Adherence to Sedation Protocol Recommendations in Intubated ICU Patients

Area of Science:

• Pediatric Critical Care Medicine
• Pharmacology
• Quality Improvement Science

Background:

• Sedation in critically ill children presents challenges, with both under- and oversedation having negative consequences.
• Standardized sedation protocols aim to reduce variability, minimize drug exposure, and improve patient outcomes.
• Protocol adherence in pediatric intensive care units (PICUs) is not well understood.

Purpose of the Study:

• To quantify the adherence to sedation protocols in critically ill children.
• To assess the alignment between sedation protocols and actual infusion titration practices in a large single-center cohort.

Main Methods:

• Retrospective cohort study conducted in three PICUs of a tertiary care children's hospital.
• Included patients receiving mechanical ventilation for >24 hours and at least one sedative infusion between 2011 and 2023.
• Adherence to five key metrics of sedation protocol titration was calculated.

Main Results:

• Analysis of 8,108 patients and 9,670 encounters revealed consistently low protocol adherence across all PICUs.
• Infusions were rarely increased when indicated (92.5% missed) and often not decreased when recommended (95.5% missed).
• Premature dose increases occurred in 54.7% of opportunities, and only 16.2% of short-duration infusions were discontinued as recommended.

Conclusions:

• Sedation titration in PICUs frequently deviates from protocol recommendations, resulting in missed opportunities for active management.
• Improving adherence to sedation protocols is a critical target for quality improvement to mitigate risks of prolonged sedation.
• Future research should identify barriers to adherence and develop interventions, such as clinical decision support tools, to enhance compliance.