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

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.

Pain and sedation management and monitoring in pediatric intensive care units across Europe: an ESPNIC survey

“…Previous studies reported that benzodiazepines are independent risk factors for delirium [ 16 , 17 ]; therefore, the replacement of benzodiazepines in favour for alternative drugs like alpha-2 agonists has been advocated [ 18 ]. The recently published clinical practice guidelines for the management of Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility (PANDEM) and the Recommendations for analgesia and sedation in critically ill children admitted to intensive care unit [ 8 , 19 ] both recommend the use of alpha 2 -agonists over benzodiazepines as a first-line sedative. It has been shown that alpha 2 -agonists is a safe and benzodiazepine sparing alternative for sedation in the pediatric population [ 20 – 22 ].…”

“…To date, only a few international and national clinical practice guidelines for the management of pain and sedation in children are available [ 5 – 8 ]. Except for the recently published PANDEM guideline, these guidelines were published more than 10 years ago with recommendations based on limited evidence.…”

Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like?

“…Protocols therefore should call for the sparing use of benzodiazepines in critically ill children, using opiates and alpha-2-agonist clonidine for firstline treatment ( 25 , 33 ). Even with our knowledge of side effects and negative long-term effects, there are still patients who are sedated using benzodiazepines.…”

“…Disoprivan, for instance, is recommended for use in children for up to 48 h within the United States but its use is not allowed for long-term sedation in Europe because of risk for propofol infusion syndrome in children under the age of 16 ( 25 , 26 ).…”

“…We advocate for nurse-controlled protocols primarily using opioid infusion supplemented by alpha-2-agonists. Additionally, non-opioid drugs should be used for mild to moderate pain without the need for further sedative effect ( 25 ). Spinal anesthesia has been shown to effectively reduce opioid use in pediatric postoperative patients and has a significant benefit in providing hemodynamic stability in infants after surgery ( 27 , 28 ).…”