Abstract

Background. Pain and sedation management is an integral part of pediatric intensive care practice. Sedoanalgesia management must be balanced in order to optimize comfort and avoid complications. In order to achieve this balance, sedoanalgesia management needs to be clarified in pediatric intensive care units (PICU). With this study, we aimed to investigate sedation, analgesia, withdrawal and delirium practices, pharmacologic agent preferences, and current experiences and practices in scoring systems in PICUs in Türkiye.

Method. A questionnaire consisting of 57 questions was sent via e-mail to the ‘Pediatric Intensive Care and Emergency’ group, which includes all intensive care specialists, subspecialty students and lecturers in Türkiye.

Results. Our study involved 36 pediatric intensive care physicians working in PICUs in Türkiye. Among the PICU specialists who participated in the study, 83.3% stated that they performed routine assessments of sedation efficacy. While dexmedetomidine was the most commonly used sedative agent in patients undergoing noninvasive mechanical ventilation, benzodiazepines were the most preferred pharmacologic agent for sedation during mechanical ventilation. Of the pediatric intensivists who participated in the study, 94.4% stated that they performed routine pain assessments in their units. Of the PICU specialists who participated in the study, 69.4% stated that muscle relaxants were most commonly used to prevent patient-ventilator incompatibility during mechanical ventilation. Of the participants, 88.8% made withdrawal assessments when discontinuing sedo-analgesic agents. Delirium assessment was routinely performed by 58.3% of the participants.

Conclusions. This study showed that the practices in sedoanalgesia management in PICUs in Türkiye are in parallel with recommendations of the sedation guideline. Despite the increased sensitivity in sedoanalgesia management, awareness in the management of delirium and withdrawal syndrome is not at the desired level. Therefore, there is a need to develop guidelines, raise awareness and increase training on these issues in our Türkiye.

Keywords: pediatric intensive care, sedation, analgesia

Copyright and license

Copyright © 2024 The Author(s). This is an open access article distributed under the Creative Commons Attribution License (CC BY), which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is properly cited.

How to cite

1.
Koçkuzu E, Korulmaz A, Altuğ Ü, Bozan G, Yıldızdaş D. Sedation - analgesia - muscle relaxant - withdrawal and delirium practices in pediatric intensive care units in Türkiye. Turk J Pediatr 2024; 66: 556-566. https://doi.org/10.24953/turkjpediatr.2024.4830

References

  1. Karapınar B. Mekanik ventilasyon sırasında sedasyon. Karaböcüoğlu M, editor. Pediatrik Mekanik Ventilasyon. Çağdaş Medikal Kitabevi, Çapa Tıp Kitabevi; 2003: 211-225.
  2. Ista E, van Dijk M, Gamel C, Tibboel D, de Hoog M. Withdrawal symptoms in critically ill children after long-term administration of sedatives and/or analgesics: a first evaluation. Crit Care Med 2008; 36: 2427-2432. https://doi.org/10.1097/CCM.0b013e318181600d
  3. Choong K. Picu-acquired complications: the new marker of the quality of care. ICU Manag Pract 2019; 19: 85-88.
  4. Smith HAB, Besunder JB, Betters KA, et al. 2022 Society of Critical Care Medicine clinical practice guidelines on prevention and management of pain, agitation, neuromuscular blockade, and delirium in critically ill pediatric patients with consideration of the ICU environment and early mobility. Pediatr Crit Care Med 2022; 23: e74-e110. https://doi.org/10.1097/PCC.0000000000002873
  5. Mondardini MC, Sperotto F, Daverio M, Amigoni A. Analgesia and sedation in critically ill pediatric patients: an update from the recent guidelines and point of view. Eur J Pediatr 2023; 182: 2013-2026. https://doi.org/10.1007/s00431-023-04905-5
  6. Vet NJ, Kleiber N, Ista E, de Hoog M, de Wildt SN. Sedation in critically ill children with respiratory failure. Front Pediatr 2016; 4: 89. https://doi.org/10.3389/fped.2016.00089
  7. Deeter KH, King MA, Ridling D, Irby GL, Lynn AM, Zimmerman JJ. Successful implementation of a pediatric sedation protocol for mechanically ventilated patients. Crit Care Med 2011; 39: 683-688. https://doi.org/10.1097/CCM.0b013e318206cebf
  8. Ista E, de Hoog M, Tibboel D, van Dijk M. Implementation of standard sedation management in paediatric intensive care: effective and feasible? J Clin Nurs 2009; 18: 2511-2520. https://doi.org/10.1111/j.1365-2702.2009.02836.x
  9. Gaillard-Le Roux B, Liet JM, Bourgoin P, Legrand A, Roze JC, Joram N. Implementation of a nurse-driven sedation protocol in a PICU decreases daily doses of midazolam. Pediatr Crit Care Med 2017; 18: e9-e17. https://doi.org/10.1097/PCC.0000000000000998
  10. Neunhoeffer F, Kumpf M, Renk H, et al. Nurse-driven pediatric analgesia and sedation protocol reduces withdrawal symptoms in critically ill medical pediatric patients. Paediatr Anaesth 2015; 25: 786-794. https://doi.org/10.1111/pan.12649
  11. Blackwood B, Tume LN, Morris KP, et al. Effect of a sedation and ventilator liberation protocol vs usual care on duration of invasive mechanical ventilation in pediatric intensive care units: a randomized clinical trial. JAMA 2021; 326: 401-410. https://doi.org/10.1001/jama.2021.10296
  12. Curley MAQ, Wypij D, Watson RS, et al. Protocolized sedation vs usual care in pediatric patients mechanically ventilated for acute respiratory failure: a randomized clinical trial. JAMA 2015; 313: 379-389. https://doi.org/10.1001/jama.2014.18399
  13. Daverio M, von Borell F, Ramelet AS, et al. Pain and sedation management and monitoring in pediatric intensive care units across Europe: an ESPNIC survey. Crit Care 2022; 26: 88. https://doi.org/10.1186/s13054-022-03957-7
  14. Twite MD, Rashid A, Zuk J, Friesen RH. Sedation, analgesia, and neuromuscular blockade in the pediatric intensive care unit: survey of fellowship training programs. Pediatr Crit Care Med 2004; 5: 521-532. https://doi.org/10.1097/01.PCC.0000144710.13710.2E
  15. Ekinci F, Yildizdas D, Horoz OO, Aslan N; Society of Pediatric Emergency Intensive Care Medicine of Turkey-Sedoanalgesia Study Group. Sedation and analgesia practices in pediatric intensive care units: a survey of 27 centers from Turkey. J Pediatr Intensive Care 2020; 10: 289-297. https://doi.org/10.1055/s-0040-1716886
  16. Rhoney DH, Murry KR. National survey on the use of sedatives and neuromuscular blocking agents in the pediatric intensive care unit. Pediatr Crit Care Med 2002; 3: 129-133. https://doi.org/10.1097/00130478-200204000-00007
  17. Playfor SD, Thomas DA, Choonara I. Sedation and neuromuscular blockade in paediatric intensive care: a review of current practice in the UK. Paediatr Anaesth 2003; 13: 147-151. https://doi.org/10.1046/j.1460-9592.2003.00989.x
  18. Long D, Horn D, Keogh S. A survey of sedation assessment and management in Australian and New Zealand paediatric intensive care patients requiring prolonged mechanical ventilation. Aust Crit Care 2005; 18: 152-157. https://doi.org/10.1016/s1036-7314(05)80028-1
  19. Tessari A, Sperotto F, Pece F, et al. Is ketamine infusion effective and safe as an adjuvant of sedation in the PICU? Results from the Ketamine Infusion Sedation Study (KISS). Pharmacotherapy 2023; 43: 622-631. https://doi.org/10.1002/phar.2754
  20. Heiberger AL, Ngorsuraches S, Olgun G, et al. Safety and utility of continuous ketamine infusion for sedation in mechanically ventilated pediatric patients. J Pediatr Pharmacol Ther 2018; 23: 447-454. https://doi.org/10.5863/1551-6776-23.6.447
  21. Fagin A, Palmieri T, Greenhalgh D, Sen S. A comparison of dexmedetomidine and midazolam for sedation in severe pediatric burn injury. J Burn Care Res 2012; 33: 759-763. https://doi.org/10.1097/BCR.0b013e318254d48e
  22. Tobias JD, Berkenbosch JW. Sedation during mechanical ventilation in infants and children: dexmedetomidine versus midazolam. South Med J 2004; 97: 451-455. https://doi.org/10.1097/00007611-200405000-00007
  23. Grant MJC, Schneider JB, Asaro LA, et al. Dexmedetomidine use in critically ill children with acute respiratory failure. Pediatr Crit Care Med 2016; 17: 1131-1141. https://doi.org/10.1097/PCC.0000000000000941
  24. Ghimire LV, Chou FS. Efficacy of prophylactic dexmedetomidine in preventing postoperative junctional ectopic tachycardia in pediatric cardiac surgery patients: a systematic review and meta-analysis. Paediatr Anaesth 2018; 28: 597-606. https://doi.org/10.1111/pan.13405
  25. Mody K, Kaur S, Mauer EA, et al. Benzodiazepines and development of delirium in critically ill children: estimating the causal effect. Crit Care Med 2018; 46: 1486-1491. https://doi.org/10.1097/CCM.0000000000003194
  26. Taffarel P, Bonetto G, Jorro Barón F, Meregalli C. Sedation and analgesia in patients on mechanical ventilation in pediatric intensive care units in Argentina. Arch Argent Pediatr 2018; 116: e196-e203. https://doi.org/10.5546/aap.2018.eng.e196
  27. Koizumi T, Kurosawa H. Survey of analgesia and sedation in pediatric intensive care units in Japan. Pediatr Int 2020; 62: 535-541. https://doi.org/10.1111/ped.14139
  28. Garcia Guerra G, Joffe AR, Cave D, et al. Survey of sedation and analgesia practice among Canadian pediatric critical care physicians. Pediatr Crit Care Med 2016; 17: 823-830. https://doi.org/10.1097/PCC.0000000000000864
  29. Srinivasan M, Bhaskar S, Carlson DW. Variation in procedural sedation practices among children’s hospitals. Hosp Pediatr 2015; 5: 148-153. https://doi.org/10.1542/hpeds.2014-0090
  30. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342: 1471-1477. https://doi.org/10.1056/NEJM200005183422002
  31. Gupta K, Gupta VK, Jayashree M, Singhi S. Randomized controlled trial of interrupted versus continuous sedative infusions in ventilated children. Pediatr Crit Care Med 2012; 13: 131-135. https://doi.org/10.1097/PCC.0b013e31820aba48
  32. Bannister CF, Brosius KK, Sigl JC, Meyer BJ, Sebel PS. The effect of bispectral index monitoring on anesthetic use and recovery in children anesthetized with sevoflurane in nitrous oxide. Anesth Analg 2001; 92: 877-881. https://doi.org/10.1097/00000539-200104000-00015
  33. Berkenbosch JW, Fichter CR, Tobias JD. The correlation of the bispectral index monitor with clinical sedation scores during mechanical ventilation in the pediatric intensive care unit. Anesth Analg 2002; 94: 506-11; table of contents. https://doi.org/10.1097/00000539-200203000-00006
  34. Traube C, Mauer EA, Gerber LM, et al. Cost associated with pediatric delirium in the ICU. Crit Care Med 2016; 44: e1175-e1179. https://doi.org/10.1097/CCM.0000000000002004
  35. Kudchadkar SR, Yaster M, Punjabi NM. Sedation, sleep promotion, and delirium screening practices in the care of mechanically ventilated children: a wake-up call for the pediatric critical care community. Crit Care Med 2014; 42: 1592-1600. https://doi.org/10.1097/CCM.0000000000000326
  36. Best KM, Boullata JI, Curley MAQ. Risk factors associated with iatrogenic opioid and benzodiazepine withdrawal in critically ill pediatric patients: a systematic review and conceptual model. Pediatr Crit Care Med 2015; 16: 175-183. https://doi.org/10.1097/PCC.0000000000000306
  37. Harris J, Ramelet AS, van Dijk M, et al. Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals. Intensive Care Med 2016; 42: 972-986. https://doi.org/10.1007/s00134-016-4344-1
  38. Ávila-Alzate JA, Gómez-Salgado J, Romero-Martín M, Martínez-Isasi S, Navarro-Abal Y, Fernández-García D. Assessment and treatment of the withdrawal syndrome in paediatric intensive care units: systematic review. Medicine (Baltimore) 2020; 99: e18502. https://doi.org/10.1097/MD.0000000000018502