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Background and Aims

In pediatric intensive care, assessment of pain, undersedation, iatrogenic withdrawal syndrome and delirium include overlapping symptoms which makes it difficult to decide why a child is not comfortable . Validated assessment tools are available but regular assessment of multiple instruments may be challenging with time-constrained staff

Methods

We performed a two-round Delphi study among experts working in PICUs worldwide to determine which cues should be included in a new holistic instrument that incorporate the assessment of the four conditions.

Results

In the first Delphi round, 38 of the 48 enrolled participants (79%) completed the questionnaire; in the second round 32 of 48 (67%). In the second round 46 items from 8 categories (e.g. facial, vocal/verbal, body movements, Sleep /behavioral state, posture/muscle tone, agitation, physiological and contextual) were considered relevant. Thirty-three of the 46 items (72%) were considered relevant for pain, 24 for undersedation (52%), 35 for IWS (76%) and 28 (61%) for pediatric delirium. Thirteen items (28%) were considered relevant for all four conditions; eleven items (24%) were considered relevant for only one condition.

Conclusions

Our Delphi study is the first step in developing a 4-in-1 comprehensive checklist to assess pain, undersedation, iatrogenic withdrawal syndrome and delirium in a holistic manner. Further validation is needed before the checklist can be applied in practice. In future, the application of the mosaIC checklist could help determine what condition is most likely to cause a child’s discomfort and at the same time help reduce the PICU nurses’ registration burden.

Background and Aims

Objectives: Different scales are used to assess pain, undersedation, iatrogenic withdrawal syndrome (IWS) and delirium in critically ill children. These scales include overlapping symptoms. Therefore, combining the information into one scale could be efficient. Based on an international Delphi study we developed the mosaIC-checklist, a tool covering the four conditions. In the current study we aimed to test the feasibility of the mosaIC-checklist.

Methods

We performed a prospective pilot study in PICU patients. A research nurses and a bedside nurse observed simultaneously a patient. The research nurse assessed with the mosaIC-checklist and the nurse the COMFORT-behavior (sedation/pain), NRS (pain), and SOS-PD (IWS and/or delirium) scale. Feasibility was defined as the duration to complete the mosaIC-checklist. Further, correlations were calculated between the mosaIC-checklist conditions and the and COMFORT-behavior, NRS, or SOS-PD scale.

Results

We included 11 patients, aged 2 months to 16 years. None of the patients was scored for pain, withdrawal, or delirium by the bedside nurses. Time to complete the mosaIC-checklist ranged from 2:30 to 4:30 minutes. The correlation with the COMFORT-behavior score and number of positive symptoms of the condition ‘sedation’of the mosaIC-checklist was 0.82. Symptoms of the mosaIC-checklist were mostly observed in the categories: facial expression (e.g. grimacing, frowning), sleep & behavior state (e.g. sleeplessness, lack of attentiveness), body movements (Kicking or legs drawn up, movements of arms and/or legs, and agitation (anxious, irritability).

Conclusions

The mosaIC-checklist is feasible to observe pain, undersedation, IWS and delirium in PICU patients. Further validation is needed before the checklist can be applied in practice.

Background and Aims

Critically ill children risk developing delirium potentially causing discomfort and suffering. Intensive care delirium has a fluctuating course complicating detection.

The aims of the present study were investigating the feasibility of: 1) using the Danish version of Sophia Observation Withdrawal Symptoms - Pediatric Delirium (SOS-PD) screening tool in clinical practice, and 2) comparing SOS-PD performance to a child psychiatrist’s assessment using the diagnostic criteria as a reference standard.

Methods

We used a descriptive and comparative design. First aim: Bedside nurses were asked to evaluate their experience of using the SOS-PD. Second aim: We compared the SOS-PD performance with the child psychiatrist assessment in 50 children aged 4 weeks to 18 years.

Results

Nurses found the Danish version of the SOS-PD applicable and easy to use. Of the 50 children included, 13 were diagnosed with delirium by the child psychiatrist. Consistency was found between the SOS-PD score and the child psychiatrist’s assessment (88%). We found 3 false-negative and 3 false-positive SOS-PD cases. The false-negative cases could be explained by the differences in time periods for the assessments. SOS-PD assessments covered the past four hours, whereas the psychiatric assessments covered the past 24 hours. We assume the false-positive cases represent an acceptable inconsistency between the two assessment methods.

Conclusions

The Danish version of the SOS-PD appeared suitable for identifying pediatric delirium. Our results emphasized the importance of assessment at least once during each nursing shift to ensure delirium detection around the clock due to the fluctuating course of delirium.

Background and Aims

Long term use of opioids and benzodiazepines are associated with important untoward effects. Our goal was to study clonidine addition to total doses of fentanyl and midazolam and duration of ventilation in pediatric ICU (PICU).

Methods

This randomized, double-blind, placebo-controlled trial was conducted in PICU of Mofid Children Hospital. Hundred children aged from 2 to 15 years were randomized 1:1 to 5 μg/kg oral clonidine every 6 hours plus 1-5 µg/kg/hr IV fentanyl and 0.05- 0.1 mg/kg/hr IV midazolam or placebo plus 1-5 µg/kg/hr fentanyl and 0.05- 0.1 mg/kg/hr midazolam.

Results

A total of 96 patients were studied. The mean age was 12 years with an excess of females (59.5%vs 40.5%). At baseline, no significant differences were observed in patients’ characteristics.Patients in placebo group received more midazolam and fentanyl compared with patients in intervention group. Mean total dose of midazolam was 4.3 ± 2.2 mg in the placebo group and 2.7 ± 2.9 mg in the intervention group (P < 0.05). Mean total dose of fentanyl was 34.4 ± 23.1 µg in the placebo group and 18.9 ± 10 µg in the intervention group (P < 0.01). No significant differences were observed in duration of ventilation and length of ICU stay. No case of severe adverse events was seen.

Conclusions

This trial showed that clonidine addition appeared to reduce ICU stay but had no effect on duration of mechanical ventilation. Due to low cost and availability, clonidine can be considered as an adjunct to the sedatives in PICU.

Background and Aims

Analgesia and sedative medications are commonly used in critically ill children to ensure comfort and safety. Yet, their prolonged use can lead to delirium and withdrawal. Several clinical practice guidelines (CPGs) are available yet their quality and applicability in the pediatric intensive care unit have not been established. This systematic review aimed to identify and appraise the quality of CPGs for management of pain, sedation, delirium and iatrogenic withdrawal.

Methods

Searches were conducted in four electronic databases, guideline repositories and websites of professional societies to identify CPGs published from 2010 to date. CPGs were included if applicable to the pediatric intensive care population (newborns to 18 years old) and included recommendation(s) for assessment of at least one of the four conditions. To assess quality of CPGs, two independent reviewers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Quality of CPGs was based on domain scores, high quality = all domains scored >60%, medium quality 30% to 60%, and low quality = at least one domain scored <30%.

Results

Following screening of 14799 records, 13 CPGs were included. Using the AGREE II domain thresholds, no CPG achieved high quality, three were medium quality and 10 were low quality. CPGs scored highest in the domain of ‘scope and purpose’ (average 62.2%) and lowest in the ‘applicability’ domain (average 27.7%).

Conclusions

This review demonstrates that current CPGs have varied methodological quality and more effort is needed to improve the reporting of the development process.