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Review
. 2023 Oct 6:11:1264717.
doi: 10.3389/fped.2023.1264717. eCollection 2023.

A systematic review of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal syndrome in pediatric intensive care

Ibo MacDonald  1 , Silvia Alvarado  1   2 , Mark T Marston  1   2 , Luz Gomez Tovar  1   3 , Vivianne Chanez  2 , Eva Favre  1   4 , Ying Gu  5 , Alexia Trombert  6 , Maria-Helena Perez  2 , Anne-Sylvie Ramelet  1   2
Affiliations
Review

A systematic review of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal syndrome in pediatric intensive care

Ibo MacDonald et al. Front Pediatr. .

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).

Keywords: critical care; delirium; iatrogenic withdrawal syndrome; intensive care units; pain; pediatric; practice guideline; sedation.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

Figures

Figure 1
Figure 1
The PRISMA flow diagram summarizes the number of studies excluded in each phase of the selection process (21).
Figure 2
Figure 2
The AGREE II scores are displayed by each domain across all CPGs. The dashed lines represent the cut-off thresholds: low = >30%, medium = 30%–59%, and high = <60%.
See this image and copyright information in PMC

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