A review of key strategies to address the shortage of analgesics and sedatives in pediatric intensive care.

Importance: Targeted analgosedation is a challenge in critically ill children, and this challenge becomes even more significant with drug shortages. Observations: Published guidelines inform the provision of analgosedation in critically ill children. This review provides insights into general approaches using these guidelines during drug shortages in Pediatric Intensive Care Units as well as strategies to optimize both pharmacological and non-pharmacological approaches in these situations. Conclusions and relevance: Considering that drug shortages are a recurrent worldwide problem, this review may guide managing these drugs in critically ill children in situations of scarcity, such as in pandemics or disasters.

Practices in sedation, analgesia, mobilization, delirium, and sleep deprivation in adult intensive care units (SAMDS-ICU): an international survey before and during the COVID-19 pandemic.

BACKGROUND: Since the publication of the 2018 Clinical Guidelines about sedation, analgesia, delirium, mobilization, and sleep deprivation in critically ill patients, no evaluation and adequacy assessment of these recommendations were studied in an international context. This survey aimed to investigate these current practices and if the COVID-19 pandemic has changed them. METHODS: This study was an open multinational electronic survey directed to physicians working in adult intensive care units (ICUs), which was performed in two steps: before and during the COVID-19 pandemic. RESULTS: We analyzed 1768 questionnaires and 1539 (87%) were complete. Before the COVID-19 pandemic, we received 1476 questionnaires and 292 were submitted later. The following practices were observed before the pandemic: the Visual Analog Scale (VAS) (61.5%), the Behavioral Pain Scale (BPS) (48.2%), the Richmond Agitation Sedation Scale (RASS) (76.6%), and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (66.6%) were the most frequently tools used to assess pain, sedation level, and delirium, respectively; midazolam and fentanyl were the most frequently used drugs for inducing sedation and analgesia (84.8% and 78.3%, respectively), whereas haloperidol (68.8%) and atypical antipsychotics (69.4%) were the most prescribed drugs for delirium treatment; some physicians regularly prescribed drugs to induce sleep (19.1%) or ordered mechanical restraints as part of their routine (6.2%) for patients on mechanical ventilation; non-pharmacological strategies were frequently applied for pain, delirium, and sleep deprivation management. During the COVID-19 pandemic, the intensive care specialty was independently associated with best practices. Moreover, the mechanical ventilation rate was higher, patients received sedation more often (94% versus 86.1%, p < 0.001) and sedation goals were discussed more frequently in daily rounds. Morphine was the main drug used for analgesia (77.2%), and some sedative drugs, such as midazolam, propofol, ketamine and quetiapine, were used more frequently. CONCLUSIONS: Most sedation, analgesia and delirium practices were comparable before and during the COVID-19 pandemic. During the pandemic, the intensive care specialty was a variable that was independently associated with the best practices. Although many findings are in accordance with evidence-based recommendations, some practices still need improvement.

Pediatric patients with COVID-19 admitted to intensive care units in Brazil: a prospective multicenter study.

OBJECTIVE: To describe the clinical characteristics of children and adolescents admitted to intensive care with confirmed COVID-19. METHOD: Prospective, multicenter, observational study, in 19 pediatric intensive care units. Patients aged 1 month to 19 years admitted consecutively (March-May 2020) were included. Demographic, clinical-epidemiological features, treatment, and outcomes were collected. Subgroups were compared according to comorbidities, age < 1 year, and need for invasive mechanical ventilation. A multivariable logistic regression model was used for predictors of severity. RESULTS: Seventy-nine patients were included (ten with multisystemic inflammatory syndrome). Median age 4 years; 54% male (multisystemic inflammatory syndrome, 80%); 41% had comorbidities (multisystemic inflammatory syndrome, 20%). Fever (76%), cough (51%), and tachypnea (50%) were common in both groups. Severe symptoms, gastrointestinal symptoms, and higher inflammatory markers were more frequent in multisystemic inflammatory syndrome. Interstitial lung infiltrates were common in both groups, but pleural effusion was more prevalent in the multisystemic inflammatory syndrome group (43% vs. 14%). Invasive mechanical ventilation was used in 18% (median 7.5 days); antibiotics, oseltamivir, and corticosteroids were used in 76%, 43%, and 23%, respectively, but not hydroxychloroquine. The median pediatric intensive care unit length-of-stay was five days; there were two deaths (3%) in the non- multisystemic inflammatory syndrome group. Patients with comorbidities were older and comorbidities were independently associated with the need for invasive mechanical ventilation (OR 5.5; 95% CI, 1.43-21.12; p = 0.01). CONCLUSIONS: In Brazilian pediatric intensive care units, COVID-19 had low mortality, age less than 1 year was not associated with a worse prognosis, and patients with multisystemic inflammatory syndrome had more severe symptoms, higher inflammatory biomarkers, and a greater predominance of males, but only comorbidities and chronic diseases were independent predictors of severity.

Delirium Detection Based on the Clinical Experience of Pediatric Intensivists.

OBJECTIVES: To estimate the frequency of delirium detected by pediatric intensivists, based only on their clinical experience, without a valid and reliable tool. DESIGN: Multicenter, prospective, descriptive, observational study. SETTINGS: Three PICUs in Rio de Janeiro, Brazil. PATIENTS: Twenty-nine days to 18 years old. INTERVENTIONS: Electronic forms were sent weekly to the pediatric intensivists responsible for the daily care of patients from March to September 2015, to fill in information about the presence of risk factors and diagnosis of delirium in all patients who remained in the PICU in the last week. Demographics and other clinical data were extracted from an electronic system. MEASUREMENTS AND MAIN RESULTS: A total of 504 admissions in the three PICUs (477 patients) were included. The pediatric intensivists reported only two episodes of delirium in two different patients, based on insufficient criteria. Considering all PICUs admissions, the reported frequency of delirium was only 0.4% (2/504). CONCLUSIONS: The low frequency of delirium detection and the insufficient criteria used for the diagnosis in these units suggest flaws in the recognition of delirium and probably the occurrence of underdiagnosis/misdiagnosis when it is based only on clinical experience, without the use of a valid and reliable tool.

Validity and Reliability of the Brazilian Portuguese Version of the Pediatric Confusion Assessment Method for the ICU.

OBJECTIVES: To determine the validity and reliability of the Brazilian Portuguese version of the Pediatric Confusion Assessment Method for the ICU for diagnosing delirium in patients with chronological and developmental ages from 5 to 17 years in Brazilian PICUs. DESIGN: Prospective, cross-sectional study. SETTINGS: Eight Brazilian PICUs (seven in Rio de Janeiro and one in São Paulo). PATIENTS: One-hundred sixteen patients, 5-17 years old, without developmental delay, submitted to mechanical ventilation or not. INTERVENTIONS: To assess the inter-observer reliability, two previously trained researchers concomitantly applied the Brazilian Portuguese version of the Pediatric Confusion Assessment Method for the ICU and independently rated the same patient. To assess the criterion validity, a pediatric neurologist or psychiatrist, blinded to the Brazilian Portuguese version of the Pediatric Confusion Assessment Method for the ICU assessments, evaluated the same patient within 30 minutes, using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, considered the reference standard. MEASUREMENTS AND MAIN RESULTS: One-hundred forty-nine paired assessments were included (some patients had more than one). Delirium was diagnosed in 11 of 149 assessments (7%), or eight of 116 patients (7%), using both the Brazilian Portuguese version of the Pediatric Confusion Assessment Method for the ICU and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. There was one false positive and one false negative diagnosis, which resulted in 90.9% sensitivity (95% CI, 58.7-99.8%) and 99.3% specificity (95% CI, 96-100%) for the Brazilian Portuguese version of the Pediatric Confusion Assessment Method for the ICU. The inter-rater reliability was considered almost perfect (κ = 1.0). CONCLUSIONS: The Brazilian Portuguese version of the Pediatric Confusion Assessment Method for the ICU is a valid and reliable tool for diagnosing delirium in pediatric patients 5-17 years old who are spontaneously breathing and not pharmacologically sedated in Brazilian PICUs. The implementation of this tool may be useful to reduce underdiagnosis, ensure monitoring and earlier intervention, provide a better prognosis, and improve research on delirium in this age group in Brazil. Further studies are necessary to test the psychometric properties of the Brazilian Portuguese version of the Pediatric Confusion Assessment Method for the ICU in sedated and mechanically ventilated children.