Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients with Consideration of the ICU Environment and Early Mobility
Patient Guideline Summary
- Critically ill pediatric patients suffer from pain, fear, limited mobility, drug effects, and the inability to understand what is happening to them.
- Patients may be agitated or lethargic, combative, or delirious. They may have a rapid pulse or elevated blood pressure.
- This patient summary focuses on minimizing a child’s distress when critically ill.
- Standardized assessment tools are recommended for evaluating a child’s degree of distress from the many discomforts of hospitalization.
- Regular monitoring of changes in stress levels along with the progress of disease management offers optimum conditions for recovery with the best outcome.
- Management of a child’s pain, mental and emotional state requires:
- Optimum use of sedation, possibly using neuromuscular blockade
- Recognition and treatment of delirium and iatrogenic (caused by medical treatment) withdrawal syndromes (IWS)
- Attention to the hospital/intensive care unit (ICU) environment
- Parental or caregiver presence
- Noise-reducing devices such as ear plugs or headphones
- Reduction of excessive disturbances and therefore improved sleep hygiene and comfort
- Early mobility
- Intravenous opioids are recommended as the primary analgesic (a drug to reduce pain).
- A nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen may be added to reduce the dose of opioids.
- Music therapy is recommended.
- Non-nutritive sucking with oral sucrose should be offered to neonates.
- The depth of sedation should be set according to a standardized tool and assessed daily.
- Alpha2-agonists such as dexmedetomidine are the preferred sedating agent.
- Propofol and ketamine are alternate agents.
- A weaning protocol should be considered.
- Endotracheal tubes (for mechanical ventilation) must be secured.
- Frequent patient monitoring is necessary.
Neuromuscular blockade (NMB)
Note: a neuromuscular blockade is a form of anesthesia that allows a patient to be unaware of pain and breathing tubes.
During NMB, a special kind of monitoring and the lowest effective dose to prevent awareness are recommended.
Electroencephalogram monitoring may be a useful addition.
- Passive eyelid closure and eye lubrication are recommended.
- All patients should be evaluated for delirium: temporary confusion, anxiety, incoherent speech, and hallucinations.
- Recommended initial treatments include:
- Sleep as uninterrupted as possible with as little sedation as possible
- Family involvement with direct-patient care
- Early mobility
- Drugs such as benzodiazepines or antipsychotics are recommended only when the above fails.
- A baseline electrocardiogram and blood electrolyte monitoring should accompany antipsychotics.
Iatrogenic (caused by medical treatment) withdrawal syndrome (IWS)
- When withdrawing from medications, a standardized tapering protocol is recommended.
- EM: Early Mobility
- ICU: Intensive Care Unit
- IWS: Iatrogenic Withdrawal Syndrome
- MV: Mechanical Ventilation
- NMB: Neuromuscular Blockade
- NSAID: Non-steroidal Anti-inflammatory Drug