Protocolized vs. Conventional Sedation Among Mechanically Ventilated Children in a Pediatric Intensive Care Unit - A Pre-Post Study

OBJECTIVES: To determine the feasibility and impact of a nurse-driven sedation protocol on the duration of mechanical ventilation (MV), sedative and opioid use, and related adverse events in a resource-limited setting. METHODS: It is a single center, prospective, before and after study, conducted between January 2018 and December 2019 in the pediatric intensive care unit (PICU) of a tertiary care teaching hospital in India. A total of 180 patients, aged between 1 mo and 12 y, requiring MV for > 24 h were included in the study. Outcomes were compared before and after the introduction of sedation protocol. RESULTS: The duration of MV was not significantly different between the two groups [median (IQR) 82 (50–167) vs. 94 (55–168) h, p = 0.56]. Daily [median IQR 3.1 (2.2–4.8) vs. 2.2 (1.6–3.3) mg/kg/d, p = 0.001] and cumulative doses of midazolam [median (IQR) 9.3 (3.8–21.9) vs. 7.8 (3.6–15.8) mg/kg, p = 0.001] were significantly lower in the protocol group. The cumulative opioid dose, expressed as morphine equivalent (mg/kg), was also significantly lower in the protocol group compared to the conventional group [median (IQR) 5.6 (2–13) vs. 1.2 (0.6–2.6), p < 0.001]. The number of patients who developed significant withdrawal symptoms was lower in the protocol group [26% vs. 8.3%, p = 0.005)]. No significant difference was observed in other secondary outcomes between the two groups. CONCLUSIONS: The implementation of a predominantly nurse-driven protocol was feasible and safe in a resource-limited setting. It did not significantly affect the duration of MV, compared with conventional group. Protocol implementation was associated with reduced cumulative doses of midazolam and opioids, as well as a lower incidence of withdrawal symptoms.