Implementation and evaluation of a paediatric nurse-driven sedation protocol in a paediatric intensive care unit

Abstract

BackgroundOptimal sedation and analgesia is a challenge in paediatric intensive care units (PICU) because of difficulties in scoring systems and specific metabolism inducing tolerance and withdrawal. Excessive sedation is associated with prolonged mechanical ventilation and hospitalisation. Adult and paediatric data suggest that goal-directed sedation algorithms reduce the duration of mechanical ventilation. We implemented a nurse-driven sedation protocol in a PICU and evaluated its impact.MethodsWe conducted a before and after protocol implementation study in a population of children aged 0–18 years who required mechanical ventilation for at least 24 h between January 2013 and March 2015. After the protocol implementation in January 2014, nurses managed analgesia and sedation following an algorithm that included the COMFORT behaviour scale (COMFORT-B). Duration of mechanical ventilation was the primary outcome; secondary outcomes were total doses and duration of medications, PICU length of stay, incidence of ventilator-associated pneumonia, and occurrence of withdrawal symptoms. Pre–post analysis followed with segmented regression analysis of interrupted time series was used to assess the effect of protocol.ResultsA total of 200 children were analysed, including 107 before implementation and 93 children after implementation of the protocol. After implementation of the protocol, the total number of COMFORT-B scores per day of mechanical ventilation significantly increased from 3.9 ± 2.5 times during the pre-implementation period to 6.6 ± 3.5 times during the post-implementation period (p < 10−3). Mean duration of mechanical ventilation tended to be lower in the post-implementation period (8.3 ± 7.3 vs 6.6 ± 5.6 days, p = 0.094), but changes in either the trend per trimester from pre-implementation to post-implementation (p = 0.933) or the immediate change after implementation (p = 0.923) were not significant with segmented regression analysis. No significant change between pre- and post-implementation was shown for total dose of sedatives, withdrawal symptoms, agitation episodes, or unplanned endotracheal extubations.ConclusionsThese results were promising and suggested that implementation of a nurse-driven sedation protocol in a PICU was feasible. Evaluation of sedation and analgesia was better after the protocol implementation; duration of mechanical ventilation and occurrence of withdrawal symptoms tended to be reduced.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-017-0256-7) contains supplementary material, which is available to authorized users.

Effectiveness of Protocolized Sedation Utilizing the COMFORT-B Scale in Mechanically Ventilated Children in a Pediatric Intensive Care Unit

“…According to the treatment protocol, the management guideline and treatment protocols varied which depended on the center. [14][15][16] We developed a well-structured design for treatment that consisted of a basic scheme, a decreasing scheme, and an increasing scheme. So, in terms of generalizability, this protocol can be applied and may have benefit in a developing unit.…”

Psychometric analysis of subjective sedation scales used for critically ill paediatric patients

“…Nolent et al's study showed that the CBS was the most frequently fully completed scale and seemed to be easier to use than other scales (Nolent et al, 2006). Dreyfus et al conducted one study in which nurses managed analgesia and sedation following an algorithm that included the CBS, and the results showed that the evaluation of sedation and analgesia was better after the protocol implementation of the CBS; the duration of mechanical ventilation and occurrence of withdrawal symptoms tended to be reduced (Dreyfus et al, 2017). The CBS may therefore currently be the best alternative to perform sedation assessment.…”

Comfort Behavior Scale Instrument: Validity And Reliability Test for Critically-ill Pediatric Patients in Indonesia

“…Conditions such as pain, inconvenience, disturbed sleep, anxiety, and fear can continuously affect the patients physically and psychologically. 1 , 2 Health workers, including the nurses working in PICUs, are responsible for minimizing the physical and psychological effects of pain on patients through sedation and analgesic administration. 1 …”

“…The administration of sedation and analgesics for critical patients can be very helpful, but their overuse can increase the need for mechanical ventilation and the length of stay. 1 , 2 Inadequate sedation can lead to agitation and cause unplanned extubation. 2 , 3 …”

“… 4 Effective analgesic and sedation management have been measured using objective sedation evaluations and validated instruments. 2 Results have shown that only 42% of PICUs regularly perform an objective sedation assessment. 5 The COMFORT Behavior Scale (CBS) is an instrument that has been validated in Portuguese, Swedish, Chinese, Norwegian, and Italian to assess the level of sedation and analyze distress in children who require mechanical ventilation or spontaneous breathing.…”