Practices of assessment of pain, sedation, iatrogenic withdrawal syndrome, and delirium in European paediatric intensive care units: A secondary analysis of the European Prevalence of Acute Rehab for Kids in the paediatric intensive care unit study

Abstract

Background: Analgosedation is standard practice to ensure comfort and safety of critically ill children in paediatric intensive care units (PICUs). However, a significant number of children develop iatrogenic withdrawal syndrome or delirium with these drugs. The European Society of Paediatric and Neonatal Intensive Care published a position statement in 2016, but how successfully its recommendations have been implemented is unknown.

Objectives: Following were the objectives of this study: (i) to describe assessment practices (prevalence, measurement instruments, and frequency) for pain, sedation, iatrogenic withdrawal syndrome and delirium; (ii) to assess how practices meet the position statement; and (iii) to identify organisational factors associated with the use of recommendations for pain and sedation assessment.

Method: A secondary analysis of prospectively collected data from the multicentre prevalence study (European Prevalence of Acute Rehab for Kids in the PICU) conducted in 38 PICUs, across 15 European countries in 2018. Data from 453 children were analysed.

Results: Of the 38 PICUs, 97% assessed pain, 89% sedation, 82% withdrawal, and 42% delirium. These four symptoms were mainly assessed and documented by the Face, Legs, Activity, Cry, Consolability scale (39%) and Numerical Rating Scale (24%) every 8, 4, or 2 h for pain; the COMFORT-B (45%) and COMFORT (24%) scales every 8 or 2 h for sedation; the Sophia Observation withdrawal Scale (37%) and Withdrawal Assessment Tool-1 (32%) scales every 8 or 4 h for withdrawal and the Cornell Assessment Pediatric-Delirium (18%) and Sophia Observation Withdrawal Symptoms-Pediatric Delirium (16%) scales every 12 or 8 h for delirium. Concordance with the position statement recommendations was low to moderate (13-69%). Adherence to recommendations were influenced by the variables of nurse-to-patient ratio, type of hospital, and the number of PICU beds.

Conclusion: Based on prospectively collected data, there was variability in pain and sedation assessment practices and a lack of adherence with recommendations in the EU, particularly for delirium. These findings highlight the need for more proactive dissemination, and investigation of barriers and implementation strategies to improve evidence-based assessment practices.

Keywords: Assessment; Delirium; Evaluation; Evidence-based practice; Iatrogenic withdrawal syndrome (IWS); Measurement instrument; Pain; Recommendation; Scale; Sedation.