Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit

Abstract

Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.

Quality of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal in pediatric intensive care: a systematic review protocol

“…Critically ill children in the paediatric intensive care unit (PICU), particularly those who are mechanically ventilated, require adequate identification and treatment of pain, sedation, delirium and iatrogenic withdrawal. 1 Healthcare professionals (HCPs) manage this with the use of analgesics and sedatives, often in combination, with 65% of children receiving both. 2 Optimal titration of analgesics and sedatives prevent pain, delirium and iatrogenic withdrawal, 3 4 as well as agitation that can cause accidental extubation.…”

“… 5 Over sedation and analgesia can result in prolonged mechanical ventilation, increased PICU length of stay, morbidity and mortality. 1 In the PICU setting, 40%–65% of children are unable to self-report due to mechanical ventilation and young age (under the age of 4). 6 7 Given the large proportion of non-communicative children and the need for quality care, it is crucial that HCPs use multiple measurement instruments to assess pain, sedation, delirium and iatrogenic withdrawal.…”

“… 8 It helps HCPs to individualise treatment and plan appropriate multimodal interventions. 1 Although, HCPs have access to several measurement instruments for assessing pain and sedation, 9 and more recently, for delirium and iatrogenic withdrawal. 10 A recent survey including 168 PICUs in 18 countries, found wide variation in the application of measurement instruments across the four conditions into practice.…”

“…Optimal titration of analgesics and sedatives prevent pain, delirium and iatrogenic withdrawal,3 4 as well as agitation that can cause accidental extubation 5. Over sedation and analgesia can result in prolonged mechanical ventilation, increased PICU length of stay, morbidity and mortality 1. In the PICU setting, 40%–65% of children are unable to self-report due to mechanical ventilation and young age (under the age of 4) 6 7.…”

Pain and sedation management and monitoring in pediatric intensive care units across Europe: an ESPNIC survey

“…Providing pain relief and sedation to ensure optimal comfort and avoid complications is a challenging balancing act for healthcare providers. The difficulties are related to a wide range of developmental ages in critically ill children, the inability to communicate, the complexity of the clinical status, and the highly variable pharmacodynamics and pharmacokinetics metabolisms [ 2 ]. The goal is to keep the child pain-free but sufficiently awake for optimal recovery.…”