(746) Monitoring Continuous Neuromuscular Blockade Use Within a Pediatric ICU: A Quality Improvement Study

Introduction: Use of neuromuscular blockade (NMB) has been recently documented to increase survival in critically ill pediatric patients with acute respiratory distress syndrome. At our Level 1 trauma academic hospital, there was no established pediatric protocol for monitoring of patients who were placed on a NMB. Appropriate monitoring of NMB decreases potential adverse effects of patient awareness during paralysis, critical illness myopathy, and residual paralysis following cessation of blockade. As the use of NMB increases, our hospital sought to establish an improved process to monitor the level of NMB using train of four devices (TOF). The aim was to increase the percentage of pediatric patients with TOF monitoring while receiving continuous NMB from 5% to 75%, within 6-months.

Methods: Supported by a review of literature and the Society of Critical Care Medicine PANDEM Guidelines for Infants and Children, this quality improvement project instituted a policy and procedure for neurologic monitoring of PICU patients using TOF devices. Training curriculum and knowledge surveys were developed based on best evidence then distributed among pediatric critical care nurses and providers. Manual and observation audits were conducted to verify generated data reports. Use and understanding of TOF was gathered before and after training intervention.

Results: Before the training, TOF was only used in 5% of patients and may be less as participants were aware of the study during baseline data collection. After the intervention, TOF was monitored on majority of eligible patients during the 6-month period, as evidenced by increased documentation to 50% with a peak month of 100% (p=0.0263). Nurse training, provider discussions, equipment availability, and re-engaging staff to existing locations for documentation were essential components of implementation. There was a 10% decrease in prevalence of positive Cornell Assessment of Pediatric Delirium (CAPD) scores after training but was not statistically significant.

Conclusions: Despite various confounding factors associated with medication use, ventilator days, and ICU length of stay, focused training can lead to the implication of an institutional protocol for monitoring continuous NMB among critically ill pediatric patients.