Search

Competing Interests: The authors declare no conflicts of interest.

Rationale: A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available., Objective: To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility., Design: The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to., Methods: Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence., Results: The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements., Conclusions: The current guidelines represent 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. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision., Competing Interests: Drs. Smith and Berkenbosch were responsible for the adjudication of any conflicts of interest for this guideline. The following relevant disclosures were provided for consideration. Dr. Srinivasan authored “Conversion from prolonged intravenous fentanyl infusion to enteral methadone in critically ill children,” World Journal of Clinical Pediatrics (May 2017). Dr. Almgren authored “Pharmacological Strategies for Decreasing Opioid Therapy and Management of Side Effects From Chronic Use”, Children (2018) and “Multidisciplinary Pain Management for Pediatric Patients with Acute and Chronic Pain: A Foundational Treatment Approach When Prescribing Opioids,” Children (2019). Dr. Grant was a lead author for the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Study Investigators (2016) and for “Dexmedetomidine Use in Critically-Ill Children with Acute Respiratory Failure,” Pediatric Critical Care Medicine. Dr. deAlmeida was a contributing author on “Delirium in Critically Ill Children: An International Point Prevalence Study,” Critical Care Medicine (2017). Dr. Simone is a lead author for “Analgesia, Sedation, Paralytics, and Opioid Syndrome (2021); Pediatric Acute Care. A Guide for Interprofessional Practice, second Edition (2019); Delirium and Pharmacologic Treatment in Critically Ill Children: A Retrospective Matched Cohort Study,” Journal of Pediatric Pharmacologic and Therapeutics (2017). “Implementation of an ICU Bundle: An Interprofessional Quality Improvement Project to Enhance Delirium Management and Monitor Delirium Prevalence in a Single PICU,” Pediatric Critical Care Medicine (2017). Dr. Su was a lead author for “Pharmacokinetics of Dexmedetomidine in Infants and Children After Orthotopic Liver Transplantation,” Anesthesia Analog (2018). Dr. Traube was a lead author on “Detection and Management of Delirium in the Neonatal Unit: A Case Series,” Pediatrics (2016); “Prospective Study to Establish the German version of the CAPD for the Assessment of Delirium in Children Undergoing Intensive Care” (German), Monatsschrift Kinderheilkunde (2016); “Cost Associated With Pediatric Delirium in the ICU,” Critical Care Medicine (2016); “Validity of the Richmond Agitation-Sedation Scale (RASS) in Critically Ill Children,” Journal of Intensive Care (2016); “Sedation, Analgesia, and Paralysis During Mechanical Ventilation of Premature Infants,”(2017), “Patterns of Postoperative Delirium in Children,” Pediatric Critical Care Medicine (2017); “Delirium in Children After Cardiac Bypass Surgery,” Pediatric Critical Care Medicine (2017); “Delirium in Critically Ill Children: An International Point Prevalence Study,”Critical Care Medicine (2017); “Delirium and Mortality in Critically Ill Children: Epidemiology and Outcomes of Pediatric Delirium,” Critical Care Medicine (2017); “Iatrogenic Withdrawal Syndrome or Undiagnosed Delirium?,” Critical Care Medicine (2017); “‘The Times They Are A-Changin’: Universal Delirium Screening in Pediatric Critical Care,” Pediatric Critical Care Medicine (2017); “Quality Improvement Initiative to Reduce Pediatric Intensive Care Unit Noise Pollution With the Use of a Pediatric Delirium Bundle,” Journal of Intensive Care Medicine (2017); “Delirium in Pediatric Critical Care,” Pediatric Clinics of North America (2017); “Delirium in the Pediatric Cardiac Extracorporeal Membrane Oxygenation Patient Population: A Case Series,” Pediatric Critical Care Medicine (2017); “Delirium in Hospitalized Children with Cancer: Incidence and Associated Risk Factors,” The Journal of Pediatrics (2017); “Provider Beliefs Regarding Early Mobilization in the Pediatric Intensive Care Unit,” Journal of Pediatric Nursing (2018); “Identify Delirium, Then Investigate for Underlying Etiology,” Pediatric Critical Care Medicine (2018); “Consensus Report by PALISI and PBMTC Joint Working Committees, Supportive Care Guidelines for Management of VOD in Children and Adolescents; Part 3: Focus on Cardio-Respiratory Dysfunction, Infections, Liver Dysfunction and Delirium,” Biology of Blood and Marrow Transplantation (2018); “Delirium is a Common and Early Finding in Patients in the Pediatric Cardiac Intensive Care Unit,” The Journal of Pediatrics (2018); “Delirium Upon Presentation to the Pediatric Emergency Department: A Case Series,” Pediatric Emergency Care (2018); “Benzodiazepines and Development of Delirium in Critically Ill Children: Estimating the Causal Effect,” Critical Care Medicine (2018); “Association Between Transfusion of RBCs and Subsequent Development of Delirium in Critically Ill Children,” Pediatric Critical Care Medicine (2018); “All Delirium May Not Be Created Equal: Consideration of Differential Effects of Delirium Based Upon Underlying Etiology,” Pediatric Critical Care Medicine (2018); “Risk Factors for the Development of Postoperative Delirium in Pediatric Intensive Care Patients,” Pediatric Critical Care Medicine (2018); “Management Guidelines For Paediatric Patients Receiving Chimeric Antigen Receptor T Cell Therapy,” Nature Reviews Clinical Oncology (2019); and “A Systematic Approach to Family Engagement: Feasibility Pilot of a Pediatric Delirium Management And Prevention Toolkit,” Palliative and Supportive Care (2019). Stacey Williams was lead author for “The Preschool Confusion Assessment Method for the ICU: Valid and Reliable Delirium Monitoring for Critically Ill Infants and Children,” Critical Care Medicine(2016). The remaining authors have disclosed that they do not have any potential conflicts of interest. Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as “strong” with “we recommend” or “conditional” with “we suggest.” Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence., (Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: We describe the process by which a PICU and a PICU care team were incorporated into a hospital-wide ICU care model during the coronavirus disease 2019 pandemic., Design: A descriptive, retrospective report from a single-center PICU., Setting: Twenty-three bed, quaternary PICU, within an 862-bed hospital., Patients: Critically ill adults, with coronavirus disease 2019-related disease., Interventions: ICU care provided by pediatric intensivists with training and support from medical intensivists., Measurements and Main Results: Within the context of the institution's comprehensive effort to centralize and systematize care for adults with severe coronavirus disease 2019 disease, the PICU was transitioned to an adult coronavirus disease 2019 critical care unit. Nurses and physicians underwent just-in-time training over 3 days and 2 weeks, respectively. Medical ICU physicians and nurses provided oversight for care and designated hospital-based teams were available for procedures and common adult emergencies. Over a 7-week period, the PICU cared for 60 adults with coronavirus disease 2019-related critical illness. Fifty-three required intubation and mechanical ventilation for a median of 18 days. Eighteen required renal replacement therapy and 17 died., Conclusions: During the current and potentially in future pandemics, where critical care resources are limited, pediatric intensivists and staff can be readily utilized to meaningfully contribute to the care of critically ill adults., Competing Interests: Dr. Torres received support for article research from the National Institutes of Health. Dr. Greenwald received funding from Bekman, Marder & Adkins; Billing, Cochran, Lyles, Mauro & Ramsey PA; and Garrubbo & Capece PC. Dr. Howell received funding from UptoDate. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2020 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: The Faces, Legs, Activity, Cry, and Consolability (FLACC) scale is one of the most widely utilized observational pain assessment scales in clinical practice. Although designed and validated to assess postoperative pain, the tool is currently applied to assess acute pain in multiple settings, including the emergency department. Scarce literature exists evaluating the reliability of the FLACC scale in the nonsurgical population and none in the emergency department. We sought to investigate the reliability of the FLACC scale in assessing acute pain in the pediatric emergency department and to examine the sensitivity of FLACC scores after the administration of analgesia., Methods: In phase 1 of this prospective study, a series of 2 independent evaluators, blinded to each other's evaluations, scored 66 patients using the FLACC tool. Degree of concordance among the 6 dyads was used to measure interrater reliability. In phase 2, FLACC scores were obtained just before the administration of analgesia in 35 patients and measured at 30 and at 60 minutes after administration., Results: Among the 6 dyads of evaluators, Kendall W demonstrated a strong concordance (27 of 30 measures; range, 0.63-1.00) for individual components of the scale and for the composite scores (range, 0.85-0.96). Significant mean reductions from preanalgesia FLACC scores [5.54; 95% confidence interval (CI), 4.79-6.30] were seen at 30 minutes (2.00; 95% CI, 1.61-2.39) and 60 minutes (1.14; 95% CI, 0.79-1.50) postanalgesia (P < 0.0001 for all comparisons)., Conclusions: The FLACC scale demonstrated high interrater reliability for both individual FLACC items and total scores in a convenience sample of patients aged 6 months to 5 years in a pediatric emergency department. It seems to be an appropriate observational tool to assess acute pain in this population.

Background: We assessed trends in the performance of transcatheter aortic valve implantation in the United Kingdom from the first case in 2007 to the end of 2012. We analyzed changes in case mix, complications, outcomes to 6 years, and predictors of mortality., Methods and Results: Annual cohorts were examined. Mortality outcomes were analyzed in the 92% of patients from England and Wales for whom independent mortality tracking was available. A total of 3980 transcatheter aortic valve implantation procedures were performed. In successive years, there was an increase in frequency of impaired left ventricular function, but there was no change in Logistic EuroSCORE. Overall 30-day mortality was 6.3%; it was highest in the first cohort (2007-2008), after which there were no further significant changes. One-year survival was 81.7%, falling to 37.3% at 6 years. Discharge by day 5 rose from 16.7% in 2007 and 2008 to 28% in 2012. The only multivariate preprocedural predictor of 30-day mortality was Logistic EuroSCORE ≥40. During long-term follow-up, multivariate predictors of mortality were preprocedural atrial fibrillation, chronic obstructive pulmonary disease, creatinine >200 μmol/L, diabetes mellitus, and coronary artery disease. The strongest independent procedural predictor of long-term mortality was periprocedural stroke (hazard ratio=3.00; P<0.0001). Nonfemoral access and postprocedural aortic regurgitation were also significant predictors of adverse outcome., Conclusions: We analyzed transcatheter aortic valve implantation in an entire country, with follow-up over 6 years. Although clinical profiles of enrolled patients remained unchanged, longer-term outcomes improved, and patients were discharged earlier. Periprocedural stroke, nonfemoral access, and postprocedural aortic regurgitation are predictors of adverse outcome, along with intrinsic patient risk factors., (© 2015 American Heart Association, Inc.)

A shared governance model was implemented within the nursing service of the Durham Veterans Affairs Medical Center in 1997. In 1999, members of the Nursing Quality/Staff Education/Research Council examined facility nurses' perceptions of governance to determine the degree to which the model had been implemented. Results of the study indicate that although imperatives at the organizational level were incompatible with three aspects of shared governance, there were three shared governance dimensions pertaining to basic nursing practice that reached or surpassed governance thresholds. This study highlights the potential of nursing management innovation within highly bureaucratic organizations.

Background: In patients with heart failure secondary to left ventricular (LV) systolic dysfunction, a short deceleration time (DT) successfully predicts clinical outcome. The impact of myocardial viability and revascularization on the mitral inflow velocities, however, is unknown., Methods and Results: Forty patients with ischemic cardiomyopathy underwent (201)Tl scintigraphy (SPECT) and 2D, Doppler, and dobutamine echocardiography (DE, to 40 microg. kg(-1). min(-1)) 2 days before CABG. Echocardiography was repeated 3 months after revascularization to determine recovery of function. Significant correlations were present between DT and LV contractile reserve by DE (r=0.72), scar perfusion defect by SPECT (r=-0.69), and the change in ejection fraction (DeltaEF) after surgery (r=0.77) (all P:<0.01). DT >150 ms effectively identified (sensitivity 79%, specificity 81%) patients with DeltaEF >/=5%. The population was divided into 2 groups according to DT: group 1 (DT >150 ms, n=21) and group 2 (DT

Background: Ischemic preconditioning has been shown to protect some tissues from ischemia/reperfusion (I/R) injury. Adenosine is believed to play an important role by attenuating leukocyte-endothelial cell adhesive interactions. Dipyridamole increases adenosine bioavailability. The purpose of this study was to evaluate the effects of mechanical (MPC) and pharmacological preconditioning (PPC) on leukocyte endothelial cell interaction in hepatic I/R injury., Methods: C57BL6 mice were subjected to 30 min of ischemia to the left lobe of the liver. Groups tested at 30 min, 2, 5, 12, and 24 hr of reperfusion had 1) sham laparotomy (n = 10, 2) I/R (n = 25), 3) ischemic preconditioning with 5 min of ischemia and 10 min reperfusion before I/R (n = 25), and 4) (PPC) with dipyridamole (n = 25). Intravital microscopic examination was used to assess leukocyte/endothelial cell adhesion. Blood was drawn for leukocyte counts and liver function tests., Results: A significant decrease in leukocyte rolling was observed at 30-min and 5-hr reperfusion intervals in the PPC and ischemic preconditioning groups compared with the I/R group. A significant decrease in leukocyte saltation was also observed in the PPC and MPC groups at 2, 5, and 12 hr of reperfusion when compared with the I/R group. aspartate aminotransferase was significantly decreased in the 5-hr preconditioning groups. There was not a significant decrease in the white blood cell count because of PPC or MPC vs. I/R CONCLUSIONS: Preconditioning decreases endothelial/ leukocyte interaction and reduces liver damage as measured by aspartate aminotransferase. These data prove that IPC and PPC provide some degree of hepatic protection in I/R injury.

Background: Although dobutamine echocardiography (DE) is widely used to assess myocardial viability in humans, little is known about the relation between contractile reserve and myocardial structure., Methods and Results: We evaluated 20 patients with coronary disease (64+/-13 years old, ejection fraction 28+/-7.5%) with DE (up to 40 micrograms . kg(-1). min(-1)), rest-redistribution (201)Tl single photon emission CT, and quantitative angiography before bypass surgery. During surgery, patients underwent transmural myocardial biopsies (n=37) guided by transesophageal echocardiography to determine the extent of interstitial fibrosis and intracellular and interstitial proteins by histopathology and immunohistochemistry. Among the 37 segments biopsied, 16 recovered function as assessed 2 to 3 months later. Segments with postoperative functional recovery had more wall thickening at low-dose DE (28% versus 3%, P<0.001), higher thallium uptake (69% versus 48%, P=0.03), and less interstitial fibrosis (2% versus 28%, P<0.001). Quantitative angiographic parameters did not predict recovery of function. Segments with DE viability (contractile reserve and/or ischemia) had less fibrosis (2.7% versus 28%, P<0.001), less vimentin and fibronectin (both P<0.01), more glycogen (P=0.016), and higher thallium uptake (64% versus 35.5%, P<0.05) than those without viability. Viable segments by both DE and thallium had less fibrosis (1%) than those viable by 1 of the 2 techniques (9%) or not viable by both (28%, P=0.005). Thickening at low-dose DE correlated well with the extent of interstitial fibrosis (r=-0.83, P<0.01)., Conclusions: Contractile reserve during DE correlates inversely with the extent of interstitial fibrosis and the amount of fibronectin and vimentin and directly with rest-redistribution thallium uptake.

Purpose: The time courses of muscle compartmental swelling and passive stiffness change were measured to determine whether muscle compartmental swelling accounted for increased stiffness., Methods: Eleven untrained female college students exercised eccentrically by lowering a weight with their elbow flexors. Measurements of muscle compartment volume, stiffness, relaxed elbow angle, circumference, and pain were recorded before exercise, immediately after exercise, and 1-5, 7, 9, and 11 d after exercise. Muscle compartment volume was calculated from cross-sectional ultrasound images taken along the upper arm. Stiffness was measured using a device that extended the elbow and recorded the torque required to hold the forearm at successive angles., Results: Elbow flexor volume increased gradually to peak on the fourth day (26.1 +/- 4.3%, P < 0.05) and then decreased to baseline values over days 7-11. Stiffness increased immediately after exercise (59.9 +/- 14.1%, P < 0.05) and remained at or above this level until decreasing to pre-exercise levels over days 7-11., Conclusions: This suggests that muscle swelling does not account for the sudden increase in stiffness of the elbow flexor muscles within the first 48 h after exercise but may play a role in the subsequent time course of stiffness.

Background: Assessment of myocardial viability by 99mTc-sestamibi remains controversial. Accordingly, we investigated the use of sestamibi as a marker of myocardial viability, defined by histopathology, and for predicting improvement of myocardial function after coronary artery bypass graft surgery (CABG)., Methods and Results: 99mTc-sestamibi perfusion tomography and radionuclide angiography were performed within 2 days before CABG in 21 patients with > or = 75% stenosis of the left anterior descending coronary artery and resting anterior wall dyssynergy. During CABG, transmural myocardial biopsies were obtained from the dyssynergic anterior wall and from normal myocardial segments to determine the extent of viable myocardium by histopathology. Improvement of regional left ventricular function was evaluated by radionuclide angiography at 6 to 8 weeks after CABG. There was a good correlation (r=.85, P<.001) between the quantified sestamibi activity and the extent of viable myocardium determined morphometrically. Among 21 biopsied dyssynergic myocardial segments, 11 improved their function after CABG and 10 failed to improve. Biopsied segments with improved postoperative function had significantly higher sestamibi activity (81+/-5% versus 49+/-16%, P<.0001) and significantly lower extent of interstitial fibrosis (7+/-4% versus 31+/-21%, P=.0002) than segments that failed to improve. A 55% threshold of 99mTc-sestamibi activity had positive and negative predictive values of 79% and 100%, respectively, for recovery of function after CABG in the biopsied segments., Conclusions: Myocardial 99mTc-sestamibi activity correlates well with the extent of viable myocardium and predicts improvement in regional function after CABG. This lends support to the use of sestamibi as a myocardial viability agent.

Swan-Ganz catheters have become a very valuable and frequently used method of monitoring hemodynamics in sick patients. Although the incidence of complications is very low, more reports are beginning to appear. One of the more serious complications is the rupture of the pulmonary artery. This report concerns three patients who had a rupture of the pulmonary artery who survived, including one of almost fatal exanguination. A literature review of all cases of pulmonary artery rupture is presented. Fifty-three per cent (8/15) were fatal. Emphasis is placed on the prevention of this by using the guidelines. Discussion also covers possible contributing causes and treatment. A high index of suspicion is necessary whenever a patient with the catheter has hemoptysis or unexplained cardiac or respiratory changes.

The search for effective administrative patterns in health service organizations has heightened in the United States. The organized anarchy model depicting these organizations suggests an emphasis on certain CEO roles, and this emphasis is different from that expected of a CEO in a "rational" organization. The degree of internal influence and coherence of coupling are two indicators of CEO effectiveness within a health service organization.

Eight subjects were studied in a randomized crossover design to determine the effect of aluminum-magnesium hydroxide (AMH), calcium carbonate (CC), and aluminum hydroxide-magnesium trisilicate (AHMT) on the bioavailability of a single, 600-mg dose of phenytoin administered orally. Each subject received phenytoin alone on two separate occasions and phenytoin plus each of the three antacids on three other occasions. Each antacid was administered as 160 mEq at 1 and 3 hr after each meal and at bedtime on the day phenytoin was given. The mean area under the curve (AUC) was significantly decreased by AMH (p less than 0.005) and CC (p less than 0.05). AHMT had a similar trend but did not reach statistical significance (p = 0.1). Large inter- and intrasubject variability in AUC was observed when phenytoin was administered alone. In two subjects, cumulative urinary 5-(4-hydroxyphenyl)-5-phenylhydantoin at 72 hr (HPPH72) was determined. The amount of HPPH recovered had similar trends as the AUC with antacid treatments but not the same magnitude. In this study, antacids altered not only the extent of absorption but also appeared to alter the rate of absorption. Antacids administered in a peptic ulcer regimen may decrease the AUC of a single dose of phenytoin. Patients should be cautioned against concomitant use of antacids and phenytoin.