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PANDEM Guidelines for Infants and Children  

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Heidi A.B. Smith, MD, MSCI; John W. Berkenbosch, MD, FAAP, FCCM;
Published: 2/4/2022

Ped Crit Care Med 2022 Feb;23(2):e74-e110

PANDEM Guidelines for Infants and Children  

Citation: Ped Crit Care Med 2022 Feb;23(2):e74-e110

Jump to Recommendations

As many as three out of five children in the pediatric intensive care unit (PICU) develop delirium. Routine monitoring for delirium, pain, agitation, and withdrawal while instituting an interdisciplinary model of care is vital to ensuring the best care and outcomes, according to the first comprehensive guidelines on caring for critically ill infants and children, developed by the Society of Critical Care Medicine (SCCM).
 
The 2022 SCCM 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 (PANDEM), published in the February 2022 issue of SCCM’s Pediatric Critical Care Medicine journal.
 
Previous guidelines focused more on identification and diagnosis than on monitoring or were less evidence based. The new guidelines are broader in scope and include 44 recommendations based on the increasingly rigorous pediatric-specific literature, featuring management strategies such as enhanced use of protocolized sedation and analgesia. The guidelines also underscore the importance of nonpharmacologic interventions and family involvement to enhance comfort, care, and possibly outcomes.

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.

Guideline Type: Clinical

Related Resources:

Many of the concepts in the PANDEM guidelines reflect the goals of SCCM’s ICU Liberation campaign, including adequately treating pain, thoughtfully determining sedation medications, assessing for and treating delirium, early mobility, and engaging families in the care of their loved one.


Critcal Connections Blog: SCCM Releases PANDEM Guidelines for Critically Ill Children and Infants
 

How the PANDEM Guidelines Relate to the ICU Liberation Campaign. Heidi A.B. Smith, MD, MSCI, shares insight into the PANDEM guidelines for children and infants and how recommendations relate to the ICU Liberation Campaign.
 
Top Practices from the PANDEM Guidelines
John W. Berkenbosch, MD, FAAP, FCCM, shares the top practices from the PANDEM guidelines for children and infants.
Listen to host Margaret M. Parker, MD, MCCM, and Heidi A. B. Smith, MD, MSCI, FAAP, discuss the guidelines in SCCM Pod-454 PCCM: PANDEM Guidelines.

 

Category: Pediatrics, Pharmacology,

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We suggest that, in critically ill pediatric patients 6 yrs old and older who are capable of communicating, pain assessment via self-report be routinely performed using the Visual Analog Scale, Numeric Rating Scale, Oucher Scale, or Wong-Baker Faces pain scale.
Quality of Evidence: Low

Faces, Legs, Activity, Cry, and Consolability or COMFORT-Behavior scales for assessing pain in non-communicative critically ill pediatric patients.
Quality of Evidence: Moderate

We recommend the use of observational pain assessment tools rather than vital signs alone for assessment of postoperative pain in critically ill pediatric patients.
Quality of Evidence: Moderate

We suggest the use of observational pain assessment tools rather than vital signs alone for assessment of procedure-related pain in critically ill pediatric patients.
Quality of Evidence: Low

We recommend that IV opioids be used as the primary analgesic for treating moderate to severe pain in critically ill pediatric patients.
Quality of Evidence: Moderate

We recommend the addition of an adjunct nonsteroidal anti-inflammatory drug (IV or oral) to improve early postoperative analgesia in critically ill pediatric patients.
Quality of Evidence: Moderate

We suggest the addition of an adjunct nonsteroidal anti-inflammatory agent (IV or oral) to decrease opioid requirements in the immediate postoperative period in critically ill pediatric patients.
Quality of Evidence: Low

We suggest the addition of adjunct acetaminophen (IV or oral) to improve early postoperative analgesia in critically ill pediatric patients.
Quality of Evidence: Low

We suggest the addition of adjunct acetaminophen (IV or oral) to decrease opioid requirements in the immediate postoperative period in critically ill pediatric patients.
Quality of Evidence: Low

We recommend that music therapy be offered to augment analgesia in critically ill postoperative pediatric patients.
Quality of Evidence: Moderate

We recommend that nonnutritive sucking with oral sucrose be offered to neonates and young infants prior to performing invasive procedures.
Quality of Evidence: High

We recommend the use of the COMFORT-Behavior Scale or the State Behavioral Scale, to assess level of sedation in mechanically ventilated pediatric patients.
Quality of Evidence: Moderate

We suggest the use of the Richmond Agitation-Sedation Scale to assess level of sedation in mechanically ventilated pediatric patients.
Quality of Evidence: Low

We suggest that all pediatric patients requiring mechanical ventilation are assigned a target depth of sedation using a validated sedation assessment tool at least once daily.
Quality of Evidence: Low

We suggest the use of protocolized sedation in all critically ill pediatric patients requiring sedation and/or analgesia during mechanical ventilation.
Quality of Evidence: Low

The addition of daily sedation interruption to sedation protocolization is not suggested due to lack of improvement in outcomes.
Quality of Evidence: Low

During the periextubation period when sedation is typically lightened, we suggest the following bundle strategies to decrease risk of inadvertent device removal: 
a) Assign a target depth of sedation at increasing frequency to adapt to changes inpatient clinical status and communicate strategies to reach titration goal. 
b) Consider a sedation weaning protocol.
c) Consider unit standards for securement of endotracheal tubes and safety plan.
d) Restrict nursing workload to facilitate frequent patient monitoring, decrease sedation requirements, and risk of self-harm.
Quality of Evidence: Low

We suggest the use of alpha2-agonists as the primary sedative class in critically ill pediatric patients requiring mechanical ventilation.
Quality of Evidence: Low

We recommend that dexmedetomidine be considered as a primary agent for sedation in critically ill pediatric post-operative cardiac surgical patients with expected early extubation.
Quality of Evidence: Moderate

We suggest the use of dexmedetomidine for sedation in critically ill pediatric postoperative cardiac surgical patients to decrease the risk of tachyarrhythmias.
Quality of Evidence: Low

We suggest that continuous propofol sedation at doses less than 4mg/kg/hr (67 µg/ kg/min) and administered for less than 48hr may be a safe sedation alternative to minimize the risk of propofol-related infusion syndrome development.
Quality of Evidence: Low

Short term (< 48hr) continuous propofol sedation may be a useful adjunct during the periextubation period to facilitate weaning of other analgosedative agents prior to extubation.

We suggest consideration of adjunct sedation with ketamine in patients who are not otherwise at an optimal sedation depth.
Quality of Evidence: Low

We suggest that train-of-four monitoring be used in concert with clinical assessment to determine depth of neuromuscular blockade.
Quality of Evidence: Low

We suggest using the lowest dose of neuromuscular blockade agents required to achieve desired clinical effects and manage undesired breakthrough movement.
Quality of Evidence: Low

Electrocephalogram-based monitoring may be a useful adjunct for assessment of sedation depth in critically ill pediatric patients receiving neuromuscular blockade agents.

We suggest that sedation and analgesia should be adequate to prevent awareness prior to and throughout neuromuscular blockade use.
Quality of Evidence: Low

We recommend routine use of passive eyelid closure and eye lubrication for the prevention of corneal abrasions in critically ill pediatric patients receiving neuromuscular blockade agents.
Quality of Evidence: Moderate

We recommend use of the preschool and pediatric Confusion Assessment Methods for the ICU or the Cornell Assessment for Pediatric Delirium as the most valid and reliable delirium monitoring tools in critically ill pediatric patients.
Quality of Evidence: High

We recommend routine screening for ICU delirium using a validated tool in critically ill pediatric patients upon admission through ICU discharge or transfer.
Quality of Evidence: High

Given low patient risk, and possible patient benefit to reduce the incidence and/or decrease duration or severity of delirium we suggest the following non-pharmacologic strategies: optimization of sleep hygiene, use of interdisciplinary rounds, family engagement on rounds, and family involvement with direct-patient care.
Quality of Evidence: Low

We suggest performing early mobility, when feasible, to reduce the development of delirium.
Quality of Evidence: Low

We recommend minimizing benzodiazepine-based sedation when feasible in critically ill pediatric patients to decrease incidence and/or duration or severity of delirium.
Quality of Evidence: Moderate

We suggest strategies to minimize overall sedation exposure whenever feasible to reduce coma and the incidence and/or severity of delirium in critically ill children.
Quality of Evidence: Low

We do not suggest routine use of haloperidol or atypical antipsychotics for the prevention of or decrease in duration of delirium in critically ill pediatric patients.
Quality of Evidence: Low

We suggest that in critically ill pediatric patients with refractory delirium, haloperidol or atypical antipsychotics be considered for the management of severe delirium manifestations, with consideration of possible adverse drug effects.
Quality of Evidence: Moderate

We recommend a baseline electrocardiogram followed by routine electrolyte and QTc interval monitoring for patients receiving haloperidol or atypical antipsychotics.
Quality of Evidence: Moderate

We recommend use of either the Withdrawal Assessment Tool-1 or Sophia Observation Scale for the assessment of Iatrogenic Withdrawal Syndrome due to opioid or benzodiazepine withdrawal in critically ill pediatric patients.
Quality of Evidence: Moderate

We suggest routine Iatrogenic Withdrawal Syndrome screening after a shorter duration (3–5 d) when higher opioid or benzodiazepine doses are used.
Quality of Evidence: Moderate

Until a validated screening tool is developed, monitoring for Iatrogenic Withdrawal Syndrome from alpha2-agonists should be performed using a combination of associated symptoms (unexplained hypertension or tachycardia) with adjunct use of a validated benzodiazepine or opioid screening tool.

We suggest that opioid related Iatrogenic Withdrawal Syndrome be treated with opioid replacement therapy to attenuate symptoms, irrespective of preceding dose and/or duration of opioid exposure.
Quality of Evidence: Low

Benzodiazepine-related Iatrogenic Withdrawal Syndrome should be treated with benzodiazepine replacement therapy to attenuate symptoms, irrespective of preceding dose and/or duration of benzodiazepine exposure.

Alpha2-agonist–related Iatrogenic Withdrawal Syndrome should be treated with IV and/or or enteral alpha2-agonist replacement therapy to attenuate symptoms, irrespective of preceding dose and/or duration of alpha2-agonist exposure.

We suggest use of a standardized protocol for sedation/analgesia weaning to decrease duration of sedation taper and attenuate emergence of Iatrogenic Withdrawal Syndrome.
Quality of Evidence: Low

We suggest facilitation of parental or caregiver presence in the PICU during routine care and interventional procedures to:
a) provide comfort to the child, 
b) decrease parental levels of stress and anxiety
c) increase level of satisfaction of care.
Quality of Evidence: Low

We suggest offering patients the use of noise reducing devices such as ear plugs or headphones to reduce the impact of non-modifiable ambient noise.
Quality of Evidence: Low

We suggest that PICU teams make environmental and/or behavioral changes to reduce excessive noise and therefore improve sleep hygiene and comfort in critically ill pediatric patients.
Quality of Evidence: Low

We suggest performing early mobility to minimize the effects of immobility in critically ill pediatric patients.
Quality of Evidence: Low

We suggest the use of a standardized early mobility protocol that outlines readiness criteria, contraindications, developmentally appropriate mobility activities and goals, and safety thresholds guided by the multidisciplinary team and family decision-making.
Quality of Evidence: Low

Heidi A.B. Smith, MD, MSCI
Heidi A.B. Smith, MD, MSCI
Heidi A.B. Smith, MD, MSCI, is an Associate Professor Anesthesiology & Pediatrics at Monroe Carell Jr. Children's Hospital at Vanderbilt in Tennessee. She served as co-chair for the committee that developed the PANDEM guidelines for infants and children. 
John W. Berkenbosch, MD, FAAP, FCCM
John W. Berkenbosch, MD, FAAP, FCCM
John W. Berkenbosch, MD, FCCM, is a Professor of Pediatrics/Pediatric Critical Care at Norton Children's Hospital in Louisville, Kentucky. He served as co-chair for the committee that developed the PANDEM guidelines for infants and children. 

A complete list of the guidelines authors and contributors is available within the published manuscript.