RATIONALE:A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available. OBJECTIVE:To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility. DESIGN:The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to. METHODS:Taskforce content experts separated into subgroups addressing pain/ analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest. " Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence. RESULTS:The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements.

At a dose of 0.25 microg/kg/h, dexmedetomidine was approximately equivalent to midazolam at 0.22 mg/kg/h. At 0.5 microg/kg/h, dexmedetomidine provided more effective sedation as demonstrated by the need for fewer bolus doses of morphine, a decrease in the 24-hour requirements for supplemental morphine, as well as a decrease in the total number of assessment points with a Ramsay score of 1 (inadequate sedation) and the number of patients who had a Ramsay score of 1.

Dexmedetomidine provided effective sedation in children undergoing noninvasive procedures and represents an alternative sedative choice for this population.

INTRODUÇÃO Feocromocitomas são tumores de células cromafins que captam, produzem, armazenam, metabolizam e liberam catecolaminas. A faixa etária de maior incidência é entre a terceira e quarta década de vida, no entanto, o tumor pode se desenvolver ainda na infância. A maioria dos feocromoci-tomas são tumores benignos tratados com remoção cirúrgica. Neste caso apresentamos a técnica anestésica empregada em um paciente submetido à ressecção de recidiva bilateral de feocromocitoma adrenal com a utilização da dexmedetomi-dina como medicação pré-anestésica e adjuvante anestésico endovenoso, buscando controle pressórico e estabilidade cardiovascular durante o procedimento. RELATO DO CASO Paciente de 8 anos, do sexo masculino, apresenta recidiva bilateral de feocromocitoma adrenal após ressecção do tumor em adrenal direita há 3 anos. O paciente foi readmitido no hospital com história de dor abdominal acompanhada de vômitos e crise hipertensiva. Depois de avaliação laboratorial e radiológica, que confirmaram a recidiva tumoral, o paciente foi submetido à ressecção do tumor sob anestesia geral associada à peridural contínua. Visando menor liberação de catecolaminas, associada a menor consumo de anestésicos e estabilidade cardiovascular, utilizamos a dexmedetomidina, agonista alfa-2 adrenérgico, como medicação pré-anestésica e adjuvante endovenoso durante a cirurgia. Durante a manipulação do tumor, foi necessário o uso de nitroprussiato de sódio para controle pressórico. O paciente foi extubado na sala cirúrgica, sem necessitar de drogas vasoati-vas, e foi encaminhado para a unidade de terapia intensiva com nebulização de oxigênio e saturação periférica de O 2 de 99%. Estava calmo e sem dor. DISCUSSÃO O manejo do paciente portador de feocromocitoma deve visar adequada manutenção da volemia e controle pressórico, se necessário, com drogas vasoativas, como alfa e betabloqueadores, e nitroprussiato de sódio. Neste caso apresentamos o emprego da dexmedetomidina, que pode ser utilizada como medicação pré-anestésica e na manutenção da anestesia, em infusão contínua para maior estabilidade cardiovascular durante a manipulação cirúrgica do tumor. REFERÊNCIAS 1. Anttila M, Penttila J, Helminen A, Vuorilehto L. Scheinin H. Bioavailability of dexmedetomi-dine after extravascular doses in healthy subjects.

A remifentanil/propofol mixture provided effective sedation and rapid recovery in pediatric patients undergoing fiberoptic bronchoscopy.

We demonstrate the usefulness of the bispectral index monitor for assessing sedation in pediatric intensive care unit patients. The bispectral index monitor correlated with clinically assessed sedation levels and was useful for differentiating adequate from inadequate sedation, which would be of value when the clinical examination is unavailable.

This case adds to the limited data regarding dexmedetomidine in pediatric critical care and suggests that caution should be used when considering sedation with dexmedetomidine in patients also receiving digoxin.

Education regarding the initial evaluation and treatment of SE should focus on the appropriate laboratory evaluation required, suggested drug therapy, and dosing guidelines.