Analgesia-Sedation in PICU and Neurological Outcome

Zellem, Lennart van; Utens, Elisabeth M. W. J.; Wildt, Saskia N. de; Vet, Nienke J.; Tibboel, Dick; Buysse, Corinne

doi:10.1097/pcc.0000000000000044

Cited by 34 publications

(25 citation statements)

References 33 publications

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“…42,43 While RESTORE focused on the process of how sedatives are administered, future studies should compare the best sedative agent for varied lengths of critical illness. Outcomes of interest include efficacy as well as an evaluation of the immediate risk-benefit ratio and an evaluation of the long-term impact of sedatives on neurocognitive development 44,45 and post-traumatic stress. 46 …”

Section: Discussionmentioning

confidence: 99%

Protocolized Sedation vs Usual Care in Pediatric Patients Mechanically Ventilated for Acute Respiratory Failure

Curley

Wypij

Watson

et al. 2015

JAMA

374

266

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Importance Protocolized sedation improves clinical outcomes in critically-ill adults, but its effect in children is unknown. Objective To determine whether critically-ill children managed with a nurse-implemented, goal-directed sedation protocol (RESTORE) would experience fewer days of mechanical ventilation than patients receiving usual care. Design, Setting, and Participants Cluster-randomized trial conducted in 31 U.S. Pediatric Intensive Care Units (PICUs). Children (n=2449; mean age 4.7 years, range 2 weeks to 17 years) mechanically ventilated for acute respiratory failure were enrolled 2009–2013 and followed until 72 hours after opioids were discontinued, 28 days, or hospital discharge. Interventions Intervention PICUs (17 sites, n=1225 patients) managed sedation using a protocol that included targeted sedation, arousal assessments, extubation readiness testing, sedation adjustment every 8 hours, and sedation weaning. Control PICUs (14 sites, n=1224 patients) managed sedation per usual care without a protocol. Main Outcome and Measures The primary outcome was duration of mechanical ventilation. Secondary outcomes included time to recovery from acute respiratory failure, duration of weaning from mechanical ventilation, neurological testing, PICU and hospital lengths of stay, in-hospital mortality, sedation-related adverse events, sedative exposure including measures of wakefulness, pain, and agitation, and occurrence of iatrogenic withdrawal. Results Duration of mechanical ventilation was not statistically significantly different between the two groups (median; interquartile range: intervention: 6.5 days; 4.1–11.2 vs. control: 6.5; 3.7–12.1). Sedation-related adverse events including inadequate pain and sedation management, clinically significant iatrogenic withdrawal, and unplanned endotracheal tube/invasive line removal were not statistically significantly different between the two groups. Intervention patients experienced more post-extubation stridor (7% vs. 4%; P=0.03) and fewer stage 2+ immobility-related pressure ulcers (<1% vs. 2%; P=0.001). In exploratory analyses, intervention patients had fewer days of opioid administration (median; interquartile range: 9; 5–15 vs. 10; 4–21; P=0.01), were exposed to fewer sedative classes (2; 2–3 vs. 3; 2–4; P<0.001), and were awake and calm for a greater percentage of study days while intubated (86%; 67–100% vs. 75%; 50–100%; P=0.004), than control patients. However, patients in the intervention group had a greater percentage of days with any report of a pain score ≥4 (50%; 27%-67% vs. 23%; 0–46%; P<0.001) and any report of agitation with a State Behavior Scale score of +1/+2 (60%; 33–80% vs. 40%; 13–67%, P=0.003), than control patients. Conclusions and Relevance Among children undergoing mechanical ventilation for acute respiratory failure, the use of a nurse-implemented, goal-directed sedation protocol compared with usual care did not reduce the duration of mechanical ventilation. Exploratory analyses of secondary outcomes suggest a complex relatio...

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Section: Discussionmentioning

confidence: 99%

Protocolized Sedation vs Usual Care in Pediatric Patients Mechanically Ventilated for Acute Respiratory Failure

Curley

Wypij

Watson

et al. 2015

JAMA

374

266

View full text Add to dashboard Cite

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“…Mobility guidelines in adults typically employ sedation interruption, but this strategy may not translate directly to children 39 . In addition, evidence to support the optimal use of pain and sedation medications to minimize impact on delirium and neurodevelopmental disability are needed elements to support PICU rehabilitation therapies 40–42 . To address these barriers and ultimately change ICU culture, centers have implemented multidisciplinary care pathways that include best practices with room for individualized care, coordination of care to optimize session scheduling between the bedside nurse and therapist, and curricula to educate healthcare and family providers on the potential benefits and safety measures of ICU rehabilitation 43–45 .…”

Section: Discussionmentioning

confidence: 99%

Physical and occupational therapy utilization in a pediatric intensive care unit

Cui

LaPorte

Civitello

et al. 2017

Journal of Critical Care

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Purpose To characterize the use of physical therapy (PT) and occupational therapy (OT) consultation in our pediatric intensive care unit (PICU). Materials and Methods We studied children aged 1 week – 18 years admitted to a tertiary care PICU for ≥ 3 days. Patient characteristics, details of PT and OT sessions and adverse events were collected. A multivariable logistic regression was performed to determine factors associated with receipt of PT and OT consultation with propensity analysis followed by a regression for factors associated with outcome. Results Of 138 children studied, 40 (29%) received PT and OT consultation. Services were initiated 6.9 ± 10.0 (mean ± standard deviation) days after PICU admission. Range of motion (83%) was the most common therapy provided and 28% of patients were ambulated. Sixty-four of 297 (21.5%) sessions were deferred and 7 (2.4%) sessions were terminated early due to physiologic instability with no serious adverse events. Children who received PT and OT were older, more likely to require neuromuscular blocking agents, and had lower pre-PICU POPC scores (all p<0.05). Conclusions Data are needed to inform on the efficacy of rehabilitative therapies initiated in the ICU to improve outcome for critically ill children.

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“…Cohorts developed in Europe suggest that cognition, adaptive behavior, and verbal and visual memory in children who survive critical illness are within normal range, but tend to be significantly lower compared to healthy controls (22,70). Multiple contributing factors have been studied or are currently under study, including glucose control, sedation strategies, overall PICU LOS, and pre-PICU co-morbidities (22,70,72). …”

Section: Neurologic Outcomes Following Picu Carementioning

confidence: 99%

“…Hospital mortality was 25% and 17% of survivors had acquired moderate disability at hospital discharge, defined as discharge POPC ≥3 and increased ≥1 from baseline POPC (74). Recent studies of long-term outcomes of children with severe sepsis showed that, at 3–9 months post-discharge, children with sepsis-associated encephalopathy had significantly decreased global and verbal intelligence quotient, compared to control sepsis patients not admitted to the PICU and to healthy controls (70–72). Evaluation of academic performance also revealed that children with sepsis who required PICU care had significantly higher rates of difficulties in completing school work, deterioration in academic performance, dividing attention and considering a variety of possible outcomes (70).…”

Section: Neurologic Outcomes Following Picu Carementioning

confidence: 99%

Neurologic Outcomes Following Care in the Pediatric Intensive Care Unit

Caprarola

Kudchadkar

Bembea

2017

Curr Treat Options Peds

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Purpose of review With increasing survival of children requiring admission to pediatric intensive care units (PICU), neurodevelopmental outcomes of these patients are an area of increased attention. Our goal was to systematically review recently published literature on neurologic outcomes of PICU patients. Recent Findings Decline in neurofunctional status occurs in 3%–20% of children requiring PICU care. This proportion varies based on primary diagnosis and severity of illness, with children admitted for primary neurologic diagnosis, children who suffer cardiac arrest or who require invasive interventions during the PICU admission, having worse outcomes. Recent research focuses on early identification and treatment of modifiable risk factors for unfavorable outcomes, and on long-term follow-up that moves beyond global cognitive outcomes and is increasingly including tests assessing multidimensional aspects of neurodevelopment. Summary The pediatric critical care research community has shifted focus from survival to survival with favorable neurologic outcomes of children admitted to the PICU.

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Analgesia-Sedation in PICU and Neurological Outcome

Abstract: The use of opioids during PICU admission was significantly associated with long-term adverse neuropsychological outcome independent of severity of illness scores in meningococcal septic shock survivors.

Cited by 34 publications

References 33 publications

Protocolized Sedation vs Usual Care in Pediatric Patients Mechanically Ventilated for Acute Respiratory Failure

Protocolized Sedation vs Usual Care in Pediatric Patients Mechanically Ventilated for Acute Respiratory Failure

Physical and occupational therapy utilization in a pediatric intensive care unit

Neurologic Outcomes Following Care in the Pediatric Intensive Care Unit

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