The ICU Liberation Bundle and Strategies for Implementation in Pediatrics

Walz, Alice; Canter, Marguerite Orsi; Betters, Kristina

doi:10.1007/s40124-020-00216-7

Cited by 22 publications

(27 citation statements)

References 89 publications

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“…As mortality in the PICU has decreased, several quality improvement initiatives have been aimed at mitigating the long-term psychologic, social, and physical impairment of critical illness (43). ICU liberation bundles, also known as ABCDEF Bundles (44) (Table 3), are evidence-based guidelines to liberate patients from the harmful effects of a PICU stay (10,43). It should be noted that sedation protocols are a critical element of these bundles, directly addressing "A" and "C" and having an impact on "B", "D", and "E".…”

Section: Role Of Sedation Protocols Within Picu Liberation Bundlesmentioning

confidence: 99%

Sedation protocols in the pediatric intensive care unit: fact or fiction?

Balit¹,

LaRosa²,

Ong³

et al. 2021

Transl Pediatr

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Comfort of the critically unwell pediatric patient is paramount to ensuring good outcomes.Analgesia-based, multimodal sedative approaches are the foundation for comfort, whereby pain is addressed first and then sedation titrated to a predefined target based on the goals of care. Given the heterogeneity of patients within the pediatric critical care population, the approach must be individualized based on the age and developmental stage of the child, physiologic status, and degree of invasive treatment required. In both the adult and pediatric intensive care unit (PICU), sedation titration is practiced as standard of care to meet therapeutic goals with a focus on facilitating early rehabilitation and extubation while avoiding underand over-sedation. Sedation protocols have been developed as methods to reduce variability and optimize goal-directed therapy. Components of a sedation protocol include routine analgesia and sedation scoring with validated tools at specified intervals and a predefined algorithm that allows the titration of analgesia and sedation based on those assessments. Sedation protocols are designed to improve communication and documentation of sedation goals while also empowering the bedside team to respond rapidly to changes in a patient's clinical status. Previously it was thought that sedation protocols would consistently reduce duration of mechanical ventilation (MV) and length of stay (LOS) for patients in the PICU, however, this has not been the case. Nonetheless, introduction of sedation protocols has provided several benefits, including: (I) reduction in benzodiazepine usage; (II) improvements in interprofessional communication surrounding sedation goals and management of sedation goals; and (III) reductions in iatrogenic withdrawal symptoms.Successful implementation of sedation protocols requires passionate clinical champions and a robust implementation, education, and sustainability plan. Emerging evidence suggests that sedation protocols as part of a bundle of quality improvement initiatives will form the basis of future studies to improve short-and long-term outcomes after PICU discharge. In this review, we aim to define sedation protocols in the context of pediatric critical care and highlight important considerations for clinical practice and research.

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Section: Role Of Sedation Protocols Within Picu Liberation Bundlesmentioning

confidence: 99%

Sedation protocols in the pediatric intensive care unit: fact or fiction?

Balit¹,

LaRosa²,

Ong³

et al. 2021

Transl Pediatr

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“…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.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2022

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Background Management and monitoring of pain and sedation to reduce discomfort as well as side effects, such as over- and under-sedation, withdrawal syndrome and delirium, is an integral part of pediatric intensive care practice. However, the current state of management and monitoring of analgosedation across European pediatric intensive care units (PICUs) remains unknown. The aim of this survey was to describe current practices across European PICUs regarding the management and monitoring of pain and sedation. Methods An online survey was distributed among 357 European PICUs assessing demographic features, drug choices and dosing, as well as usage of instruments for monitoring pain and sedation. We also compared low- and high-volume PICUs practices. Responses were collected from January to April 2021. Results A total of 215 (60% response rate) PICUs from 27 European countries responded. Seventy-one percent of PICUs stated to use protocols for analgosedation management, more frequently in high-volume PICUs (77% vs 63%, p = 0.028). First-choice drug combination was an opioid with a benzodiazepine, namely fentanyl (51%) and midazolam (71%) being the preferred drugs. The starting doses differed between PICUs from 0.1 to 5 mcg/kg/h for fentanyl, and 0.01 to 0.5 mg/kg/h for midazolam. Daily assessment and documentation for pain (81%) and sedation (87%) was reported by most of the PICUs, using the preferred validated FLACC scale (54%) and the COMFORT Behavioural scale (48%), respectively. Both analgesia and sedation were mainly monitored by nurses (92% and 84%, respectively). Eighty-six percent of the responding PICUs stated to use neuromuscular blocking agents in some scenarios. Monitoring of paralysed patients was preferably done by observation of vital signs with electronic devices support. Conclusions This survey provides an overview of current analgosedation practices among European PICUs. Drugs of choice, dosing and assessment strategies were shown to differ widely. Further research and development of evidence-based guidelines for optimal drug dosing and analgosedation assessment are needed.

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“…As surviving critical illness can have long-term effects on both PICU survivors and parents, who play a key role in helping to recover, follow-up care for parents is necessary to be able to adequately support the patient and parents. Early mobility exercises, the practice of physical therapy during critical illness, and family engagement/empowerment are promising intervention strategies ( 91 , 92 ).…”

Section: Discussionmentioning

confidence: 99%