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 3, 2022
Last Updated: March 14, 2022

Analgesia

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Recommendations
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
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

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