Background Palliative Care in the Intensive Care Unit (ICU) is a new field, with significant advances being made in the past 15 years . These include the establishment of Compassionate Extubation (CE) guidelines, especially since the COVID-19 pandemic saw a surge in patients dying on a ventilator. Guidelines globally advocate for good and early communication, the use of opioids, benzodiazepines, and anticholinergic medications for symptom management, the discontinuation of non-comfort directed measures, and steroids to mitigate upper airway obstruction .

The majority of in-hospital pediatric deaths occur in the Pediatric ICU (PICU), with 70% following withdrawal/limitation of life-sustaining therapy . However, the available guidelines for CE in the PICU setting are limited. In a recent scoping review of Pediatric CE, only six studies were available with only 3 based in the PICU .

This study aimed to review the current landscape in Pediatric CE and identify gaps in care as well as recommendations for future research.

Methods A broad search using PubMed and Google Scholar to screen for existing guidelines on CE in the PICU was followed by consultation with regional and international experts in the field. Guidelines were chosen based on relevance to the aim of this study and individual guidelines were assessed and compared using the AGREE II tool.

Results Eleven guidelines were reviewed, with 7 excluded because they lacked specific recommendations for CE/symptom management. No guideline was of high quality globally, with the domain most lacking in quality being rigour of development. This was likely because evidence in Pediatrics is lacking, with significant extrapolation from the more established adult services. More studies are needed to assess symptom control after CE to guide management. An audit of cases using the protocols evaluated may also identify further room for quality improvement.