Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility
Publication Date: February 4, 2022
Last Updated: March 14, 2022
Analgesia
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Recommendations
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Strength | Quality |
| We suggest that, in critically ill pediatric patients 6 yr old and older who are capable of communicating, pain assessment via self-report be routinely performed using the Visual Analog Scale, Numeric Rating Scale, Oucher Scale, or Wong-Baker Faces pain scale. | Conditional | Low |
| We recommend the use of either the Faces, Legs, Activity, Cry, and Consolability or COMFORT-B scales for assessing pain in non-communicative critically ill pediatric patients. | Strong | Moderate |
| We recommend the use of observational pain assessment tools rather than vital signs alone for assessment of postoperative pain in critically ill pediatric patients. | Strong | Moderate |
| We suggest the use of observational pain assessment tools rather than vital signs alone for assessment of procedure-related pain in critically ill pediatric patients. | Conditional | Low |
| We recommend that IV opioids be used as the primary analgesic for treating moderate to severe pain in critically ill pediatric patients. | Strong | Moderate |
| We recommend the addition of an adjunct NSAID (IV or oral) to improve early postoperative analgesia in critically ill pediatric patients. | Strong | Moderate |
| We suggest the addition of an adjunct NSAID agent (IV or oral) to decrease opioid requirements in the immediate postoperative period in critically ill pediatric patients. | Conditional | Low |
| We suggest the addition of adjunct acetaminophen (IV or oral) to improve early postoperative analgesia in critically ill pediatric patients. | Conditional | Low |
| We suggest the addition of adjunct acetaminophen (IV or oral) to decrease opioid requirements in the immediate postoperative period in critically ill pediatric patients. | Conditional | Low |
| We recommend that music therapy be offered to augment analgesia in critically ill postoperative pediatric patients. | Strong | Moderate |
| We recommend that nonnutritive sucking with oral sucrose be offered to neonates and young infants prior to performing invasive procedures. | Strong | High |
Sedation
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Recommendations
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Strength | Quality |
| We recommend the use of the COMFORT-B Scale or the State Behavioral Scale, to assess level of sedation in mechanically ventilated pediatric patients. | Strong | Moderate |
| We suggest the use of the Richmond Agitation-Sedation Scale to assess level of sedation in mechanically ventilated pediatric patients. | Conditional | Low |
| We suggest that all pediatric patients requiring MV are assigned a target depth of sedation using a validated sedation assessment tool at least once daily. | Conditional | Low |
| We suggest the use of protocolized sedation in all critically ill pediatric patients requiring sedation and/or analgesia during MV. | Conditional | Low |
| The addition of daily sedation interruption to sedation protocolization is not suggested due to lack of improvement in outcomes. | Conditional | Low |
| During the periextubation period when sedation is typically lightened, we suggest the following bundle strategies to decrease risk of inadvertent device removal:   a) Assign a target depth of sedation at increasing frequency to adapt to changes inpatient clinical status and communicate strategies to reach titration goal.   b) Consider a sedation weaning protocol.   c) Consider unit standards for securement of endotracheal tubes and safety plan.   d) Restrict nursing workload to facilitate frequent patient monitoring, decrease sedation requirements, and risk of self-harm. |
Conditional | Low |
| We suggest the use of alpha2-agonists as the primary sedative class in critically ill pediatric patients requiring MV. | Conditional | Low |
| We recommend that dexmedetomidine be considered as a primary agent for sedation in critically ill pediatric post-operative cardiac surgical patients with expected early extubation. | Strong | Moderate |
| We suggest the use of dexmedetomidine for sedation in critically ill pediatric postoperative cardiac surgical patients to decrease the risk of tachyarrhythmias. | Conditional | Low |
| We suggest that continuous propofol sedation at doses less than 4 mg/kg/hr (67 µg/kg/min) and administered for less than 48 hr may be a safe sedation alternative to minimize the risk of propofol-related infusion syndrome development. | Conditional | Low |
| Short term (< 48 hr) continuous propofol sedation may be a useful adjunct during the periextubation period to facilitate weaning of other analgosedative agents prior to extubation. | Good practice | |
| We suggest consideration of adjunct sedation with ketamine in patients who are not otherwise at an optimal sedation depth. | Conditional | Low |
| During the periextubation period when sedation is typically lightened, we suggest the following bundle strategies to decrease risk of inadvertent device removal:    a) Assign a target depth of sedation at increasing frequency to adapt to changes inpatient clinical status and communicate strategies to reach titration goal.    c) Consider a sedation weaning protocol.    e) Consider unit standards for securement of endotracheal tubes and safety plan.    d) Restrict nursing workload to facilitate frequent patient monitoring, decrease sedation requirements, and risk of self-harm. |
Conditional | Low |
Neuromuscular blockade
Neuromuscular blockade
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Recommendations
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Strength | Quality |
| We suggest that train-of-four monitoring be used in concert with clinical assessment to determine depth of neuromuscular blockade. | Conditional | Low |
| We suggest using the lowest dose of NMBAs required to achieve desired clinical effects and manage undesired breakthrough movement. | Conditional | Low |
| Electroencephalogram-based monitoring may be a useful adjunct for assessment of sedation depth in critically ill pediatric patients receiving NMBAs. | Good practice | |
| We suggest that sedation and analgesia should be adequate to prevent awareness prior to and throughout NMBA use. | Conditional | Low |
| We recommend routine use of passive eyelid closure and eye lubrication for the prevention of corneal abrasions in critically ill pediatric patients receiving NMBAs. | Strong | Moderate |
ICU delirium
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Recommendations
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Strength | Quality |
| We recommend use of the preschool and pediatric Confusion Assessment Methods for the ICU or the Cornell Assessment for Pediatric Delirium as the most valid and reliable delirium monitoring tools in critically ill pediatric patients. | Strong | High |
| We recommend routine screening for ICU delirium using a validated tool in critically ill pediatric patients upon admission through ICU discharge or transfer. | Strong | High |
| Given low patient risk, and possible patient benefit to reduce the incidence and/or decrease duration or severity of delirium we suggest the following non-pharmacologic strategies: optimization of sleep hygiene, use of interdisciplinary rounds, family engagement on rounds, and family involvement with direct-patient care. | Conditional | Low |
| We suggest performing EM, when feasible, to reduce the development of delirium. | Conditional | Low |
| We recommend minimizing benzodiazepine-based sedation when feasible in critically ill pediatric patients to decrease incidence and/or duration or severity of delirium. | Strong | Moderate |
| We suggest strategies to minimize overall sedation exposure whenever feasible to reduce coma and the incidence and/or severity of delirium in critically ill children. | Conditional | Low |
| We do not suggest routine use of haloperidol or atypical antipsychotics for the prevention of or decrease in duration of delirium in critically ill pediatric patients. | Conditional | Low |
| We suggest that in critically ill pediatric patients with refractory delirium, haloperidol or atypical antipsychotics be considered for the management of severe delirium manifestations, with consideration of possible adverse drug effects. | Conditional | Moderate |
| We recommend a baseline electrocardiogram followed by routine electrolyte and QTc interval monitoring for patients receiving haloperidol or atypical antipsychotics. | Strong | Moderate |
IWS
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Recommendations
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Strength | Quality |
| We recommend use of either the Withdrawal Assessment Tool-1or Sophia Observation Scale for the assessment of IWS due to opioid or benzodiazepine withdrawal in critically ill pediatric patients. | Strong | Moderate |
| We suggest routine IWS screening after a shorter duration (3–5 d) when higher opioid or benzodiazepine doses are used. | Conditional | Moderate |
| Until a validated screening tool is developed, monitoring for IWS from alpha2-agonists should be performed using a combination of associated symptoms (unexplained hypertension or tachycardia) with adjunct use of a validated benzodiazepine or opioid screening tool. | Good practice | |
| We suggest that opioid related IWS be treated with opioid replacement therapy to attenuate symptoms, irrespective of preceding dose and /or duration or opioid exposure. | Conditional | Low |
| Benzodiazepine-related IWS should be treated with benzodiazepine replacement therapy to attenuate symptoms, irrespective of preceding dose and/or duration of benzodiazepine exposure. | Good practice | |
| Alpha2-agonist–related IWS should be treated with IV and/or or enteral alpha2-agonist replacement therapy to attenuate symptoms, irrespective of preceding dose and/or duration of alpha2-agonist exposure. | Good practice | |
| We suggest use of a standardized protocol for sedation/analgesia weaning to decrease duration of sedation taper and attenuate emergence of IWS. | Conditional | Low |
Optimizing environment
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Recommendations
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Strength | Quality |
| We suggest facilitation of parental or caregiver presence in the PICU during routine care and interventional procedures to a) provide comfort to the child, b) decrease parental levels of stress and anxiety and c) increase level of satisfaction of care. | Conditional | Low |
| We suggest offering patients the use of noise reducing devices such as ear plugs or headphones to reduce the impact of non-modifiable ambient noise (conditional, low-level evidence). | Conditional | Low |
| We suggest that PICU teams make environmental and/or behavioral changes to reduce excessive noise and therefore improve sleep hygiene and comfort, in critically ill pediatric patients. | Conditional | Low |
| We suggest performing EM to minimize the effects of immobility in critically ill pediatric patients. | Conditional | Low |
| We suggest the use of a standardized EM protocol that outlines readiness criteria, contraindications, developmentally appropriate mobility activities and goals, and safety thresholds guided by the multidisciplinary team and family decision-making. | Conditional | Low |
Recommendation Grading
Overview
Title
Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility
Authoring Organization
Society of Critical Care Medicine
Publication Month/Year
February 4, 2022
Last Updated Month/Year
February 12, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Inclusion Criteria
Male, Female, Adolescent, Child, Infant
Health Care Settings
Emergency care, Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management, Prevention
Diseases/Conditions (MeSH)
D019148 - Neuromuscular Blockade, D003693 - Delirium
Keywords
delirium, pediatrics, Agitation, neuromuscular blockade, ICU, delirium prevention
Source Citation
Smith HAB, Besunder JB, Betters KA, Johnson PN, Srinivasan V, Stormorken A, Farrington E, Golianu B, Godshall AJ, Acinelli L, Almgren C, Bailey CH, Boyd JM, Cisco MJ, Damian M, deAlmeida ML, Fehr J, Fenton KE, Gilliland F, Grant MJC, Howell J, Ruggles CA, Simone S, Su F, Sullivan JE, Tegtmeyer K, Traube C, Williams S, Berkenbosch JW. 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. Pediatr Crit Care Med. 2022 Feb 1;23(2):e74-e110. doi: 10.1097/PCC.0000000000002873. PMID: 35119438.
Supplemental Methodology Resources
Methodology
Number of Source Documents
348
Literature Search Start Date
January 1, 1990
Literature Search End Date
January 1, 2020