Levomepromazine for difficult sedation in pediatric intensive care

Sedation and analgesia using opioids and benzodiazepines is frequently required in critically ill children to minimize pain and anxiety. In some patients, difficult sedation occurs when tolerance or unacceptable side effects limit the efficacy of conventional analgo-sedative treatment. We describe seven patients (age range 1 to 17 yr) where difficult sedation was successfully managed with enteral levomepromazine (LMZ). LMZ is a neuroleptic antipsychotic agent that exhibits potent analgo-sedative properties without respiratory depression, through non-opioid and non-benzodiazepine pathways. We describe its use in our pediatric intensive care unit to control agitation in patients with known behavioral disorders who frequently pose a significant sedation challenge. We also illustrate its successful use in cases of withdrawal syndrome and delirium, and discuss the association of fever and its distinction from neuroleptic malignant syndrome in two patients. LMZ should be considered as a useful sedative in critically ill children where difficult sedation occurs and conventional agents are exhausted.