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Sedation Management for Critically Ill Children with Pre-Existing Cognitive Impairment
Kaitlin M Best1, Lisa A Asaro2, Martha A Q Curley3
1Department of Nursing, Respiratory Care and Neurodiagnostic Services, Children's Hospital of Philadelphia, Philadelphia, PA.
Insights
Critically ill children with cognitive impairment received less analgesia and sedation, but it is unclear if their needs are lower or assessment is inadequate. Development of specific pain and sedation assessment tools is recommended.
Area of Science:
- Pediatric Critical Care Medicine
- Neuroscience
- Pharmacology
Background:
- Pain and sedation management in critically ill children is crucial.
- Cognitive impairment may affect a child's ability to communicate pain or discomfort.
- Existing assessment tools may not be adequate for all pediatric intensive care unit (PICU) populations.
Purpose of the Study:
- To compare analgesia and sedation practices in critically ill children with and without cognitive impairment.
- To identify potential indicators of therapeutic efficacy in these groups.
- To inform the development of better assessment tools for vulnerable pediatric populations.
Main Methods:
- Secondary analysis of prospective data from the RESTORE clinical trial.
- Inclusion of 2449 children admitted to the PICU with mechanical ventilation for acute respiratory failure.
- Definition of cognitive impairment using the Pediatric Cerebral Performance Category (PCPC) ≥3, with regression analysis accounting for PICU clustering.
Main Results:
- 17% of subjects (412 children) had cognitive impairment; they were older and had more severe acute respiratory distress syndrome.
- Children with cognitive impairment received lower cumulative doses of opioids and benzodiazepines.
- Despite lower medication, they had more days awake/calm, fewer pain episodes, and less unplanned tube removal, but more iatrogenic withdrawal symptoms.
Conclusions:
- Critically ill children with cognitive impairment received less analgesia/sedation.
- It remains unclear if this reflects lower requirements or inadequate assessment due to a lack of validated tools.
- Development of specific pain and sedation assessment tools for this population is recommended.
Objective:
To compare current analgesia and sedation management practices between critically ill children with pre-existing cognitive impairment and critically ill neurotypical children, including possible indicators of therapeutic efficacy.
Study Design:
This study used secondary analysis of prospective data from the RESTORE clinical trial, with 2449 children admitted to the pediatric intensive care unit and receiving mechanical ventilation for acute respiratory failure. Subjects with a baseline Pediatric Cerebral Performance Category ≥3 were defined as subjects with cognitive impairment, and differences between groups were explored using regression methods accounting for pediatric intensive care unit as a cluster variable.
Results:
This study identified 412 subjects (17%) with cognitive impairment. Compared with neurotypical subjects, subjects with cognitive impairment were older (median, years, 6.2 vs 1.4; P < .001) with more severe pediatric acute respiratory distress syndrome (40% vs 33%; P = .009). They received significantly lower cumulative doses of opioids (median, mg/kg, 14.2 vs 16.2; P < .001) and benzodiazepines (10.6 vs 14.4; P < .001). Three nonverbal subjects with cognitive impairment received no analgesia or sedation. Subjects with cognitive impairment were assessed as having more study days awake and calm and fewer study days with an episode of pain. They were less likely to be assessed as having inadequate pain/sedation management or unplanned endotracheal/invasive tube removal. Subjects with cognitive impairment had more documented iatrogenic withdrawal symptoms than neurotypical subjects.
Conclusions:
Subjects with cognitive impairment in this study received less medication, but it is unclear whether they have authentically lower analgesic and/or sedative requirements or are vulnerable to inadequate assessment of discomfort because of the lack of validated assessment tools. We recommend the development of pain and sedation assessment tools specific to this patient population.
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