Related Experiment Videos
Optimal sedation of mechanically ventilated pediatric critical care patients
C M Marx1, P G Smith, L H Lowrie
1Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH.
Insights
The COMFORT Scale offers a more consistent method for assessing pediatric sedation adequacy in intensive care than physician judgment alone. This validated scale provides a reliable target range for optimal sedation management.
Area of Science:
- Pediatric intensive care
- Sedation assessment
- Clinical outcomes
Background:
- Optimal sedation is crucial for mechanically ventilated children.
- Current methods of assessing sedation adequacy can be subjective.
- The COMFORT Scale is a validated tool for rating distress.
Purpose of the Study:
- To establish a target range for optimal sedation using the COMFORT Scale.
- To prospectively validate this target range against intensivist assessments.
- To compare the consistency of the COMFORT Scale with physician global assessment.
Main Methods:
- Serial prospective agreement cohort studies were conducted in a pediatric intensive care unit.
- Eighty-five mechanically ventilated children (0-102 months) were included.
- Simultaneous, independent ratings using the COMFORT Scale and physician global assessment were compared.
Main Results:
- A target range of COMFORT scores (17-26) for optimal sedation was derived and validated.
- The COMFORT Scale strongly correlated with intensivist ratings (r2 = .662).
- The COMFORT Scale demonstrated greater consistency and precision in assessing sedation adequacy compared to physician global assessment.
Conclusions:
- The COMFORT Scale provides a more consistent and precise measure of sedation adequacy than intensivist global assessment.
- This supports the use of the COMFORT Scale for optimizing sedation in pediatric intensive care.
- The derived target range aids in standardizing sedation assessment.
Objective:
To derive a target range of optimal sedation for the COMFORT Scale and to prospectively test that target range against intensivist assessment of adequacy of sedation.
Design:
Serial prospective agreement cohort studies.
Setting:
Twelve-bed pediatric intensive care unit in an urban academic teaching hospital.
Patients:
Eighty-five mechanically ventilated children (aged 0 to 102 months).
Interventions:
Three serial prospective studies comparing simultaneous, independent ratings conducted by trained observers using an objective scale and intensive care physicians using global assessment. The initial study was designed to derive the target range. The second study was conducted to verify that target range in a second population. The third study was added to evaluate relative variability in methods used in the second study.
Measurements And Main Results:
Adequacy of sedation using visual analog scale and descriptive ratings or the COMFORT Scale (a previously validated behaviorally anchored scale to rate eight behavioral or physiologic dimensions of distress). The first study comprised 100 observations. Groups of patients described by the intensivist as inadequately sedated, optimally sedated, and excessively sedated had different mean COMFORT scores (30.5 +/- 0.7 vs. 22.9 +/- 5.8 vs. 14.3 +/- 0.7, respectively, p < .05). The target range of optimal sedation was defined as COMFORT scores of 17 to 26. The second study verified the target range prospectively in a second group of 96 observations. The COMFORT score was strongly associated with the sedation adequacy rating by the intensivist (p < .001; r2 = .662). COMFORT scores accurately predicted the patient assignment to adequacy of sedation categories by the intensivist in 66.1% of observations. Discrepancy between physicians occurred in 38.5% of 16 paired physician ratings in the second study. In the third study, 120 observations comparing paired COMFORT scores to paired physician ratings of the same subjects demonstrated significantly less variability in COMFORT assessment of adequacy of sedation. COMFORT scores were similarly unbiased (1.1% vs. 0.22%) but more precise (8.0% vs. 16.7%) than intensivist ratings (p < .025).
Conclusion:
Adequacy of sedation is measured more consistently by observers using the COMFORT Scale than by intensivist global assessment.