2022 guidelines for management of critically ill infants and children

Analgesia

• The authors 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.
• The authors 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.
• The authors recommend the use of observational pain assessment tools rather than vital signs alone for the assessment of postoperative pain in critically ill pediatric patients.
• The authors suggest the use of observational pain assessment tools rather than vital signs alone for the assessment of procedure-related pain in critically ill pediatric patients.
• The authors recommend that IV opioids be used as the primary analgesic for treating moderate to severe pain in critically ill pediatric patients.
• The authors recommend the addition of an adjunct NSAID (IV or oral) to improve early postoperative analgesia in critically ill pediatric patients.
• The authors 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.
• The authors suggest the addition of adjunct acetaminophen (IV or oral) to improve early postoperative analgesia in critically ill pediatric patients.
• The authors suggest the addition of adjunct acetaminophen (IV or oral) to decrease opioid requirements in the immediate postoperative period in critically ill pediatric patients.
• The authors recommend that music therapy be offered to augment analgesia in critically ill postoperative pediatric patients.
• The authors recommend that nonnutritive sucking with oral sucrose be offered to neonates and young infants prior to performing invasive procedures.

Sedation

• The authors recommend the use of the COMFORT-B Scale or the State Behavioral Scale, to assess level of sedation in mechanically ventilated pediatric patients.
• The authors suggest the use of the Richmond Agitation-Sedation Scale to assess level of sedation in mechanically ventilated pediatric patients.
• The authors suggest that all pediatric patients requiring MV are assigned a target depth of sedation using a validated sedation assessment tool at least once daily.
• The authors suggest the use of protocolized sedation in all critically ill pediatric patients requiring sedation and/or analgesia during MV.
• The addition of daily sedation interruption to sedation protocolization is not suggested due to lack of improvement in outcomes.
• 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.
• The authors suggest the use of alpha₂-agonists as the primary sedative class in critically ill pediatric patients requiring MV.
• The authors recommend that dexmedetomidine be considered as a primary agent for sedation in critically ill pediatric post-operative cardiac surgical patients with expected early extubation.
• The authors suggest the use of dexmedetomidine for sedation in critically ill pediatric postoperative cardiac surgical patients to decrease the risk of tachyarrhythmias.
• The authors 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.
• 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.
• The authors suggest consideration of adjunct sedation with ketamine in patients who are not otherwise at an optimal sedation depth.
• During the periextubation period when sedation is typically lightened, the authors 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.

• The authors suggest that train-of-four monitoring be used in concert with clinical assessment to determine depth of neuromuscular blockade.
• The authors suggest using the lowest dose of NMBAs required to achieve desired clinical effects and manage undesired breakthrough movement.
• Electroencephalogram-based monitoring may be a useful adjunct for assessment of sedation depth in critically ill pediatric patients receiving NMBAs.
• The authors suggest that sedation and analgesia should be adequate to prevent awareness prior to and throughout NMBA use.
• The authors recommend routine use of passive eyelid closure and eye lubrication for the prevention of corneal abrasions in critically ill pediatric patients receiving NMBAs.

ICU delirium

• The authors 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.
• The authors recommend routine screening for ICU delirium using a validated tool in critically ill pediatric patients upon admission through ICU discharge or transfer.
• 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.
• The authors suggest performing EM, when feasible, to reduce the development of delirium.
• The authors recommend minimizing benzodiazepine-based sedation when feasible in critically ill pediatric patients to decrease incidence and/or duration or severity of delirium.
• The authors suggest strategies to minimize overall sedation exposure whenever feasible to reduce coma and the incidence and/or severity of delirium in critically ill children.
• The authors 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.
• The authors 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.
• The authors recommend a baseline electrocardiogram followed by routine electrolyte and QTc interval monitoring for patients receiving haloperidol or atypical antipsychotics.

• The authors recommend the 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.
• The authors suggest routine IWS screening after a shorter duration (3–5 d) when higher opioid or benzodiazepine doses are used.
• 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.
• The authors suggest that opioid-related IWS be treated with opioid replacement therapy to attenuate symptoms, irrespective of the preceding dose and /or duration or opioid exposure.
• Benzodiazepine-related IWS should be treated with benzodiazepine replacement therapy to attenuate symptoms, irrespective of the preceding dose and/or duration of benzodiazepine exposure.
• Alpha₂-agonist–related IWS should be treated with IV and/or enteral alpha₂-agonist replacement therapy to attenuate symptoms, irrespective of preceding dose and/or duration of alpha₂-agonist exposure.
• The authors suggest the use of a standardized protocol for sedation/analgesia weaning to decrease the duration of sedation taper and attenuate emergence of IWS.

Optimizing environment

• The authors suggest the facilitation of parental or caregiver present 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.
• The authors suggest offering patients the use of noise-reducing devices such as earplugs or headphones to reduce the impact of non-modifiable ambient noise (conditional, low-level evidence).
• The authors 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.
• The authors suggest performing EM to minimize the effects of immobility in critically ill pediatric patients.
• The authors 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.