Importance of the use of protocols for the management of analgesia and sedation in pediatric intensive care unit

Abstract

Summary Introduction: Analgesia and sedation are essential elements in patient care in the intensive care unit (ICU), in order to promote the control of pain, anxiety and agitation, prevent the loss of devices, accidental extubation, and improve the synchrony of the patient with mechanical ventilation. However, excess of these medications leads to rise in morbidity and mortality. The ideal management will depend on the adoption of clinical and pharmacological measures, guided by scales and protocols. Objective: Literature review on the main aspects of analgesia and sedation, abstinence syndrome, and delirium in the pediatric intensive care unit, in order to show the importance of the use of protocols on the management of critically ill patients. Method: Articles published in the past 16 years on PubMed, Lilacs, and the Cochrane Library, with the terms analgesia, sedation, abstinence syndrome, mild sedation, daily interruption, and intensive care unit. Results: Seventy-six articles considered relevant were selected to describe the importance of using a protocol of sedation and analgesia. They recommended mild sedation and the use of assessment scales, daily interruptions, and spontaneous breathing test. These measures shorten the time of mechanical ventilation, as well as length of hospital stay, and help to control abstinence and delirium, without increasing the risk of morbidity and morbidity. Conclusion: Despite the lack of controlled and randomized clinical trials in the pediatric setting, the use of protocols, optimizing mild sedation, leads to decreased morbidity.

Sedación y analgesia en pacientes con asistencia ventilatoria mecánica en unidades de cuidados intensivos pediátricos de Argentina

“…El síndrome de abstinencia (SA) tuvo una prevalencia del 34-70% en pacientes con sedoanalgesia. 26 Se asoció a un aumento de la morbilidad, duración de la estancia hospitalaria y alteraciones psicológicas. El uso de metadona y/o dexmedetomidina para facilitar el destete de opioides en infusión continua ocupó un lugar preponderante en nuestro trabajo.…”

Considerations for pediatric burn sedation and analgesia

“…Initially, anxiety should be allayed with attempts to normalize the child’s surroundings with non-pharmacologic interventions. Communication, continuous reorientation, reassurance, and the presence of relatives at the bedside can allay anxiety, while environmental factors such as noise reduction, utilization of adequately lighting to promote an adequate sleep awake cycle, promoting time to rest and sleep to maintain a circadian orientation, restricting procedures to daytime, keeping the patient in a comfortable position using cushions, and attention to fluids and feeding may improve comfort [ 16 – 18 ]. Non-pharmacologic interventions to reduce stress, such as live or recorded music, have primarily been studied in adults, but make sense for children as well [ 16 ].…”

“…Non-pharmacologic interventions continue to have importance in the care of the burned child, but frequently are inadequate to fully treat pain and anxiety. Analgesia and sedation are essential elements in patient care in the ICU to control pain, anxiety, and agitation; prevent the loss of devices or accidental extubation; and improve the synchrony of the patient with mechanical ventilation [ 16 , 18 , 19 ]. The ideal sedative agent should have rapid onset, short duration of action, minimal active metabolites, few side effects, predictable pharmacokinetics (PK), and cost-effectiveness [ 1 , 20 ].…”

Delirio en niños críticamente enfermos

“…De ellos se ha documentado una asociación estadísticamente significativa con el uso de inotrópicos > 12 horas, inhibidores de colinesterasa, anti-colinérgicos, anti-psicóticos, antidepresivos y dosis de fentanyl > 10 mcg/kg que aumenta el riesgo de delirio en 3.4 veces (56). Las benzodiacepinas, especialmente en infusión, provocan un aumento en el riesgo de delirio dependiente de la dosis (57,58,59). También se han encontrado asociaciones con el uso de corticosteroides aunque estos hallazgos han sido inconsistentes (49).Los factores ambientales tales como la falta de luz del día, las alteraciones del ciclo circadiano, el nivel del sonido de la UCI y las interrupciones del sueño se asocian igualmente con riesgo de delirio (20, 24, 26, 60-64).P u b l i c a c i ó n a n t i c i p a d a .…”