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.

A reappraisal of the conservation status of the indigenous New Zealand vascular plant flora is presented. The list comprises 792 taxa (34% of New Zealand's total indigenous vascular flora) in the following categories: Extinct 4 taxa, Acutely Threatened 122 taxa (comprising 47 taxa Nationally Critical, 54 Nationally Endangered, 21 Nationally Vulnerable), Chronically Threatened 96 taxa (comprising Serious Decline 26 taxa, Gradual Decline 70 taxa), At Risk 499 taxa (comprising Sparse 126 taxa, Range Restricted 373 taxa), Non-resident Native 26 taxa (comprising Vagrant 16 taxa, Colonist 10 taxa), and Data Deficient 45 taxa. A further 208 plants are listed as Taxonomically Indeterminate, being those which might warrant further conservation attention once their taxonomic status is clarified. A further 31 named taxa and 18 rated as Taxonomically Indeterminate, and previously considered to be threatened and/or uncommon, are removed from this updated listing. A concordance of plant names is provided. The lists presented use a new threat classification system developed by the New Zealand Department of Conservation for sole use within this country. This paper represents the first time the entire known indigenous vascular flora has been assessed from a conservation perspective since the mid 1970s. A brief analysis of the patterns of rarity exhibited by the taxa listed is presented.

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