Liberating the Critically-ill Child: Pain, Sedation, Delirium and more
Myron Yaster MD, Justin L. Lockman MD MSEd, and Sapna Kudchadkar MD PhD
One of the great things about my time at Johns Hopkins was that I worked in the Division of Pediatric Anesthesiology, Critical Care Medicine, and Pain Medicine. Anesthesiologists directed and worked in all 3 of these areas. Although nationwide pediatric anesthesiologists remain active in pain management, they are increasingly disappearing from the ICUs. Today’s special article from the journal Pediatric Critical Care Medicine is precisely why we need to continue our presence in the ICUs. It focuses on areas of our expertise: pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility. I’ve asked Dr. Sapna Kudchadkar to join Justin Lockman, our primary PAAD ICU contributor, and me in writing today’s Pediatric Anesthesia Article of the Day. For those who don’t know her, Sapna is the anesthesiologist-in-chief at the Johns Hopkins Children’s Center and Vice Chair for Peds ACCM, and a leader in early mobility in PICU patients and the prevention of sleep disturbances and delirium in the PICU.(1-3) Like Justin, Sapna is one of my former fellows and is my mentee and I couldn’t be more proud of her and Justin! Myron Yaster MD
Original article
Heidi A B Smith, James B Besunder, Kristina A Betters, et al. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatr Crit Care Med. 2022 Feb 1;23(2):e74-e110 PMID: 35119438
This encyclopedic review is the product of almost 12 years of effort by leading experts in the field. It is a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children in the PICU and not the NICU. Main areas of focus include 1) the need for the routine monitoring for pain, agitation, withdrawal, and delirium using validated tools, 2) the enhanced use of protocolized sedation and analgesia regimens, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.(4) We will review some of the highlights and urge all of you to read the guidelines in full – especially if you practice critical care. These guidelines couldn’t come soon enough, because attention to each of these areas is urgently needed based on Sapna’s study of ICU Liberation practices in 161 international PICUs.(5)
Analgesia: “Analgesia is provided to relieve pain, control agitation, prevent accidental removal of devices (i.e., endotracheal tubes [ETTs], thoracostomy tubes, and intravascular devices), improve patient-ventilator synchrony, optimize hemodynamics, decrease oxygen consumption, and modulate the stress response.”(4) IV opioids remain the foundational building block in multi-modal pain management. “Nonpharmacologic therapies, such as music therapy complement pharmacologic interventions by decreasing environmental stressors, facilitating relaxation and distraction, and facilitating sleep.”(4) Pain assessment is critical using developmental age-appropriate self-assessment and behavioral pain scores.
Sedation: “Finding a balance between over- and undersedation is paramount. Undersedation may lead to inadvertent device removal, or increased anxiety which may lead to residual psychologic and behavioral sequelae post PICU discharge. Undersedation can also lead to problems with ventilator synchrony. Oversedation is associated with prolonged mechanical ventilation, increased risk of inadvertent tracheal extubation failure, delirium, prolonged PICU length of stay, and the development of tolerance and iatrogenic withdrawal.”(4) Sedation assessment scales and the advantages of protocolized sedation and analgesia regimens are discussed in detail. Relatively new concepts include drug holidays, daily sedation interruption/pauses, and the rotation of some of the drugs used for sedation. There is a push to get away from benzodiazepines particularly by continuous infusion and switching to alpha–2 agonists (i.e., dexmedetomidine) as the primary sedative in the PICU, as mounting evidence is showing harm from the use of long term benzodiazepine infusions in both adults and pediatric ICU patients. Propofol and/or ketamine are increasingly being used as backup or during the weaning, pre-extubation period. Obviously, propofol must be used in low doses and for short periods of time (< 48 hours) in children to avoid propofol infusion syndrome (PRIS).(6)
Neuromuscular blockade (NMB): NMB use has declined overall, but is still sometimes necessary. Its decline is due to concerns about complications such as ICU neuropathy/weakness as well as the risk of awake paralysis. Train of four monitoring and intermittent NMB discontinuation (or bolus only dosing) are recommended. The article doesn’t recommend how to monitor TOF, but we know that just as in the OR, most PICUs use qualitative monitors which are notoriously inaccurate. As discussed in previous PAADs, quantitative monitoring is the 21st century way to go.(7)
ICU delirium: Delirium is common in PICU patients (up to 80%) and is characterized by inattention with hypoactivity, hyperactivity, or a mixture of the two. It is important to note that HYPOACTIVE delirium is the most common subtype in PICUs, in contrast to the hyperactive emergence delirium that we so commonly see in the PACU. “Predisposing risk factors for delirium include younger age, neurodevelopmental delay, poor nutritional status, and cyanotic heart disease. ‘Precipitating risk factors’ include benzodiazepine exposure, coma and deep sedation, requirement for invasive MV, and prolonged cardiopulmonary bypass time.”(4) Importantly (and perhaps unlike PACU emergence delirium), PICU delirium is associated with increased length of stay and mortality.(8) Assessment tools are available and described in detail. Some strategies to prevent delirium include sleep hygiene (sleep at night, awake in daytime), family presence, and elimination of benzodiazepines and deep sedation.
Iatrogenic withdrawal syndrome: Prolonged use of opioids, benzodiazepines, and dexmedetomidine result in tolerance, development of delirium, and (with weaning) withdrawal. Symptoms can often be nonspecific, frequently representing autonomic activation and/or dysfunction (tachypnea, tachycardia, hyperpyrexia, and diaphoresis), gastrointestinal dysfunction (vomiting and diarrhea), and/or CNS alterations (agitation, jitteriness, seizures, hallucinations, delirium). Symptoms can be acute or delayed. One obvious treatment method is to NOT suddenly stop these medications particularly around the time of extubation and removal of mechanical ventilation. It is far better to slowly wean and use a withdrawal assessment tool to help guide therapy. Another is to switch to single agents for each receptor activity. For example, It is very common for PICU patients to be on multiple opioids and benzodiazepines. Combining equipotent doses of all opioids to a methadone equivalent can be a first step in the weaning process in patients with normal QT intervals.
Early mobility: On any given day, 20% of all PICU patients in the U.S. are completely immobile, with repercussions for short and long-term functional outcomes.(9) Early mobility in the PICU was pioneered by John J. “Jack” Downes (of blessed memory) and his CHOP colleagues in the 1980s and was subsequently forgotten; it was rediscovered by Sapna and her Johns Hopkins team in 2016. Using protocols and a multidisciplinary team including physicians, nurses, respiratory therapists, and physical and occupational therapists, dramatic improvements in rehabilitation can occur without increasing adverse events (2). As pediatric anesthesiologists, simple things like avoiding foot IVs to facilitate inpatient ambulation or optimizing regional anesthesia, can go a long way to facilitate the principle that “illness doesn’t mean stillness.”
Finally, we haven’t really done justice to all of the issues raised in this article. Again, we highly recommend it to all of you who care for patients in the PICU. But since all of us interact regularly with PICU patients for procedures, pain management, and more, it’s really worth a read by everyone. This is an area in which that we as anesthesiology consultants, have an incredibly important role to play.
Myron Yaster MD, Justin L. Lockman MD MSEd, and Sapna Kudchadkar MD PhD
References
1. Patel RV, Redivo J, Nelliot A, Eakin MN, Wieczorek B, Quinn J, Gurses AP, Balas MC, Needham DM, Kudchadkar SR. Early Mobilization in a PICU: A Qualitative Sustainability Analysis of PICU Up! Pediatr Crit Care Med 2021;22:e233-e42.
2. Wieczorek B, Ascenzi J, Kim Y, Lenker H, Potter C, Shata NJ, Mitchell L, Haut C, Berkowitz I, Pidcock F, Hoch J, Malamed C, Kravitz T, Kudchadkar SR. PICU Up!: Impact of a Quality Improvement Intervention to Promote Early Mobilization in Critically Ill Children. Pediatr Crit Care Med 2016;17:e559-e66.
3. Kudchadkar SR, Yaster M, Punjabi AN, Quan SF, Goodwin JL, Easley RB, Punjabi NM. Temporal Characteristics of the Sleep EEG Power Spectrum in Critically Ill Children. J Clin Sleep Med 2015;11:1449-54.
4. Smith HAB, Besunder JB, Betters KA, Johnson PN, Srinivasan V, Stormorken A, Farrington E, Golianu B, Godshall AJ, Acinelli L, Almgren C, Bailey CH, Boyd JM, Cisco MJ, Damian M, deAlmeida ML, Fehr J, Fenton KE, Gilliland F, Grant MJC, Howell J, Ruggles CA, Simone S, Su F, Sullivan JE, Tegtmeyer K, Traube C, Williams S, Berkenbosch JW. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatr Crit Care Med 2022;23:e74-e110.
5. Ista E, Redivo J, Kananur P, Choong K, Colleti J, Jr., Needham DM, Awojoodu R, Kudchadkar SR. ABCDEF Bundle Practices for Critically Ill Children: An International Survey of 161 PICUs in 18 Countries. Crit Care Med 2022;50:114-25.
6. Vasile B, Rasulo F, Candiani A, Latronico N. The pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome. Intensive Care Med 2003;29:1417-25.
7. Murphy GS, Brull SJ. Quantitative Neuromuscular Monitoring and Postoperative Outcomes: A Narrative Review. Anesthesiology 2022;136:345-61.
8. Dervan LA, Di Gennaro JL, Farris RWD, Watson RS. Delirium in a Tertiary PICU: Risk Factors and Outcomes. Pediatr Crit Care Med 2020;21:21-32.
9. Kudchadkar SR, Nelliot A, Awojoodu R, Vaidya D, Traube C, Walker T, Needham DM. Physical Rehabilitation in Critically Ill Children: A Multicenter Point Prevalence Study in the United States. Crit Care Med 2020;48:634-44.