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Pediatric intensive care sedation: survey of fellowship training programs
C M Marx1, D I Rosenberg, B Ambuel
1Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH.
Insights
Pediatric intensive care unit sedation practices reveal frequent opioid and benzodiazepine use. Efficacy is a major concern, with clinical judgment often guiding dosing over objective measures.
Area of Science:
- Pediatric Critical Care Medicine
- Pharmacology
- Patient Sedation Management
Background:
- Children in pediatric intensive care units (PICUs) often experience distress.
- Sedation is commonly used to manage distress and improve patient outcomes.
- Current sedation practices in PICUs require further investigation.
Purpose of the Study:
- To identify the patterns of sedative agent use in pediatric critical care patients.
- To understand the goals and challenges associated with sedation in PICUs.
- To assess physician and nurse satisfaction with commonly used sedative agents.
Main Methods:
- A questionnaire survey was distributed to directors of Pediatric Critical Care Fellowship Training Programs.
- The survey achieved a 75.6% response rate from 34 program directors.
- Data collected focused on sedative agent selection, dosing, goals, and perceived problems.
Main Results:
- Opioids (morphine, fentanyl), chloral hydrate, and benzodiazepines were most frequently used.
- Sedation goals included reducing patient distress and preventing unplanned extubations.
- Physician/nurse clinical impression was prioritized over objective criteria for dosing.
- Efficacy was identified as the primary challenge (76.4%), while drug withdrawal was a lesser concern (6.9%).
- Opioids were associated with higher satisfaction than benzodiazepines.
Conclusions:
- Optimal sedation in PICUs remains a challenge despite frequent sedative administration.
- Systematic investigation into the pharmacodynamic responses of sedatives in pediatric critical care is warranted.
- Current practices highlight a need for improved efficacy and potentially more objective sedation monitoring.
Abstract:
Children hospitalized in a pediatric intensive care unit are frequently distressed. The purpose of this study was to identify the patterns of use of sedative agents in pediatric critical care patients. A questionnaire survey was mailed to 45 directors of Pediatric Critical Care Fellowship Training Programs listed in Critical Care Medicine, January 1989. The response rate was 75.6% (34 questionnaires). The most commonly identified goals of sedation were reduced patient discomfort or distress and fewer unplanned extubations. The agents most frequently employed for this purpose were opioids (morphine or fentanyl), chloral hydrate, or benzodiazepines. Although conventional doses are used, opioids and benzodiazepines are often given hourly or by continuous infusion. Satisfaction with the efficacy and safety of commonly used opioids was greater (most common response "very satisfied") than for the benzodiazepines ("somewhat satisfied"). The physician's or nurse's clinical impression was reported to be the "most important" criterion for deciding when a patient required a dose of sedative; objective criteria were selected as less important. The majority of patients (65.7%) in the surveyed units were ideally "sedated to the point of no distress with as-needed medication." The majority of respondents (76.4%) identified efficacy as the major problem with sedation. Drug withdrawal was considered to be the major problem with sedative use by only a minority of respondents (6.9%). Although withdrawal is seen in 61.8% of units, it is generally treated when recognized, rather than prevented by routine tapering of sedation. Optimal sedation of pediatric intensive care unit patients is considered problematic, despite the use of frequent doses of many sedatives. Systematic investigation of pharmacodynamic response to these agents in the pediatric critical care population is indicated.