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Daily Sedation Interruption vs Continuous Sedation in Pediatric Patients Receiving Mechanical Ventilation: A

Theresa Shu Wen Toh¹, Pravin R R², Karen Hwee Ying Ho¹

¹Department of Pediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore.

JAMA Network Open

|August 7, 2024

Insights

Daily sedation interruption (DSI) in critically ill pediatric patients significantly reduced length of stay in the pediatric intensive care unit (PICU) without increasing adverse events. This sedation strategy shows promise for improving patient outcomes.

Area of Science:

Critical Care Medicine
Pediatric Intensive Care
Pharmacology

Background:

Daily sedation interruption (DSI) is a strategy to temporarily halt sedation in critically ill patients.
Its effectiveness in pediatric intensive care unit (PICU) settings, particularly for invasively ventilated children, requires robust evidence.
Current literature lacks a clear demonstration of DSI's impact on clinical outcomes in this vulnerable population.

Purpose of the Study:

To systematically review and meta-analyze the clinical outcomes of DSI compared to continuous intravenous (IV) sedation.
To evaluate the impact of DSI on mechanical ventilation duration, PICU length of stay, sedative doses, adverse events, and mortality in pediatric patients.
To provide evidence-based insights into the efficacy and safety of DSI in the PICU.

Main Methods:

A systematic literature search was performed across major databases (PubMed, Embase, Web of Science, CINAHL, Cochrane) up to October 31, 2023.
Included studies comprised retrospective/prospective observational studies, randomized clinical trials (RCTs), and systematic reviews comparing DSI to continuous IV sedation in pediatric patients requiring mechanical ventilation.
Data extraction followed PRISMA guidelines, and a random-effects model was employed for meta-analysis of primary (MV duration, PICU stay) and secondary outcomes.

Main Results:

Six RCTs involving 2810 pediatric patients were analyzed.
Daily sedation interruption (DSI) was associated with a significant reduction in PICU length of stay (mean difference: -1.45 days; P=.03).
No significant differences were observed in mechanical ventilation duration, total sedative doses (midazolam, morphine), adverse events, or mortality between DSI and continuous IV sedation groups.

Conclusions:

Daily sedation interruption (DSI) in pediatric patients receiving mechanical ventilation is associated with a shorter PICU length of stay.
The implementation of DSI did not lead to an increase in adverse events or mortality.
Further research is warranted to explore the long-term neurodevelopmental outcomes in pediatric survivors treated with DSI.

Read full analysis

Abstract

Importance:

The effectiveness of daily sedation interruption (DSI, defined as temporary interruption of sedation) has yet to be demonstrated in critically ill pediatric patients.

Objective:

To compare the clinical outcomes of DSI vs continuous intravenous (IV) sedation in patients receiving invasive mechanical ventilation (MV) support in the pediatric intensive care unit (PICU).

Data Sources:

A systematic search for studies was conducted using predefined keywords and Medical Subject Headings in 5 major databases (PubMed, Embase, Web of Science, CINAHL [Cumulated Index to Nursing and Allied Health Literature], and Cochrane Central Register of Controlled Trials) from database inception to October 31, 2023.

Study Selection:

Retrospective and prospective observational studies, randomized clinical trials (RCTs), and systematic reviews were assessed for inclusion. Studies were eligible if they compared DSI to continuous IV sedation in patients aged 18 years or younger requiring MV in the PICU.

Data Extraction And Synthesis:

Study characteristics, including the types of sedation, sedation protocols, and clinical outcomes, were extracted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline was followed. A random-effects model was used to pool results from articles for the meta-analysis.

Main Outcomes And Measures:

The primary outcomes of interest were duration of MV and length of PICU stay. Secondary outcomes included total sedative dose requirement, adverse events (eg, complications associated with MV, withdrawal, and delirium), and mortality.

Results:

A total of 6 RCTs with 2810 pediatric patients (1569 males [55.8%]; mean age, 26.5 [95% CI, 15.0-37.9] months) were included in the final analysis; patients had a mean PRISM (Pediatric Risk of Mortality) score of 13.68 (95% CI, 10.75-16.61). Compared with continuous IV sedation, DSI was associated with a reduction in length of PICU stay (5 studies, n = 2770; mean difference [MD], -1.45 [95% CI, -2.75 to -0.15] days; P = .03]. There was no difference in MV duration (5 studies, n = 2750; MD, -0.93 [95% CI, -1.89 to 0.04] days; P = .06), total doses of midazolam (3 studies, n = 191; MD, -1.66 [95% CI, -3.95 to 0.63] mg/kg) and morphine used (2 studies, n = 189; MD, -2.63 [95% CI, -7.01 to 1.75] mg/kg), or adverse events (risk ratio [RR], 1.03 [95% CI, 0.74-1.42]; P = .88). There was no difference in mortality between patients exposed vs not exposed to DSI (RR, 0.89 [95% CI, 0.55-1.46]; P = .65).

Conclusions And Relevance:

This systematic review and meta-analysis found that use of DSI in pediatric patients was associated with reduced length of PICU stay with no increase in adverse events. Further research is needed to ascertain whether this strategy is associated with improved neurodevelopmental outcomes in PICU survivors.

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