Sedation protocols in the pediatric intensive care unit: fact or fiction?

Abstract

Comfort of the critically unwell pediatric patient is paramount to ensuring good outcomes.Analgesia-based, multimodal sedative approaches are the foundation for comfort, whereby pain is addressed first and then sedation titrated to a predefined target based on the goals of care. Given the heterogeneity of patients within the pediatric critical care population, the approach must be individualized based on the age and developmental stage of the child, physiologic status, and degree of invasive treatment required. In both the adult and pediatric intensive care unit (PICU), sedation titration is practiced as standard of care to meet therapeutic goals with a focus on facilitating early rehabilitation and extubation while avoiding underand over-sedation. Sedation protocols have been developed as methods to reduce variability and optimize goal-directed therapy. Components of a sedation protocol include routine analgesia and sedation scoring with validated tools at specified intervals and a predefined algorithm that allows the titration of analgesia and sedation based on those assessments. Sedation protocols are designed to improve communication and documentation of sedation goals while also empowering the bedside team to respond rapidly to changes in a patient's clinical status. Previously it was thought that sedation protocols would consistently reduce duration of mechanical ventilation (MV) and length of stay (LOS) for patients in the PICU, however, this has not been the case. Nonetheless, introduction of sedation protocols has provided several benefits, including: (I) reduction in benzodiazepine usage; (II) improvements in interprofessional communication surrounding sedation goals and management of sedation goals; and (III) reductions in iatrogenic withdrawal symptoms.Successful implementation of sedation protocols requires passionate clinical champions and a robust implementation, education, and sustainability plan. Emerging evidence suggests that sedation protocols as part of a bundle of quality improvement initiatives will form the basis of future studies to improve short-and long-term outcomes after PICU discharge. In this review, we aim to define sedation protocols in the context of pediatric critical care and highlight important considerations for clinical practice and research.

Retracted Article: The Effects of Quran Recitation on Sedation and Pain in Children

“…1 Analgesia-based, multimodal sedative approaches are the foundation for comfort, whereby pain is addressed first and then sedation titrated to a predefined target based on the goals of care. 1…”

“…A great deal has been published on (1) standardizing measures of comfort; (2) the best non-pharmacologic and pharmacologic therapies to use; (3) the best way to deliver these therapies; and (4) how to ensure quick and appropriate responses to changes in a patient's comfort level. 1 Analgesia-based, multimodal sedative approaches are the foundation for comfort, whereby pain is addressed first and then sedation titrated to a predefined target based on the goals of care. 1 Non-pharmacological interventions can reduce the total requirement and associated side effects of sedation and analgesia medications and have been recommended by international sedation guidelines in PICU.…”

“…1 Analgesia-based, multimodal sedative approaches are the foundation for comfort, whereby pain is addressed first and then sedation titrated to a predefined target based on the goals of care. 1 Non-pharmacological interventions can reduce the total requirement and associated side effects of sedation and analgesia medications and have been recommended by international sedation guidelines in PICU. 2 For example, use of musical intervention has beneficial effects on the level of sedation in children admitted to PICU.…”

Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like?

“…In a letter to the editor, Patak et al ( 87 ) wrote “Perhaps communication should be a vital sign,” noting the lack of standardized assessment and documentation of patient communication. For further development of pediatric ABCDEF-Bundles we propose following their suggestion and renaming bundle “C” for Communication ( 87 ), including necessary education and training protocols for staff ( 37 ), standardized systems for information and discussion with parents including informational packets in different languages and reliable access to translator services where needed, implementation and further development of age appropriate communication strategies and tools for intubated or otherwise impaired critically ill children and providing support and infrastructure for calls and video communication with siblings and friends who are unable to visit. Considering the relevant psychological impact any trauma or severe illness has on parents, siblings and other relatives, psychologists should be an integral part of any PICU-team.…”

“…While not all studies show a reduction in length of mechanical ventilation after implementation of sedation protocols, they do show a decrease in days with pain, withdrawal or delirium ( 35 , 36 ). Use of sedation protocols has been shown to help in reducing use of benzodiazepines, support the interdisciplinary communication in order to set and manage goals of sedation and to lessen the presentation of iatrogenic withdrawal symptoms ( 37 ).…”