Analgesia and Sedation Protocol for Mechanically Ventilated Postsurgical Children Reduces Benzodiazepines and Withdrawal Symptoms—But Not in All Patients

Background We demonstrated recently that the implementation of a nurse-driven analgesia and sedation protocol (pediatric analgesia and sedation protocol [pASP]) for mechanically ventilated nonpostsurgical patients reduces the total dose of benzodiazepines and the withdrawal symptoms significantly. It has not been investigated if these results can also be expected in the group of patients undergoing surgery. Objectives To evaluate the effects of the pASP in mechanically ventilated postsurgical children regarding drug dosage, duration of mechanical ventilation, length of stay, and rate of withdrawal symptoms. Methods This is a two-phase prospective observational control study. The preimplementation group was managed by the physician's order and the postimplementation group was managed with the pASP including COMFORT-B, nurse interpretation of sedation, and Sophia observation withdrawal symptoms scale scoring. Measurements and Main Results One hundred and sixteen patients were included before and one hundred and ten patients after implementation. The pASP had no effect on length of pediatric intensive care unit stay or duration of mechanical ventilation. The protocol reduced total (5.0 mg/kg [0.5–58.0] vs 4.0 mg/kg [0.0–47.0]; p = 0.021) and daily doses (4.4 mg/kg/d [1.1–33.9] vs 2.9 mg/kg/d [0.0–9.9]; p < 0.001) of benzodiazepines significantly. No difference was observed in total and daily doses of opioids (5.0 mg/kg [0.1–67.0] vs 3.0 mg/kg [0.1–71.0]; p = 0.81) and (0.7 mg/kg/d [0.0–7.0] vs. 0.8 mg/kg/d [0.0–3.7]; p = 0.35), respectively. Rate of withdrawal symptoms was significantly lower after implementation (35.3 vs 20.0%; p = 0.01), but not in patients after solid organ transplantation or oncological patients. Conclusion The nurse-driven analgesia and sedation protocol is an effective procedure to reduce the total doses of benzodiazepines and occurrence of withdrawal symptoms in postsurgical children, which are naïve to opioids or benzodiazepines.

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Effectiveness of Protocolized Sedation Utilizing the COMFORT-B Scale in Mechanically Ventilated Children in a Pediatric Intensive Care Unit

Journal of Pediatric Intensive Care ◽

10.1055/s-0039-1678730 ◽

2019 ◽

Vol 08 (03) ◽

pp. 156-163 ◽

Cited By ~ 1

Author(s):

Kantara Saelim ◽

Shevachut Chavananon ◽

Kanokpan Ruangnapa ◽

Pharsai Prasertsan ◽

Wanaporn Anuntaseree

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Cohort Study ◽

Intensive Care ◽

Prospective Cohort ◽

Pediatric Intensive Care ◽

Mechanically Ventilated ◽

Mechanically Ventilated Patients ◽

Sedation Protocol ◽

Ventilated Patients

AbstractAppropriate sedation in mechanically ventilated patients is important to facilitate adequate respiratory support and maintain patient safety. However, the optimal sedation protocol for children is unclear. This study assessed the effectiveness of a sedation protocol utilizing the COMFORT-B sedation scale in reducing the duration of mechanical ventilation in children. This was a nonrandomized prospective cohort study compared with a historical control. The prospective cohort study was conducted between November 2015 and August 2016 and included 58 mechanically ventilated patients admitted to the pediatric intensive care unit (PICU). All patients received protocolized sedation utilizing the COMFORT-B scale, which was assessed every 12 hours after intubation by a single assessor. The prospective data were compared with retrospective data of 58 mechanically ventilated patients who received sedation by usual care from November 2014 to August 2015. Fifty percent of 116 patients were male and the mean age was 22 months (interquartile range [IQR]: 6.6–68.4). Patients in the intervention group showed no difference in the duration of mechanical ventilation (median 4.5 [IQR: 2.2–10.5] vs. 5 [IQR: 3–8.8] days). Also, there were no significant differences in the PICU length of stay (LOS; median 7 vs. 7 days, p = 0.59) and hospital LOS (median 18 vs. 14 days, p = 0.14) between the intervention and control groups. The percentages of sedative drugs, including fentanyl, morphine, and midazolam, in each group were not statistically different. The COMFORT-B scale with protocolized sedation in mechanically ventilated pediatric patients in the PICU did not reduce the duration of mechanical ventilation compared with usual care.

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Filamentous Fungi in a Tertiary Care Hospital Environmental Surveillance and Susceptibility to Antifungal Drugs

Infection Control and Hospital Epidemiology ◽

10.1086/508832 ◽

2007 ◽

Vol 28 (1) ◽

pp. 60-67 ◽

Cited By ~ 27

Author(s):

Paraskevi Panagopoulou ◽

Joanna Filioti ◽

Evangelia Farmaki ◽

Avgi Maloukou ◽

Emmanuel Roilides

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Organ Transplantation ◽

Filamentous Fungi ◽

Tap Water ◽

Tertiary Care ◽

Solid Organ Transplantation ◽

Pediatric Intensive Care ◽

Solid Organ ◽

Colony Forming Units

Objective.To evaluate filamentous fungi with respect to environmental load and potential drug resistance in a tertiary care teaching hospital.Design.Monthly survey in 2 buildings of the hospital during a 12-month period.Setting.Hippokration Hospital in Thessaloniki, Greece.Methods.Air, surface, and tap water sampling was performed in 4 departments with high-risk patients. As sampling sites, the solid-organ transplantation department and the hematology department (in the older building) and the pediatric oncology department and the pediatric intensive care unit (in the newer building) were selected.Results.From January to May of 2000, the fungal load in air (FLA) was low, ranging from 0 to 12 colony-forming units (cfu) per m3 in both buildings. During the summer months, when high temperature and humidity predominate, the FLA increased to 4-56 cfu/m3. The fungi commonly recovered from culture of air specimens wereAspergillus niger(25.9%),Aspergillus flavus(17.7%), andAspergillus fumigatus(12.4%). Non-Aspergillusfilamentous fungi, such asZygomycetesandDematiaceousspecies, were also recovered. The pediatric intensive care unit had the lowest mean FLA (7.7 cfu/m3), compared with the pediatric oncology department (8.7 cfu/m3), the solid-organ transplantation department (16.1 cfu/m3), and the hematology department (22.6 cfu/m3). Environmental surfaces were swabbed, and 62.7% of the swab samples cultured yielded filamentous fungi similar to the fungi recovered from air but with low numbers of colony-forming units. Despite vigorous sampling, culture of tap water yielded no fungi. The increase in FLA observed during the summer coincided with renovation in the building that housed the solid-organ transplantation and hematology departments. All 54Aspergillusair isolates randomly selected exhibited relatively low minimum inhibitory or effective concentrations for amphotericin B, itraconazole, voriconazole, posaconazole, micafungin, and anidulafungin.Conclusion.Air and surface fungal loads may vary in different departments of the same hospital, especially during months when the temperature and humidity are high. EnvironmentalAspergillusisolates are characterized by lack of resistance to clinically important antifungal agents.

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“Difficult to Sedate”: Successful Implementation of a Benzodiazepine-Sparing Analgosedation-Protocol in Mechanically Ventilated Children

Children ◽

10.3390/children8050348 ◽

2021 ◽

Vol 8 (5) ◽

pp. 348

Author(s):

Nataly Shildt ◽

Chani Traube ◽

Mary Dealmeida ◽

Ishaan Dave ◽

Scott Gillespie ◽

...

Keyword(s):

Mechanical Ventilation ◽

Length Of Stay ◽

Pediatric Intensive Care ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Opiate Withdrawal ◽

Successful Implementation ◽

Chromosomal Disorders ◽

Mechanically Ventilated ◽

Single Center Study

We sought to evaluate the success rate of a benzodiazepine-sparing analgosedation protocol (ASP) in mechanically ventilated children and determine the effect of compliance with ASP on in-hospital outcome measures. In this single center study from a quaternary pediatric intensive care unit, our objective was to evaluate the ASP protocol, which included opiate and dexmedetomidine infusions and was used as first-line sedation for all intubated patients. In this study we included 424 patients. Sixty-nine percent (n = 293) were successfully sedated with the ASP. Thirty-one percent (n = 131) deviated from the ASP and received benzodiazepine infusions. Children sedated with the ASP had decrease in opiate withdrawal (OR 0.16, 0.08–0.32), decreased duration of mechanical ventilation (adjusted mean duration 1.81 vs. 3.39 days, p = 0.018), and decreased PICU length of stay (adjusted mean 3.15 vs. 4.7 days, p = 0.011), when compared to the cohort of children who received continuous benzodiazepine infusions. Using ASP, we report that 69% of mechanically ventilated children were successfully managed with no requirement for continuous benzodiazepine infusions. The 69% who were successfully managed with ASP included infants, severely ill patients, and children with chromosomal disorders and developmental disabilities. Use of ASP was associated with decreased need for methadone use, decreased duration of mechanical ventilation, and decreased ICU and hospital length of stay.

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Prescription practice and clinical utility of chest radiographs in a pediatric intensive care unit: a prospective observational study

BMC Medical Imaging ◽

10.1186/s12880-021-00576-6 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Rajeev Gupta ◽

Karthi Nallasamy ◽

Vijai Williams ◽

Akshay Kumar Saxena ◽

Muralidharan Jayashree

Keyword(s):

Mechanical Ventilation ◽

Intensive Care ◽

Image Quality ◽

Observational Study ◽

Radiation Exposure ◽

Chest Radiograph ◽

Prospective Observational Study ◽

Pediatric Intensive Care ◽

Mechanically Ventilated ◽

On Demand

Abstract Background Chest radiograph (CXR) prescribing pattern and practice vary widely among pediatric intensive care units (PICU). ‘On demand’ approach is increasingly recommended as against daily ‘routine’ CXRs; however, the real-world practice is largely unknown. Methods This was a prospective observational study performed in children younger than 12 years admitted to PICU of a tertiary care teaching hospital in India. Data were collected on all consecutive CXRs performed between December 2016 and April 2017. The primary outcome was to assess the factors that were associated with higher chest radiograph prescriptions in PICU. Secondary outcomes were to study the indications, association with mechanical ventilation, image quality and avoidable radiation exposure. Results Of 303 children admitted during the study period, 159 underwent a total of 524 CXRs in PICU. Median (IQR) age of the study cohort was 2 (0.6–5) years. More than two thirds [n = 115, 72.3%] were mechanically ventilated. Most CXRs (n = 449, 85.7%) were performed on mechanically ventilated patients, amounting to a median (IQR) of 3 (2–5) radiographs per ventilated patient. With increasing duration of ventilation, the number of CXRs proportionately increased in the first two weeks of mechanical ventilation. In non-ventilated children, about two thirds (68%) underwent only one CXR. Majority of the prescriptions were on demand (n = 461, 88%). Most common indications were peri-procedure prescriptions (37%) followed by evaluation for respiratory disease status (24%). About 40% CXRs resulted in interventions; adjustment in ventilator settings (13.5%) was the most frequent intervention. In 26% (n = 138) of radiographs, image quality required improvement. One or more additional body part exposure other than chest and upper abdomen were noted 336 (64%) images. Children with > 3 CXR had higher PRISM III score, more often mechanically ventilated, had higher number of indwelling devices [mean (SD) 2.6 (1.2) vs. 1.7 (1.0)] and stayed longer in PICU [median (IQR) 11(7.5–18.5) vs. 6 (3–9)]. Conclusion On demand prescription was the prevalent practice in our PICU. Most non-ventilated children underwent only one CXR while duration of PICU stay and the number of devices determined the number of CXRs in mechanically ventilated children. Quality improvement strategies should concentrate on the process of acquisition of images and limiting the radiation exposure to unwanted body parts.

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Fluid overload and length of mechanical ventilation in pediatric sepsis

Paediatrica Indonesiana ◽

10.14238/pi59.4.2019.211-6 ◽

2019 ◽

Vol 59 (4) ◽

pp. 211-6

Author(s):

Winda Paramitha ◽

Rina Triasih ◽

Desy Rusmawatiningtyas

Keyword(s):

Mechanical Ventilation ◽

Fluid Overload ◽

Secondary Data ◽

Pediatric Intensive Care ◽

Extubation Failure ◽

Critically Ill Children ◽

Inclusion Criteria ◽

Mechanically Ventilated ◽

Mechanical Ventilation Duration ◽

Pediatric Sepsis

Background Children with sepsis often experience hemodynamic failure and would benefit from fluid resuscitation. On the other hand, critically ill children with sepsis have a higher risk of fluid accumulation due to increased capillary hydrostatic pressure and permeability. Therefore, fluid overload may result in higher morbidity and mortality during pediatric intensive care unit (PICU) hospitalization. Objective To evaluate the correlation between fluid overload and the length of mechanical ventilation in children with sepsis admitted to the PICU. Methods Our retrospective cohort study included children aged 1 month-18 years with sepsis who were admitted to the PICU between January 2013 and June 2018 and mechanically-ventilated. Secondary data was extracted from subjects’ medical records. Data analyses used were independent T-test and survival analysis. Results Of 444 children admitted to the PICU, 166 initially met the inclusion criteria. Of those, 17 children were excluded due to congenital heart disease. Subjects’ median age was 19 months and median PELOD-2 score was 8. Eighteen children (12.1%) had positive fluid balance in the first 48 hours. Median mechanical ventilation duration was 5 days. Fluid overload was significantly correlated with length of mechanical ventilation (P=0.01) and PICU mortality (RR=2.06; 95%CI 2.56 to 166; P=0.001). Neither length of PICU stay nor extubation failure were significantly correlated to fluid overload. Conclusion Fluid overload was significantly correlated with length of mechanical ventilation and may be a predictor of mortality in children with sepsis in the PICU.

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Nurse-driven pediatric analgesia and sedation protocol reduces withdrawal symptoms in critically ill medical pediatric patients

Pediatric Anesthesia ◽

10.1111/pan.12649 ◽

2015 ◽

Vol 25 (8) ◽

pp. 786-794 ◽

Cited By ~ 36

Author(s):

Felix Neunhoeffer ◽

Matthias Kumpf ◽

Hanna Renk ◽

Malte Hanelt ◽

Nicole Berneck ◽

...

Keyword(s):

Critically Ill ◽

Pediatric Patients ◽

Withdrawal Symptoms ◽

Sedation Protocol ◽

Pediatric Analgesia

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Safety and Utility of Continuous Ketamine Infusion for Sedation in Mechanically Ventilated Pediatric Patients

The Journal of Pediatric Pharmacology and Therapeutics ◽

10.5863/1551-6776-23.6.447 ◽

2018 ◽

Vol 23 (6) ◽

pp. 447-454

Author(s):

Amy L. Heiberger ◽

Surachat Ngorsuraches ◽

Gokhan Olgun ◽

Lisa Luze ◽

Caitlin Leimbach ◽

...

Keyword(s):

Adverse Events ◽

Continuous Infusion ◽

Pediatric Patients ◽

Average Rate ◽

Pediatric Intensive Care ◽

Mechanically Ventilated ◽

Ketamine Infusion ◽

Sedation Protocol ◽

Before And After ◽

Adequate Sedation

OBJECTIVES The selection of sedative medications for mechanically ventilated pediatric patients remains an ongoing clinical challenge. Although continuous ketamine infusion has been used in this population, support for its use remains largely anecdotal. This study describes a single institution's use of ketamine infusions as part of a sedation protocol in the pediatric intensive care unit (PICU). METHODS This was a retrospective study of children who received ketamine infusions as part of a multidrug sedation protocol in a 12-bed PICU at a tertiary children's hospital. Outcomes included effectiveness of ketamine infusion in providing adequate sedation as determined by State Behavioral Scale (SBS) scores and incidence of adverse events. RESULTS A total of 22 children receiving ketamine continuous infusion as part of a multidrug sedation protocol from February 2014 through October 2015 were eligible and enrolled in the study. Ketamine continuous infusion was administered in addition to at least 2 other sedation infusions at an average rate of 1.02 ± 0.50 mg/kg/hr, with a range of 0.07 to 2.0 mg/kg/hr. The duration of ketamine was 65.7 ± 41.01 hours, with a range of 19 to 153 hours. There was no significant change in SBS scores before and after initiation of ketamine infusion. Although not statistically significant, patients with inadequate sedation prior to starting ketamine required fewer bolus sedation doses and had improved sedation after ketamine was started. There were no reported adverse events. CONCLUSIONS The addition of a ketamine infusion as part of a multidrug sedation regimen was at least as effective as patients' regimen prior to ketamine addition in this population of intubated pediatric patients, with no adverse events.

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Continuous sedation vs. daily sedation interruption in mechanically-ventilated children

Paediatrica Indonesiana ◽

10.14238/pi56.1.2016.19-23 ◽

2016 ◽

Vol 56 (1) ◽

pp. 19

Author(s):

Henri Azis ◽

Silvia Triratna ◽

Erial Bahar

Keyword(s):

Mechanical Ventilation ◽

Adverse Events ◽

Severity Of Illness ◽

Pediatric Intensive Care ◽

Interquartile Range ◽

Open Label ◽

Mechanically Ventilated ◽

Continuous Sedation ◽

Sedation Group ◽

Daily Sedation Interruption

Background A daily sedation interruption (DSI) protocol in ventilated patientsis an effective method of improving sedation management that decreases the duration of mechanical ventilation. In adult patients, it is a safe and effective approach, as well as common practice. For ventilated children,its effectiveness and feasibilityare unknown.Objective To compare continuous sedation and DSI in mechanically-ventilated children with respect todurationof mechanical ventilation, the time needed for patients to awaken, and the frequency of adverse events.Method This randomized, controlled, open-label trial, was performed in a pediatric intensive care unit (PICU). Forty children on mechanical ventilation were included. Patients were randomly assigned to receive either continuous sedation or DSI. The duration of mechanical ventilation was the primary outcome, while the time for patients to awaken on sedative infusion and the frequency of adverse events were secondary outcomes.Results Forty patients were randomized into the continuous sedation protocol (18 subjects) or into the DSI protocol (22 subjects). The median (interquartile range) duration of mechanical ventilation was significantly shorter in the DSI compared to the continuous sedation group [41.50 (30-96) hours vs. 61 (30-132) hours, respectively; (P=0.033)]. The time for patients to awaken was also significantly lower in the DSI than in the continuous sedation group [median (interquartile range): 28 (24-78) vs. 45.5 (25-12) hours, respectively; (P=0.003)]. The frequencies of adverse events were similar in both groups. The severity of illness contributed to outcome variables.Conclusion The duration of mechanical ventilation and the time for patients to awaken are significantly reduced in the DSI group compared to the continuous sedation group.

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