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An Exploratory Study of Sevoflurane as an Alternative for Difficult Sedation in Critically Ill Children
Santiago Mencía, Alba Palacios1, Miriam García
1Pediatric Intensive Care Unit, Department of Pediatrics, 12 de Octubre Hospital, Madrid, Spain.
Insights
Inhaled sevoflurane effectively sedated critically ill children when conventional drugs failed. This method, using the AnaConDa system, offers a viable option, though prolonged use may lead to withdrawal syndrome.
Area of Science:
- Pediatric Critical Care Medicine
- Anesthesiology
- Pharmacology
Background:
- Sedation in critically ill children is challenging.
- Conventional sedatives may be insufficient for some patients.
- Alternative sedative agents are needed for difficult-to-sedate pediatric patients.
Purpose of the Study:
- To evaluate the efficacy of inhaled sevoflurane for sedation in critically ill children.
- To assess the feasibility of using sevoflurane with the anesthetic conserving device (AnaConDa) in pediatric intensive care units (PICUs).
Main Methods:
- Prospective observational case series conducted in two Spanish PICUs.
- Inhaled sevoflurane administered via AnaConDa system connected to a Servo-I ventilator.
- Morphine infusion for analgesia; data on demographics, sedatives, and sedation scores collected.
Main Results:
- Twenty-three children (median age 6 months) received sevoflurane; 50% had critical heart disease.
- Sevoflurane use allowed discontinuation of other sedatives in 78% of patients within 48 hours.
- Median Bispectral Index Score decreased significantly after sevoflurane initiation (p < 0.05).
- Hypotension occurred in 30% of patients; withdrawal syndrome in 26% after prolonged use (≥6 days).
Conclusions:
- Inhaled sevoflurane is an effective sedative for critically ill, mechanically ventilated children with difficult-to-manage sedation.
- The AnaConDa system facilitates easy administration of sevoflurane in PICUs.
- Potential for withdrawal syndrome necessitates careful monitoring with prolonged sevoflurane treatment.
Objectives:
To analyze the effectiveness of inhaled sevoflurane in critically ill children with challenging sedation.
Design:
Prospective case series.
Setting:
Two PICUs of university hospitals in Spain.
Interventions:
Prospective observational study and exploratory investigation conducted in two PICUs in Madrid, Spain, over a 6-year period. Children treated with inhaled sevoflurane due to difficult sedation were included. Sevoflurane was administered via the anesthetic conserving device (AnaConDa) connected to a Servo-I ventilator (Maquet, Solna, Sweden). A morphine infusion was added to sevoflurane for analgesia. Demographic and clinical data, oral and IV sedatives, Sedation and Analgesic Clinical scores, and Bispectral Index Score monitoring were registered.
Measurements And Main Results:
Twenty-three patients with a median age of 6 months old were included. Fifty percentage of the patients had critical heart diseases. Sedative and analgesic drugs used before starting sevoflurane were mainly midazolam (63%) and fentanyl (53%). Six patients (32%) also received muscle relaxants. Sevoflurane was administered for a median of 5 days (interquartile range, 5.5-8.5 d). Median end-tidal sevoflurane concentration was 0.8% (interquartile range, 0.7-0.85%), achieved with an infusion rate of 7.5 mL/hr (5.7-8.6 mL/hr). After 48 hours of treatment, some sedative drugs could be removed in 18 patients (78%). Median Bispectral Index Score value prior to sevoflurane administration was 61 (interquartile range, 49-62), falling to 42 (interquartile range, 41-47; p < 0.05) after 6 hours of treatment. Six patients (26%) presented withdrawal syndrome after sevoflurane suspension, and all of them had received sevoflurane at least for 6 days. The main side effect was moderate hypotension in seven patients (30%).
Conclusions:
Inhaled sevoflurane appeared to be an effective sedative agent in critically ill children and can be useful in those patients on mechanical ventilation difficult to sedate with conventional drugs. It can be administered easily in the PICU with conventional ventilators using the AnaConDa system. Withdrawal syndrome may occur with prolonged treatment.
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