Sedation In Pediatric Intensive Care Unit Research Articles

Sedation in pediatric intensive care unit and its impact on outcomes of ventilated children: a prospective observational study

BackgroundSedation is an integral part in the management of critical patients in the pediatric intensive care unit (PICU). Optimum sedation is when the child is asleep but easily arousable. The patient should be able to breathe synergistically with the ventilator and should tolerate or be compliant with other therapeutic procedures. Undersedation can make the children hypertensive, tachycardic, and agitated. Conversely, oversedation can cause increased tolerance and prolonged ventilation. Both undersedation and oversedation have negative impacts on patient outcomes such as prolonged mechanical ventilation and ICU stay and increased risk of contracting ventilator-associated pneumonia, thus contributing to significant morbidity and mortality. This study aims to assess sedation levels in ventilated children using RASS in the first 48hrs of ventilation and study their correlation with patient outcomes.ResultsOf the 111 children enrolled in the study, 2 were excluded because the sedation was discontinued before 48 h, and 9 were excluded because they were ventilated for more than 7 days. Majority of the children receiving ventilation in PICU were oversedated (40%). Adequately sedated children were observed to have significantly lesser duration of mechanical ventilation (p-value: 0.022) and PICU stay (p-value: 0.01). Undersedated children were noted to have significantly higher incidence of self extubation (p-value: < 0.001), reintubation (p-value: < 0.001), and higher requirement of restraints (p-value: < 0.001). Oversedated had a higher incidence of VAP and mortality (p-value: < 0.001).ConclusionThe findings of this study highlight the importance of achieving adequate sedation in PICU which is associated with better outcomes with respect to duration of ventilation, PICU stay, hospital stay, and mortality. This study also reflects the impact of absence of sedation protocols and emphasizes the need for monitoring of sedation and having protocols to guide clinical practice in order to improve patient outcome.

Outcomes Associated with a Pediatric Intensive Care Unit Sedation Weaning Protocol

Abstract Objective This article compares patient outcomes before and after implementation of a risk stratified pediatric sedation weaning protocol. Methods This observational cohort study, in a 30-bed tertiary care pediatric intensive care unit (PICU), included patients requiring opioid, benzodiazepine, and/or dexmedetomidine infusions. Outcomes (duration of wean, PICU length of stay [LOS], and Withdrawal Assessment Tool [WAT-1] scores) were collected by retrospective chart review for 12 months before and after protocol implementation. The influence of the protocol was assessed using an interrupted time series (ITS) analysis. Results There were 49 patients before and 47 patients after protocol implementation. Median opioid wean duration preprotocol was 10.5 days (interquartile range [IQR]: 4.25, 20.75) versus 9.0 days (IQR: 5.0, 16.75) postprotocol (p = 0.66). Median benzodiazepine wean duration was 11.5 days (IQR: 3.0, 19.8) preprotocol versus 5.0 days (IQR: 2.0, 13.5) postprotocol (p = 0.31). Median alpha-agonist wean duration was 7.0 days (IQR: 3.5, 17.0) preprotocol versus 3 days (IQR: 1.0, 14.0) postprotocol (p = 0.03). The ITS indicated a reduction in opioid wean by 6.7 days (p = 0.35), a reduction in benzodiazepine wean by 13.4 days (p = 0.12), and a reduction in alpha-agonist wean by 12.9 days (p = 0.06). WAT-1 scores &gt; 3 (12.6% preprotocol vs. 9.9% postprotocol, p = 0.569) and PICU LOS (16.0 days [IQR: 11.0, 26.0] vs. 17.0 days [IQR: 11.0, 26.5], p = 0.796) did not differ between groups. Conclusion Implementation of a risk stratified sedation weaning protocol in the PICU was associated with a significant reduction in alpha-agonist wean duration without a significant increase in withdrawal symptoms.

Validity and Reliability of the Richmond Agitation-Sedation Scale in Pediatric Intensive Care Patients: A Multicenter Study.

Background: There is limited data about the psychometric properties of the Richmond Agitation-Sedation Scale (RASS) in children. This study aims to analyze the validity and reliability of the RASS in assessing sedation and agitation in critically ill children.Methods: A multicenter prospective study in children admitted to pediatric intensive care, aged between 1 month and 18 years. Twenty-eight observers from 14 PICUs (pediatric intensive care units) participated. Every observation was assessed by 4 observers: 2 nurses and 2 pediatric intensivists. We analyzed RASS inter-rater reliability, construct validity by comparing RASS to the COMFORT behavior (COMFORT-B) scale and the numeric rating scale (NRS), and by its ability to distinguish between levels of sedation, and responsiveness to changes in sedative dose levels.Results: 139 episodes in 55 patients were analyzed, with a median age 3.6 years (interquartile range 0.7–7.8). Inter-rater reliability was excellent, weighted kappa (κw) 0.946 (95% CI, 0.93–0.96; p < 0.001). RASS correlation with COMFORT-B scale, rho = 0.935 (p < 0.001) and NRS, rho = 0.958 (p < 0.001) was excellent. The RASS scores were significantly different (p < 0.001) for the 3 sedation categories (over-sedation, optimum and under-sedation) of the COMFORT-B scale, with a good agreement between both scales, κw 0.827 (95% CI, 0.789–0.865; p < 0.001), κ 0.762 (95% CI, 0.713–0.811, p < 0.001). A significant change in RASS scores (p < 0.001) was recorded with the variance of sedative doses.Conclusions: The RASS showed good measurement properties in PICU, in terms of inter-rater reliability, construct validity, and responsiveness. These properties, including its ability to categorize the patients into deep sedation, moderate-light sedation, and agitation, makes the RASS a useful instrument for monitoring sedation in PICU.

Music Use for Sedation in Critically ill Children (MUSiCC trial): study protocol for a pilot randomized controlled trial

BackgroundStress induced by pain and anxiety is common in pediatric intensive care unit (PICU) patients. Sedation/analgesia in PICU is usually achieved through various analgesics and sedatives. Excessive use of these drugs can put patients at risk for hemodynamic/respiratory instability, prolonged ventilation, withdrawal, delirium, and critical illness polyneuromyopathy.The use of non-pharmacologic interventions has been recommended by sedation guidelines. However, non-pharmacological measures in PICU, including music and noise reduction, have been inadequately studied.MethodsThe Music Use for Sedation in Critically ill Children (MUSiCC trial) pilot study is an investigator-initiated, three-arm, randomized controlled trial (RCT) on the use of music for sedation in PICU. The main goal of the study is to demonstrate feasibility of a music trial in PICU and to obtain the necessary information to plan a larger trial. The study compares music versus noise cancelation versus control in sedated and mechanically ventilated children admitted to PICU. In the music group, children receive the music (modified classical music) three times a day for 30 min at a time. Music is delivered with noise cancelation headphones. The noise cancelation group receives the same intervention but with a no music (sham playlist). The control group receives usual care with no specific intervention. Children remain in the study until extubation or a maximum of 7 days. The primary outcomes of the study are feasibility and sedation/analgesia requirements. Secondary outcomes include change in vital signs before and during the intervention, ICU delirium, and adverse effects related to the intervention. The estimated sample size is 20 subjects per group for a total of 60 children.DiscussionDespite being recommended by current guidelines, evidence to support the use of music in PICU is lacking. Music has the potential to reduce sedation requirements and their negative side effects. This pilot RCT will demonstrate feasibility and provide the necessary information to plan a larger trial focusing on the effectiveness of the intervention.Trial registrationThe study was registered at ClinicalTrials.gov (NCT03497559) on April 13, 2018.

Randomized controlled comparative trial between low dose dexmedetomidine sedation and that of fentanyl in children after surgical procedures in surgical Pediatric Intensive Care Unit

BackgroundChildren undergoing different surgical procedures and requiring postoperative ventilation need intense analgesia and sedation. This was done using opioids and benzodiazepines with their common side effects as respiratory depression and prolonged sedation.Aim of the studyTo study the efficacy of sedation and time taken form stopping the infusion to extubation using low dose of dexmedetomidine compared with fentanyl sedation in post-operative Pediatric surgical Intensive Care Unit (PICU).Patients and MethodsA randomized double-blind study involving 50 children undergoing different surgical procedures was performed. The patients were equally divided into two groups, each including 25 patients. One group sedated with fentanyl at 1 μg/kg/h (Fen Group) and the other group sedated with dexmedetomidine at 0.3 μg/kg/h (Dex Group) for 18 h post-operatively with intermittent rescue fentanyl 0.5 μg/kg bolus in the 2 groups as required during endotracheal suctioning. The depth of sedation was assessed using the Ramsay sedation score, the tracheal suctioning score and pediatric intensive care unit sedation score. The time taken from discontinuation of infusion till extubation was recorded.ResultsAll sedation scores in the fentanyl and dexmedetomidine groups were comparable. Hemodynamic parameters were comparable between the two groups. Average time (in minutes) required for extubation after stopping the infusions was 136.2 (±54.2 SD) in the Dex group compared with 341.4 (±125.4 SD) in the Fen group. The difference in mean time for extubation was statistically significant. Conclusions: Low dose dexmedetomidine provides adequate sedation for mechanically ventilated children and also early extubation as compared with fentanyl.

Evidence of safety of chloral hydrate for prolonged sedation in PICU in a tertiary teaching hospital in southern Brazil

To evaluate the utilization of chloral hydrate (CH) for sedation in pediatric intensive care and the incidence of adverse drug reactions. This was a cohort study including patients with prescription of chloral hydrate hospitalized in the pediatric intensive care unit (PICU) of a university-affiliated, general, tertiary teaching hospital. Data were collected from a spreadsheet for daily monitoring, and clinical events registered in the patient records were analyzed to evaluate the causality of suspected adverse drug reactions (ADR), applying the Naranjo algorithm. Three hundred forty-three patients who had been prescribed CH were studied. Ages ranged from 0 to 18 years, and 63% were male. The most frequent cause for PICU admission was bronchiolitis (77.6%), and 58.6% required mechanical ventilation. In 92.7% of cases, CH was indicated to control agitation and in 7.3% for procedural sedation. The median time of CH use was 6 days. The incidence of suspected ADR was 22.7% ± 2.3. Oxygen desaturation was the most frequent adverse event (64.6%), followed by hypotension. Specific treatment was required in 60.9% of the events. Chloral hydrate as cause for suspected ADR was classified as probable in 39 events (35.5%) and as possible in 70 (63.6%), and no event was classified as definite. In the multivariate analysis, only mechanical ventilation was predictive of ADR to CH. The study described the clinical practice of sedation with CH in the PICU setting of a tertiary teaching hospital in southern Brazil. Data suggest that CH is an alternative for prolonged sedation in PICU

National survey on the use of sedatives and neuromuscular blocking agents in the pediatric intensive care unit.

OBJECTIVES: To describe the sedative and neuromuscular blocking agents (NMBA) that are currently used in pediatric intensive care units across the country and to assess the use of written protocols for their use, criteria used for selecting these agents, monitoring practices, and clinicians responsible for making therapeutic decisions in the pediatric intensive care units. DESIGN: A questionnaire was mailed to pediatric attending physician members of the Society of Critical Care Medicine practicing in the United States in January 1997. A cover letter was also enclosed that explained the purpose of the survey and asked the respondent to forward the questionnaire to a colleague if unable to complete. RESULTS: A total of 176 questionnaires were returned, which represented 145 pediatric institutions across the country, for a response rate of 51%. The agents reported to be used most often for sedation were the opioids and benzodiazepines, which were used for >72 hrs. The NMBA used were vecuronium and pancuronium, which were used for >48 hrs. Newer agents such as propofol and cisatracurium were being used by some clinicians as well. Respondents primarily use the intravenous route of administration as either intermittent bolus or continuous infusion. Frequently cited indications for sedatives were anxiety, fear, and amnesia and facilitation of intubation and maintenance of mechanical ventilation for NMBA. Only 13.4% indicated using written protocols for sedatives and 26.1% for NMBA. Decisions regarding the choice of agent were usually based on clinician preference and experience and the duration of action of the agent. Respondents most often reported using clinical assessment (57%) or the Glasgow Coma Scale (47.3%) to monitor the depth or adequacy of sedation. Over 80% of those surveyed use a peripheral nerve stimulator to monitor NMBA activity. CONCLUSION: Clinicians continue to use the opioids and benzodiazepines most often for sedation in the pediatric intensive care units, but newer agents are being used more often and warrant further investigation. The use of written protocols is very low, possibly because of the lack of guidelines in the literature on pediatric intensive care unit sedation and neuromuscular blockade. Development and implementation of protocols for the selection, use, and monitoring of sedatives and NMBA through a multidisciplinary team approach may be a beneficial way to provide safe and cost-effective therapy to critically ill pediatric patients.

The correlation of the bispectral index monitor with clinical sedation scores during mechanical ventilation in the pediatric intensive care unit.

In patients who are mechanically ventilated in the pediatric intensive care unit (PICU), sedative and/or analgesic medications are routinely provided and titrated to effect based on clinical assessment of the patient. The bispectral index (BIS) monitor uses a modified electroencephalogram to quantify the effects of central nervous system-acting drugs on the level of consciousness. To evaluate the usefulness of the BIS monitor to predict clinical sedation levels in the PICU, we compared BIS values with simultaneously obtained clinical sedation scores in 24 mechanically ventilated pediatric patients aged 5.7 plus minus 6.1 yr. For each sedation scale used, the BIS value correlated with increasing depth of sedation (P < 0.0001) and was independent of the drug(s) used for sedation. To differentiate adequate from inadequate sedation, a BIS value <70 had a sensitivity of 0.87--0.89 and a positive predictive value of 0.68--0.84. To differentiate adequate from excessive sedation, a BIS value <50 had a sensitivity of 0.67--0.75 and a positive predictive value of 0.07--0.52. We conclude that the BIS monitor may be a useful adjunct for the assessment of sedation in PICU patients. We demonstrate the usefulness of the bispectral index monitor for assessing sedation in pediatric intensive care unit patients. The bispectral index monitor correlated with clinically assessed sedation levels and was useful for differentiating adequate from inadequate sedation, which would be of value when the clinical examination is unavailable.