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An international survey of management of pain and sedation after paediatric cardiac surgery.

ABSTRACT: Objective:The mainstay of pain treatment after paediatric cardiac surgery is the use of opioids. Current guidelines for its optimal use are based on small, non-randomised clinical trials, and data on the pharmacokinetics (PK) and pharmacodynamics (PD) of opioids are lacking. This study aims at providing an overview of international hospital practices on the treatment of pain and sedation after paediatric cardiac surgery. Design:A multicentre survey study assessed the management of pain and sedation in children aged 0-18 years after cardiac surgery. Setting:Pediatric intensive care units (PICU)of 19 tertiary children's hospitals worldwide were invited to participate. The focus of the survey was on type and dose of analgesic and sedative drugs and the tools used for their pharmacodynamic assessment. Results:Fifteen hospitals (response rate 79%) filled out the survey. Morphine was the primary analgesic in most hospitals, and its doses for continuous infusion ranged from 10 to 60 mcg kg-1 h-1 in children aged 0-36 months. Benzodiazepines were the first choice for sedation, with midazolam used in all study hospitals. Eight hospitals (53%) reported routine use of sedatives with pain treatment. Overall, type and dosing of analgesic and sedative drugs differed substantially between hospitals. All participating hospitals used validated pain and sedation assessment tools. Conclusion:There was a large variation in the type and dosing of drugs employed in the treatment of pain and sedation after paediatric cardiac surgery. As a consequence, there is a need to rationalise pain and sedation management for this vulnerable patient group.

SUBMITTER: Zeilmaker-Roest GA

PROVIDER: S-EPMC5862168 | biostudies-literature | 2017

REPOSITORIES: biostudies-literature

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An international survey of management of pain and sedation after paediatric cardiac surgery.

Zeilmaker-Roest Gerdien A GA Wildschut Enno D ED van Dijk Monique M Anderson Brian J BJ Breatnach Cormac C Bogers Ad J J C AJJC Tibboel Dick D

BMJ paediatrics open 20170705 1

<h4>Objective</h4>The mainstay of pain treatment after paediatric cardiac surgery is the use of opioids. Current guidelines for its optimal use are based on small, non-randomised clinical trials, and data on the pharmacokinetics (PK) and pharmacodynamics (PD) of opioids are lacking. This study aims at providing an overview of international hospital practices on the treatment of pain and sedation after paediatric cardiac surgery.<h4>Design</h4>A multicentre survey study assessed the management of ...[more]

PMID: 29637103

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Project description:Protective ventilation is associated with a lower incidence of pulmonary complications. However, there are few published data on routine pulmonary management in adult cardiac surgery. The present study's primary objective was to survey pulmonary management in this high-risk population, as practiced by anesthesiologists in France. All 460 registered France-based cardiac anesthesiologists were invited (by e-mail) to participate in an online survey in January-February 2015. The survey's questionnaire was designed to assess current practice in pre-, per-, and postoperative pulmonary management. In all, 198 anesthesiologists (43% of those invited) participated in the survey. Other than during the cardiopulmonary bypass (CPB) per se, 179 anesthesiologists (91% of respondees) [95% confidence interval (CI): 87-95] used a low-tidal-volume approach (6-8 mL/kg), whereas techniques based on positive end-expiratory pressure and recruitment maneuvers vary greatly from 1 anesthesiologist to another. During CPB, 104 (53%) [95% CI: 46-60] anesthesiologists withdrew mechanical ventilation (with disconnection, in some cases) and 97 (49%) [95% CI: 42-56] did not prescribe positive end-expiratory pressure. One hundred sixty-five (83%) [95% CI: 78-88] anesthesiologists stated that a written protocol for peroperative pulmonary management was not available. Twenty (10%) [95% CI: 6-14] and 11 (5%) [95% CI: 2-8] anesthesiologists stated that they did use protocols for ventilator use and recruitment maneuvers, respectively. The preoperative period (pulmonary examinations and prescription of additional assessments) and the postoperative period (extubation, and noninvasive ventilation) periods vary greatly from 1 anesthesiologist to another. The great majority of French cardiac anesthesiologists use a low tidal volume during cardiac surgery (other than during CPB per se). However, pulmonary management procedures varied markedly from 1 anesthesiologist to another. There is a clear need for large clinical studies designed to identify best practice in pulmonary management.

Project description:OBJECTIVE:Limited evidence exists on use of corticosteroids in low cardiac output syndrome following cardiac surgery. We sought to determine physicians' practices and beliefs with regard to corticosteroids therapy for low cardiac output syndrome. DESIGN:Multinational internet-based survey. SETTING:Pediatric Cardiac Intensive Care Society member database. SUBJECTS:Pediatric cardiac intensive care physicians. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:We received 188 responses from 85 centers throughout the world including 57 U.S. congenital heart centers, eight Canadian centers, and 20 international centers. The majority of respondents (51%) reported performing at least 200 bypass cases per year and had separate dedicated cardiac ICUs (57%). Most physicians (89%) rarely or never prescribe corticosteroids for mild low cardiac output syndrome (single vasoactive agent and mildly decreased perfusion), whereas 94% of those surveyed sometimes or always administer corticosteroids to patients with severe low cardiac output syndrome (two or more vasoactive agents and persistent hypotension). Hydrocortisone was the most commonly used corticosteroids (88%), but there was no consensus on dosage used. There was a variable approach to cortisol level measurement and cortisol stimulation testing to inform therapy with corticosteroids. A majority of respondents (75%) stated that they would be willing to randomize patients with severe low cardiac output syndrome into a trial of corticosteroids efficacy. CONCLUSIONS:Our survey demonstrates considerable practice variability with regard to the type of patients in whom corticosteroids are administered, adrenal axis testing is performed, and dosage of hydrocortisone used. The majority of physicians, however, stated their willingness to randomize patients with severe low cardiac output syndrome in a corticosteroids trial. This survey identified multiple areas for future research on use of corticosteroids for low cardiac output syndrome.

Dataset Information

An international survey of management of pain and sedation after paediatric cardiac surgery.

Publications

An international survey of management of pain and sedation after paediatric cardiac surgery.

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