Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients with Consideration of the ICU Environment and Early Mobility

Patient Guideline Summary

Publication Date: February 3, 2022
Last Updated: March 3, 2023

Objective

Objective

This patient summary means to discuss key recommendations from the Society of Critical Care Medicine for the prevention and management of pain, agitation, neuromuscular blockade, and delirium in critically ill pediatric patients.

Overview

Overview

  • Critically ill pediatric patients suffer from pain, fear, limited mobility, drug effects, and the inability to understand what is happening to them.
  • Patients may be agitated or lethargic, combative, or delirious. They may have a rapid pulse or elevated blood pressure.
  • This patient summary focuses on minimizing a child’s distress when critically ill.

Diagnosis

Diagnosis

  • Standardized assessment tools are recommended for evaluating a child’s degree of distress from the many discomforts of hospitalization.
  • Regular monitoring of changes in stress levels along with the progress of disease management offers optimum conditions for recovery with the best outcome.

Treatment

Treatment

  • Management of a child’s pain, mental and emotional state requires:
    • Optimum use of sedation, possibly using neuromuscular blockade
    • Recognition and treatment of delirium and iatrogenic (caused by medical treatment) withdrawal syndromes (IWS)
    • Attention to the hospital/intensive care unit (ICU) environment
      • Parental or caregiver presence
      • Noise-reducing devices such as ear plugs or headphones
      • Reduction of excessive disturbances and therefore improved sleep hygiene and comfort
      • Early mobility
Pain
  • Intravenous opioids are recommended as the primary analgesic (a drug to reduce pain).
    • A nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen may be added to reduce the dose of opioids.
  • Music therapy is recommended.
  • Non-nutritive sucking with oral sucrose should be offered to neonates.

Sedation
  • The depth of sedation should be set according to a standardized tool and assessed daily.
    • Alpha2-agonists such as dexmedetomidine are the preferred sedating agent.
    • Propofol and ketamine are alternate agents.
    • A weaning protocol should be considered.
  • Endotracheal tubes (for mechanical ventilation) must be secured.
  • Frequent patient monitoring is necessary.

Neuromuscular blockade (NMB)
Note: a neuromuscular blockade is a form of anesthesia that allows a patient to be unaware of pain and breathing tubes.
During NMB, a special kind of monitoring and the lowest effective dose to prevent awareness are recommended.

Electroencephalogram monitoring may be a useful addition.
  • Passive eyelid closure and eye lubrication are recommended.

ICU delirium
  • All patients should be evaluated for delirium: temporary confusion, anxiety, incoherent speech, and hallucinations.
  • Recommended initial treatments include:
    • Sleep as uninterrupted as possible with as little sedation as possible
    • Family involvement with direct-patient care
    • Early mobility
  • Drugs such as benzodiazepines or antipsychotics are recommended only when the above fails.
    • A baseline electrocardiogram and blood electrolyte monitoring should accompany antipsychotics.

Iatrogenic (caused by medical treatment) withdrawal syndrome (IWS)
  • When withdrawing from medications, a standardized tapering protocol is recommended.

Abbreviations

  • EM: Early Mobility
  • ICU: Intensive Care Unit
  • IWS: Iatrogenic Withdrawal Syndrome
  • MV: Mechanical Ventilation
  • NMB: Neuromuscular Blockade
  • NSAID: Non-steroidal Anti-inflammatory Drug

Source Citation

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 Feb 1;23(2):e74-e110. doi: 10.1097/PCC.0000000000002873. PMID: 35119438.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.