Consensus guidelines for sustained neuromuscular blockade in critically ill children

Playfor, Stephen; Jenkins, Ian; Boyles, C. E.; Choonara, Imti; Davies, G E; Haywood, Tim; Hinson, Gillian; Mayer, Anton; Morton, Neil S.; Ralph, Tanya; Wolf, Andrew

doi:10.1111/j.1460-9592.2007.02313.x

Cited by 34 publications

(26 citation statements)

References 20 publications

(18 reference statements)

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“…The use of several drug classes, multiple agents, large variations in the doses, frequency, and routes of administration, off-label use of analgesic drugs, or untested drug combinations occurs routinely, often driven by individual preferences or local culture (1, 6, 13). Consensus guidelines for sedation, analgesia, or neuromuscular blockade in PICU patients have highlighted the paucity of high-quality evidence and called for more randomized trials in this area (14, 15). …”

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confidence: 99%

Opioid Analgesia in Mechanically Ventilated Children

Anand

Clark

Willson

et al. 2013

Pediatric Critical Care Medicine

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Objective To examine the clinical factors associated with increased opioid dose among mechanically ventilated children in the Pediatric Intensive Care Unit (PICU). Design Prospective, observational study with 100% accrual of eligible patients. Setting Seven PICUs from tertiary-care children’s hospitals in the Collaborative Pediatric Critical Care Research Network. Patients 419 children treated with morphine or fentanyl infusions. Interventions None Measurements and Main Results Data on opioid use, concomitant therapy, demographic and explanatory variables were collected. Significant variability occurred in clinical practices, with up to 100-fold differences in baseline opioid doses, average daily or total doses, or peak infusion rates. Opioid exposure for 7 or 14 days required doubling of the daily opioid dose in 16% patients (95%CI: 12–19%) and 20% patients (95%CI: 16–24%) respectively. Among patients receiving opioids for longer than 3 days (n=225), this occurred in 28% (95%CI 22–33%) and 35% (95%CI 29–41%) by 7 or 14 days respectively. Doubling of the opioid dose was more likely to occur following opioid infusions for 7 days or longer (OR 7.9, 95%CI 4.3–14.3; p<0.001) or co-therapy with midazolam (OR 5.6, 95%CI 2.4–12.9; p<0.001), and it was less likely to occur if morphine was used as the primary opioid (vs. fentanyl) (OR 0.48, 95%CI 0.25–0.92; p=0.03), for patients receiving higher initial doses (OR 0.96, 95%CI 0.95–0.98; p<0.001), or if patients had prior PICU admissions (OR 0.37, 95%CI 0.15–0.89, p=0.03). Conclusions Mechanically ventilated children require increasing opioid doses, often associated with prolonged opioid exposure or the need for additional sedation. Efforts to reduce prolonged opioid exposure and clinical practice variation may prevent the complications of opioid therapy.

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confidence: 99%

Opioid Analgesia in Mechanically Ventilated Children

Anand

Clark

Willson

et al. 2013

Pediatric Critical Care Medicine

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“…In these guidelines, while recommending that their use be left to the treating clinician based on the lack of sufficient evidence, the experts on the panel recommended the use of NMBA within the algorithm as a “first-line” therapy based on their experience. The paucity of evidence for the indications for use of NMBA is reflected more broadly in the UK Paediatric Intensive Care Guidelines from 2007, which simply recommend a case-by-case evaluation of the risks and benefits of NMBA in children with critical illness (20). In the more recent guidelines from 2012, no new studies were identified to answer this important question (6).…”

Section: Discussionmentioning

confidence: 99%

Effect of Administration of Neuromuscular Blocking Agents in Children With Severe Traumatic Brain Injury on Acute Complication Rates and Outcomes

Wisniewski

et al. 2015

Pediatric Critical Care Medicine

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Objective To evaluate the association between neuromuscular blocking agents (NMBA) and outcome, intracranial pressure (ICP) and medical complications in children with severe TBI. Design A secondary analysis of a randomized, controlled trial of therapeutic hypothermia. Setting 17 hospitals in US, Australia, and New Zealand Patients Children (< 18 y) with severe TBI. Interventions None for this secondary analysis. Measurements and Main Results Children received NMBA on the majority of days of the study (69.6%) and the modified Pediatric Intensity Level of Therapy (mPILOT) scores (modified by removing NMBA administration from the score) were increased on days when NMBA were used (9.67 ± 0.21 vs. 5.48 ± 0.26, p < 0.001). Children were stratified into groups based on exposure to NMBA (Group 1 received NMBA each study day; Group 2 did not). Group 1 had increased number of daily ICP readings > 20 mmHg (4.4 ± 1.1 v. 2.4 ± 0.5, p = 0.015) and longer ICU length of stay (LOS) and hospital length of stay (p = 0.003 and 0.07, respectively, Kaplan-Meier). The Glasgow Outcome Score – Extended for Pediatrics at hospital discharge, 3 mo, 6 mo and 12 mo after TBI and medical complications observed during the acute hospitalization were similar between groups. Conclusions Administration of NMBA was ubiquitous and daily administration of NMBA was associated with intracranial hypertension but not outcomes – likely indicating that increased injury severity prompted their use. Despite this, NMBA use was not associated with complications. A different study design – perhaps using randomization or methodologies – of a larger cohort will be required to determine if NMBA use is helpful after severe TBI in children.

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“…Neuromuscular blocking agents are associated to critical illness polyneuropathy and myopathy and therefore should be restricted to special circumstances, discontinued as soon as possible and used at the smallest possible dose (76, 77). The level of evidence supporting their prolonged use for particular indications is poor (76, 78). They are recommended if effective mechanical ventilation cannot be achieved despite profound sedation [e.g., ARDS (77), severe asthma (25, 79)].…”

Section: Commonly Used Agentsmentioning

confidence: 99%

Sedation in Critically Ill Children with Respiratory Failure

Vet¹,

Kleiber²,

Ista³

et al. 2016

Front. Pediatr.

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This article discusses the rationale of sedation in respiratory failure, sedation goals, how to assess the need for sedation as well as effectiveness of interventions in critically ill children, with validated observational sedation scales. The drugs and non-pharmacological approaches used for optimal sedation in ventilated children are reviewed, and specifically the rationale for drug selection, including short- and long-term efficacy and safety aspects of the selected drugs. The specific pharmacokinetic and pharmacodynamic aspects of sedative drugs in the critically ill child and consequences for dosing are presented. Furthermore, we discuss different sedation strategies and their adverse events, such as iatrogenic withdrawal syndrome and delirium. These principles can guide clinicians in the choice of sedative drugs in pediatric respiratory failure.

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Consensus guidelines for sustained neuromuscular blockade in critically ill children

Cited by 34 publications

References 20 publications

Opioid Analgesia in Mechanically Ventilated Children

Opioid Analgesia in Mechanically Ventilated Children

Effect of Administration of Neuromuscular Blocking Agents in Children With Severe Traumatic Brain Injury on Acute Complication Rates and Outcomes

Sedation in Critically Ill Children with Respiratory Failure

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