Sedation, Sleep Promotion, and Delirium Screening Practices in the Care of Mechanically Ventilated Children

Abstract

Objective To examine pediatric intensivist sedation management, sleep promotion, and delirium screening practices for intubated and mechanically ventilated children. Design An international, online survey of questions regarding sedative and analgesic medication choices and availability, sedation protocols, sleep optimization, and delirium recognition and treatment. Setting Member societies of the World Federation of Pediatric Intensive and Critical Care Societies were asked to send the survey to their mailing lists; responses were collected from July 2012 to January 2013. Interventions Survey Measurements and Main Results The survey was completed by 341 respondents, the majority of whom were from North America (70%). Twenty-seven percent of respondents reported having written sedation protocols. Most respondents worked in pediatric intensive care units (PICUs) with sedation scoring systems (70%), although only 42% of those with access to scoring systems reported routine daily use for goal-directed sedation management. The State Behavioral Scale was the most commonly used scoring system in North America (22%), with the COMFORT score more prevalent in all other countries (39%). The most commonly used sedation regimen for intubated children was a combination of opioid and benzodiazepine (72%). Most intensivists chose fentanyl as their first-line opioid (66%) and midazolam as their first-line benzodiazepine (86%), and prefer to administer these medications as continuous infusions. Propofol and dexmedetomidine were the most commonly restricted medications in PICUs internationally. Use of earplugs, eye masks, noise reduction, and lighting optimization for sleep promotion was uncommon. Delirium screening was not practiced in 71% of respondent’s PICUs, and only 2% reported routine screening at least twice a day. Conclusions The results highlight the heterogeneity in sedation practices among intensivists who care for critically ill children, as well as a paucity of sleep promotion and delirium screening in PICUs worldwide.

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

“…9,10,21 Fentanyl is the most used opioid, being used by 66% of the intensive care physicians, as shown by Kudchadkar SR et al, 26 due to a lower incidence of side effects when compared to morphine. 21,26 Management of sedation/agitation Patients admitted to intensive care units present some degree of discomfort, physical or psychic distress, sometimes requiring the use of sedatives, especially those in mechanical ventilation. Reaching optimal/mild sedation is ideal, avoiding oversedation or subdoses, each with its own adverse reactions.…”

“…3 The use of sedation scales is yet difficult to implement in ICUs, with a study by Hudchadkar et al showing that scales are routinely used in only 42% of the American pediatric ICUs. 21 Nevertheless, its use is recommended as an attempt to reduce the duration of mechanical ventilation, length of ICU and hospital stay. 2,22,23,27 In pediatrics, in 1992, Ambuel et al developed a method to evaluate sedation in ventilated patients, the COMFORT scale, which aggregates six behavioral and two physiological parameters.…”

Nurses Perceptions of Pediatric Intensive Care Unit Environment and Work Experience After Transition to Single-Patient Rooms

“…However, current evidence suggests that most PICUs internationally do not have either noise or light optimization protocols in place for sleep promotion. 26 Another important issue raised by the questionnaire was the struggle between optimizing patient safety and promoting sleep. Dimming lights in the rooms of the most critically ill children may not be feasible because staff need to make continual visual assessments of the patients and provide frequent care.…”

“…15,25 Most PICUs internationally have a layout with multipatient rooms, which, although convenient for the workflow of daily patient care, may not be conducive for sleep continuity or the preservation of circadian rhythm. 26 Since the 1990s, hospital designs have been shifting from multipatient to single-patient room configurations. In acute care, compared with multipatient rooms, single-patient rooms are associated with lower rates of medical errors, increased control of room light and temperature, lower sound levels, and even decreased prevalence of delirium.…”

Delirium in Children: Identification, Prevention, and Management

“…8,29,30 Inadequate sleep quality and duration, often experienced by patients in the ICU, are associated with the development of delirium. 30,31 However, in a survey 8 of 341 pediatric nurse and physician members of the World Federation of Pediatric Intensive and Consider room location and modify as tolerated:…”