for this guideline. The following relevant disclosures were provided for consideration. Dr. Srinivasan authored “Conversion from prolonged intravenous fentanyl infusion to enteral methadone in critically ill children,” World Journal of Clinical Pediatrics (May 2017). Dr. Almgren authored “Pharmacological Strategies for Decreasing Opioid Therapy and Management of Side Effects From Chronic Use”, Children (2018) and “Multidisciplinary Pain Management for Pediatric Patients with Acute and Chronic Pain: A Foundational Treatment Approach When Prescribing Opioids,” Children (2019). Dr. Grant was a lead author for the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Study Investigators (2016) and for “Dexmedetomidine Use in Critically-Ill Children with Acute Respiratory Failure,” Pediatric Critical Care Medicine. Dr. deAlmeida was a contributing author on “Delirium in Critically Ill Children: An International Point Prevalence Study,” Critical Care Medicine (2017). Dr. Simone is a lead author for “Analgesia, Sedation, Paralytics, and Opioid Syndrome (2021); Pediatric Acute Care. A Guide for Interprofessional Practice, second Edition (2019); Delirium and Pharmacologic Treatment in Critically Ill Children: A Retrospective Matched Cohort Study,” Journal of Pediatric Pharmacologic and Therapeutics (2017). “Implementation of an ICU Bundle: An Interprofessional Quality Improvement Project to Enhance Delirium Management and Monitor Delirium Prevalence in a Single PICU,” Pediatric Critical Care Medicine (2017). Dr. Su was a lead author for “Pharmacokinetics of Dexmedetomidine in Infants and Children After Orthotopic Liver Transplantation,” Anesthesia Analog (2018). Dr. Traube was a lead author on “Detection and Management of Delirium in the Neonatal Unit: A Case Series,” Pediatrics (2016); “Prospective Study to Establish the German version of the CAPD for the Assessment of Delirium in Children Undergoing Intensive Care” (German), Monatsschrift Kinderheilkunde (2016); “Cost Associated With Pediatric Delirium in the ICU,” Critical Care Medicine (2016); “Validity of the Richmond Agitation-Sedation Scale (RASS) in Critically Ill Children,” Journal of Intensive Care (2016); “Sedation, Analgesia, and Paralysis During Mechanical Ventilation of Premature Infants,”(2017), “Patterns of Postoperative Delirium in Children,” Pediatric Critical Care Medicine (2017); “Delirium in Children After Cardiac Bypass Surgery,” Pediatric Critical Care Medicine (2017); “Delirium in Critically Ill Children: An International Point Prevalence Study,”Critical Care Medicine (2017); “Delirium and Mortality in Critically Ill Children: Epidemiology and Outcomes of Pediatric Delirium,” Critical Care Medicine (2017); “Iatrogenic Withdrawal Syndrome or Undiagnosed Delirium?,” Critical Care Medicine (2017); “‘The Times They Are A-Changin’: Universal Delirium Screening in Pediatric Critical Care,” Pediatric Critical Care Medicine (2017); “Quality Improvement Initiative to Reduce Pediatric Intensive Care Unit Noise Pollution With the Use of a Pediatric Delirium Bundle,” Journal of Intensive Care Medicine (2017); “Delirium in Pediatric Critical Care,” Pediatric Clinics of North America (2017); “Delirium in the Pediatric Cardiac Extracorporeal Membrane Oxygenation Patient Population: A Case Series,” Pediatric Critical Care Medicine (2017); “Delirium in Hospitalized Children with Cancer: Incidence and Associated Risk Factors,” The Journal of Pediatrics (2017); “Provider Beliefs Regarding Early Mobilization in the Pediatric Intensive Care Unit,” Journal of Pediatric Nursing (2018); “Identify Delirium, Then Investigate for Underlying Etiology,” Pediatric Critical Care Medicine (2018); “Consensus Report by PALISI and PBMTC Joint Working Committees, Supportive Care Guidelines for Management of VOD in Children and Adolescents; Part 3: Focus on Cardio-Respiratory Dysfunction, Infections, Liver Dysfunction and Delirium,” Biology of Blood and Marrow Transplantation (2018); “Delirium is a Common and Early Finding in Patients in the Pediatric Cardiac Intensive Care Unit,” The Journal of Pediatrics (2018); “Delirium Upon Presentation to the Pediatric Emergency Department: A Case Series,” Pediatric Emergency Care (2018); “Benzodiazepines and Development of Delirium in Critically Ill Children: Estimating the Causal Effect,” Critical Care Medicine (2018); “Association Between Transfusion of RBCs and Subsequent Development of Delirium in Critically Ill Children,” Pediatric Critical Care Medicine (2018); “All Delirium May Not Be Created Equal: Consideration of Differential Effects of Delirium Based Upon Underlying Etiology,” Pediatric Critical Care Medicine (2018); “Risk Factors for the Development of Postoperative Delirium in Pediatric Intensive Care Patients,” Pediatric Critical Care Medicine (2018); “Management Guidelines For Paediatric Patients Receiving Chimeric Antigen Receptor T Cell Therapy,” Nature Reviews Clinical Oncology (2019); and “A Systematic Approach to Family Engagement: Feasibility Pilot of a Pediatric Delirium Management And Prevention Toolkit,” Palliative and Supportive Care (2019). Stacey Williams was lead author for “The Preschool Confusion Assessment Method for the ICU: Valid and Reliable Delirium Monitoring for Critically Ill Infants and Children,” Critical Care Medicine(2016). The remaining authors have disclosed that they do not have any potential conflicts of interest. Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as “strong” with “we recommend” or “conditional” with “we suggest.” Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence.

Comment in

About PANDEM 2022 and "Rationale: Ketamine Appears to Be a Safe...".
Selandari JO, Pellegrini S, Filippini S, Garcia MDJ, Cinqui GC, Galvan ME, Flores Tonfi ML, Zuazaga M, Montonati MM, Landry LM. Selandari JO, et al. Pediatr Crit Care Med. 2022 Oct 1;23(10):e489-e490. doi: 10.1097/PCC.0000000000003004. Epub 2022 Oct 3. Pediatr Crit Care Med. 2022. PMID: 36190365 No abstract available.

References

1. Barr J, Fraser GL, Puntillo K, et al.; American College of Critical Care Medicine: Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41:263–306
1. Devlin JW, Skrobik Y, Gélinas C, et al.: Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med 2018; 46:e825–e873
1. Twite MD, Rashid A, Zuk J, et al.: Sedation, analgesia, and neuromuscular blockade in the pediatric intensive care unit: Survey of fellowship training programs. Pediatr Crit Care Med 2004; 5:521–532
1. Long D, Horn D, Keogh S: A survey of sedation assessment and management in Australian and New Zealand paediatric intensive care patients requiring prolonged mechanical ventilation. Aust Crit Care 2005; 18:152–157
1. Jenkins IA, Playfor SD, Bevan C, et al.: Current United Kingdom sedation practice in pediatric intensive care. Paediatr Anaesth 2007; 17:675–683

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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

Affiliations

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

Authors

Affiliations

Abstract

Conflict of interest statement

Comment in

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Medical