Monitoring sedation in the critically ill child

Abstract

SummarySedation is an essential part of the management of the critically ill child, and its monitoring must be individualised and continuous in order to adjust drug doses according to the clinical state. There is no ideal method for evaluating sedation in the critically ill child. Haemodynamic variables have not been found to be useful. Clinical scales are useful when sedation is moderate, but are limited by their subjective nature, the use of stimuli, and the impossibility of evaluating profoundly sedated patients or those receiving neuromuscular blocking drugs; in addition, many of these scales have not been evaluated in children. The COMFORT scale is the most appropriate, as it was designed and validated for critically ill children requiring mechanical ventilation. Electroencephalography‐derived methods permit continuous monitoring, provide an early indication of changes in the level of sedation, and facilitate a rapid adjustment of medication. However, these methods were designed and validated for patients under anaesthesia and their results cannot be fully extrapolated to the critically ill patient; in addition, some of them have not been validated in small children and there is still little experience in critically ill children. The main indications for the use of these methods are in patients with deep sedation and/or neuromuscular blockade. The bispectral index is the most widely used method at the present time. Analysis and comparison of the efficacy of the different methods for evaluating sedation in the critically ill child is required.

A review of the utility of EEG depth of anaesthesia monitors in the paediatric intensive care environment

“…To date, the most comprehensive review examining the uses and limitations of BIS, MLAEP, and several clinical sedation scoring systems to evaluate PIC sedation was conducted by Lamas and Lopez-Herce (2010). Whilst only briefly mentioning the methods used in their review, Lamas and LopezHerce (2010) conclude that there is currently no ideal mode to assess sedation for PIC patients.…”

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

“…Most of the systematic reviews studying these scales showed that evaluation of pain and sedation in the paediatric ICU patient population is challenging (De Jonghe et al, 2000;Harris et al, 2016;Hartman et al, 2009;Vet et al, 2013). Lamas and López-Herce (2010) indicated that the CS is adequate to evaluate sedation in critically ill children requiring mechanical ventilation. However, no review has used one psychometric analysis scoring system to evaluate all the sedation scales in an integrated and thorough approach.…”

Sedação da criança submetida à ventilação pulmonar mecânica: estamos avançando

“…Differentiating between sedation and analgesia is thus very difficult in young children. (3) However, there is a consensus that sedation and analgesia are essential for the comfort and safety of MV patients. Indeed, sedation and analgesia are proven to reduce MV-associated discomfort, which in turn reduces the use of oxygen, modulates the response to stress intensity, reduces the risk of injury associated with agitation and the displacement of invasive devices, and therefore promotes a patient's safety and facilitates bedside care.…”

“…To date, no optimal general method to assess sedation in critically ill children is available. (3) Scoring systems, such as the COMFORT system, have only been validated for severely ill MV children, (3) and these systems are useful mainly in children requiring moderate sedation/analgesia. (3) Moreover, little clinical experience is currently available for electroencephalogram (EEG) derived methods, such as the 'bispectral index' (BIS), and these methods have been validated only for anesthetized patients.…”

“…(3) Scoring systems, such as the COMFORT system, have only been validated for severely ill MV children, (3) and these systems are useful mainly in children requiring moderate sedation/analgesia. (3) Moreover, little clinical experience is currently available for electroencephalogram (EEG) derived methods, such as the 'bispectral index' (BIS), and these methods have been validated only for anesthetized patients. (3) Although analgesic/sedative medications are widely prescribed drugs, (14) in contrast to their use in adult patients, few protocols and guidelines for their use have been published in Pediatrics, (5,15) and only scarce data are available regarding the dosages, safety and efficacy of these drugs and their combinations.…”