Successful implementation of a pediatric sedation protocol for

mechanically ventilated patients*

Kristina H. Deeter, MD; Mary A. King, MD, MPH; Debra Ridling, CCRN; Gretchen L. Irby, PharmD;
Anne M. Lynn, MD; Jerry J. Zimmerman, MD, PhD, FCCM

Objective: To evaluate the effect of a nursing-driven sedation days for the observation period and 5 days for the intervention
protocol for mechanically ventilated pediatric patients on duration period (p ⴝ .026). Specifically, the median duration of morphine
of use of analgesic and sedative medications. We hypothesized infusion was 6 days for the observation period and 5 days for the
that a protocol would decrease length of sedation use and de- intervention period (p ⴝ .015), whereas the median duration of
crease days of mechanical ventilation and length of stay. lorazepam infusion was 2 days for the observation period and 0
Design: Retrospective cohort study with historical controls. days for the intervention period. After adjusting for severity of
Setting: Thirty-one-bed tertiary care, medical-surgical-cardiac illness with the pediatric risk of mortality III (PRISM III) score, the
pediatric intensive care unit in a metropolitan university-affiliated Cox proportional hazards regression analysis demonstrated that
children’s hospital. at any point in time, patients in the intervention group were 23%
Patients: Children requiring mechanical ventilation longer than more likely to be off all sedation (heart rate 0.77, p ⴝ .020).
48 hrs not meeting exclusion criteria. Additionally, the intervention group tended to be associated with
Interventions: Before protocol implementation, sedation was fewer days of mechanical ventilation (heart rate 0.81, p ⴝ .060)
managed per individual physician orders. During the intervention and decreased pediatric intensive care unit length of stay (heart
period, analgesia and sedation were managed by nurses following rate 0.81, p ⴝ .058), although these associations did not quite
an algorithm-based sedation protocol based on a comfort score. reach statistical significance.
Measurements and Main Results: The observation group in- Conclusion: A pediatric sedation protocol can significantly
cluded consecutive patients admitted during the 12-month period decrease days of benzodiazepine and opiate administration,
before protocol education and implementation (n ⴝ 153). The which may improve pediatric intensive care unit resource utiliza-
intervention group included patients admitted during the 12 tion. (Crit Care Med 2011; 39:683– 688)
months following protocol implementation (n ⴝ 166). The median KEY WORDS: sedation protocol; pediatric sedation; continuous pro-
duration of total sedation days (intravenous plus enteral) was 7 cess improvement; morphine; lorazepam; opiates; benzodiazepines

O ne of the most common and care units (ICUs) as a means to provide a are incompletely understood. Of particular
important interventions in continuous level of comfort to critically ill concern, anesthetic drugs that alter synaptic
providing care for critically patients (1, 2). This approach has been transmission at ␥-aminobutyrate type A
ill children is the alleviation proven to decrease the discomfort associ- and/or N-methyl-D-aspartate glutamate re-
of pain and anxiety. The selection and ated with mechanical ventilation (MV), ceptors cause neuroapoptosis in the develop-
method of administering sedative and an- traumatic and surgical wounds, invasive ing brain and subsequent neurocognitive im-
algesic medications to accomplish this goal devices, and procedures. In addition, anal- pairment in neonatal animal models (9–11).
is highly variable. Historically it has been gesics and sedatives decrease oxygen con- There is growing evidence that a seda-
based on individual physician preference sumption, modulate the intensity of the tion protocol for mechanically ventilated
and subjective nursing assessment of pain stress response, foster patient safety in a patients may decrease morbidity, LOS,
and anxiety. Infusions of analgesic and sed- potentially dangerous ICU environment (by and time on MV for critical care patients.
ative agents are frequently used in intensive reducing risks of agitation-related injury and Although there are published guidelines
dislodgement of critical invasive devices), and and many protocol examples for adult
facilitate bedside nursing care (2–5). patients in the literature (8, 12–14), there
*See also p. 887. Despite these benefits, continuous infu- is a paucity of practical evidence for chil-
From the Departments of Pediatrics (KHD, MAK, DR, sions of analgesics and sedatives have been dren (15, 16). Adapting published adult
GLI, AML, JJZ) and Anesthesiology (AML), Seattle Chil-
identified as independent predictors of lon- protocols for pediatric patients is challeng-
dren’s Hospital University of Washington, Seattle, WA.
This study was supported, in part, by the National ger duration of MV as well as extended ICU ing, and the safety and efficacy of a sedation
Institutes of Health. and hospital length of stay (LOS) (6, 7). and weaning protocol in children is un-
The authors have not disclosed any potential con- Prolonged sedation has been associated known, although it is currently being stud-
flicts of interest.
with increased procedures, acquired neuro- ied in a multi-institutional randomized,
For information regarding this article, E-mail:
[email protected] muscular disorders, delirium, and post- controlled trial (The Randomized Evalua-
Copyright © 2011 by the Society of Critical Care traumatic stress disorder (8). Lastly, the tion of Sedation Titration for Respiratory
Medicine and Lippincott Williams & Wilkins long-term consequences of analgesics and Failure [RESTORE] study, NCT00814099;
DOI: 10.1097/CCM.0b013e318206cebf sedatives on the developing brains of children http://clinicaltrials.gov). With a strategy

Crit Care Med 2011 Vol. 39, No. 4 683

supported by continuous process improve-
ment principles and Lean methodology in
use at our institution (17), our multidisci-
plinary research team sought to design a
pediatric sedation protocol that would be
safe and effective and could be rapidly im- Hour 1: Bolus morphine 0.1 mg/kg (MAX 4mg per dose) and start infusion at 20 mcg/kg/hr.
After admission If already on infusion from OR or ER, continue infusion at current rate.
plemented in our large pediatric ICU and/or intubation: Bolus morphine 0.1 mg/kg IV q15 minutes during first hour (MAX 4mg per dose) to goal comfort score.
(PICU). Our hypothesis was that a nurs- If 3 boluses are needed, then increase drip by 5 mcg/kg/hr.
May give lorazepam 0.1mg/kg once (MAX 2mg/dose) prn anxiety.
ing-driven pediatric sedation protocol
would decrease exposure to analgesics Hour 2: Achieving comfort goals?

and sedatives, decrease ICU LOS, and

decrease days of MV. YES NO
May give lorazepam 0.1 mg/kg once
Continue current infusion rate. (MAX 2mg—call MD for order).
Bolus morphine 0.1 mg/kg q15 min prn Continue morphine boluses q15 min.
METHODS to goal comfort score (MAX 4mg). If > 3 boluses given, increase infusion
rate by 5 mcg/kg/hr.
Protocol Development. A multidisciplinary
Every 4 hours:
team that included PICU physicians, nurses, 0400
Reassess every 4 hrs.
Were < 3 boluses required in a 4 hour time period?
and a pharmacist met regularly over a period 0800
1200
of 6 months to develop the Seattle Children’s 1600 YES NO
Comfort Protocol (SCCP) (Fig. 1). The team 2000 Continue infusion with boluses as needed:
Increase infusion by 5mcg/kg/hr immediately
2400 -- Morphine 0.1 mg/kg q1hr prn pain
after third bolus required in each 4 hour period.
extensively reviewed published literature, or- -- Lorazepam 0.1 mg/kg q2 hr prn anxiety
Continue morphine 0.1mg/kg q1 prn pain.
Notify MD if at max 100 mcg/kg/hr
der sets and protocols available from other Use lorazepam 0.1 mg/kg q2 hr prn anxiety.
institutions, and recommendations from indi-
Every 12 hours:
vidual experts in the field, such as Seattle 0400
Reassess at 0400 and 1600.
Maintaining goal comfort score?
Children’s Hospital Pain Service physicians. 1600
Consensus was reached by all members of the YES NO
team to continue with accepted institution Decrease drip by 5 mcg/kg/hr. Discuss with MD. Consider increasing max dose
Continue boluses prn. or using alternative medications
preference for morphine and lorazepam due to If on lorazepam infusion, decrease this first (Fentanyl, Dilaudid, Dexmedetomidine).
Continue increasing drip every time 3 boluses
staff comfort, experience, and clinical success —may also decrease both at the same time.
are required in 4 hour time period.
with these medications. We did not reach team
consensus on inclusion of a daily interruption After 24 hours If > 4 lorazepam boluses in 12 hr period,
of sedation in the initial protocol, which is of ventilation: may notify MD to order lorazepam drip
to start at 10 mcg/kg/hr.
often found in adult protocols (18, 19), and as Increase by 5 mcg/kg/hr immediately
after 3rd bolus given in 6 hour period.
such it was not included. Concerns included Decrease by 5 mcg/kg/hr at 0400 and
timing of the interruption, variability of awak- 1600 if no boluses given.

ening time, ability to provide 1:1 nursing to

Consider increasing goal comfort score.
closely watch each patient during awakening, Prior to Ask MD to order “PICU Extubation
extubation:
safety and risk of self-extubation, and variable Orderset” AND “PICU Opioid and
Benzodiazepine Weaning Orderset”.
pediatric developmental level as related to Ask MD to decrease morphine and
lorazepam prn doses by half and space
ability to understand verbal commands and to q2 and q4 prn respectively.
calming.
It was agreed that one protocol based on a Figure 1. Seattle Children’s Comfort Protocol. PICU, pediatric intensive care unit; MD, medical doctor;
comfort score would be developed in contrast prn, as needed; IV, intravenous; OR, operating room; ER, emergency room; PCA, patient-controlled
to many adult protocols that separate pain and analgesia; q, every.
anxiety. To maximize compliance and facili-
tate education, we decided to continue with 0
Patient receiving neuromuscular blockage
use of our institution’s comfort scoring sys-
tem, the Seattle PICU Comfort Score (Fig. 2), 1
Deep sleep, heavily sedated, minimal movement, or unconscious
although there are other nationally recog-
nized and validated comfort scores available 2
Sleepy, calm, arousable, cooperative with care or age appropriate
for pediatrics (20, 21). A specific goal comfort
score is ordered on morning interdisciplinary 3
Tearing, restless, startles easily, fussy, but consolable
rounds depending on the depth of sedation
4
Guarding, anxious, may be grimacing, uncooperative with care, does
preferred for an individual patient. For most not calm easily
patients, a score of “2” is typically appropriate, 5
Agitated, crying, tense posture or guarding, grimacing, not accepting
although as they near extubation, this order mechanical ventilation (infants may exhibit apnea with pain)
may be adjusted to a “3.”
6
Dangerously agitated, pulling at tubes and lines, requires restraints
Once the protocol was finalized, all staff
completed 1 hr of required small group train- Figure 2. Seattle Pediatric Intensive Unit (PICU) Comfort Score.
ing that included a pharmacology review and
direction on the use of the order set and SCCP.
During the first week of implementation, a bility for daily auditing of protocol adherence, decided to objectively review the impact of the
nurse educator was assigned to work individ- order accuracy, and reviewing compliance sedation protocol on the clinical care of our
ually with each bedside nurse to answer ques- with titration instructions. patient population. This research was con-
tions and ensure the SCCP was being properly Study Design and Data Collection. Early in ducted at Seattle Children’s Hospital, a uni-
implemented. Pharmacy staff took responsi- the protocol development process, the team versity-affiliated metropolitan children’s hos-

684 Crit Care Med 2011 Vol. 39, No. 4

pital, and approved by the Institutional Review Observation period ICU admits = 1388 Intervention period ICU admits = 1074
Board. Primary outcome measure was days of
exposure to sedative and analgesic medica- MV > 2 days = 285 MV > 2 days = 325
tions. This included benzodiazepines and opi-
Acute/chronic neurologic disease
ates administered in intravenous (IV) form to 46 30

maintain comfort and ventilator synchrony as 6 Transfer from another ICU 11

well as enteral opiates (morphine and metha-
15 Tracheostomy in place 28
done) and benzodiazepines (typically loraz-
epam) dosed on a scheduled basis to prevent 8 PCA/epidural 11
or treat symptoms of withdrawal. Secondary
17 Required ECLS (survived) 10
outcome measures were duration of MV and
PICU LOS. Inclusion criteria: Admission to the 40 Expired during admission ** 39
ICU (medical, surgical, and cardiac); age new- N/A MD exclusion 30
born to 21 yrs; and need for MV for more than
2 days. Exclusion criteria: Diagnoses of sei- 153 TOTAL PATIENTS INCLUDED 166
zures, acute or chronic neurologic dysfunc-
Figure 3. Subject flow chart with exclusions. **Includes patients meeting other exclusion criteria, i.e.,
tion; extracorporeal life support; tracheostomy
on extracorporeal life support before death. ICU, intensive care unit; MV, mechanical ventilation; PCA,
in place for any part of the ICU admission;
patient-controlled analgesia; ECLS, extracorporeal life support.
infusion of a neuromuscular blocking agent;
transfer from another ICU; or death during
admission. Each subject met all inclusion and
no exclusion criteria.
for physician orders for the SCCP and noted for alternative narcotic, concerns for pro-
any reasons for protocol noncompliance. found hypotension or heart failure, rein-
During the observation period, patients
Statistical Analysis. Baseline patient char- tubation or readmission before previous
were managed by using independent physi-
acteristics of the two study groups were com- narcotic weans, parent refusal, or mor-
cian-directed approaches requiring specific
pared by using descriptive statistics. We ob- phine allergy. Median PRISM III score for
physician’s orders for sedation selection, dos-
served a non-normal distribution of the study
ing, and titration. During the intervention pe- these patients was comparable with study
patient outcome measures (total sedation
riod (following healthcare staff education and days, duration of MV, and LOS) when the data populations at 6.5. Of note, more than
training), children admitted to the ICU already were plotted as histograms. Outcome mea- half of all exclusions took place in the
intubated or who required intubation during sures were reported as both mean and median first 4 months of protocol introduction
admission were placed on the SCCP, although values with respective standard deviations and with the remainder in the following 8
only those patients requiring MV for longer interquartile ranges. Wilcoxon’s rank sum test months as staff became more comfortable
than 2 days were included in our retrospective was used to compare continuous nonparamet- with use of the SCCP.
review. ric outcome measures between groups. Simi- Outcomes. The duration of sedation
Medical record numbers for patients meeting larly, given the non-normal distribution of the exposure, duration of MV, and PICU LOS
inclusion criteria were obtained from the virtual data, a Cox proportional hazards regression
were compared by study group (Table 2).
PICU system (vPICU, http://www.vpicu.org) for analysis was performed to assess the differ-
ences between the intervention group and the Patients in the intervention group were
both the observation period (January 1 to De-
traditional group after adjustment for pediat- exposed to significantly fewer days of
cember 31, 2007) and intervention period
(May 1, 2008 to April 30, 2009). Data ab- ric severity of illness (using a PRISM III score). morphine infusion, lorazepam infusion,
stracted from electronic charts included inclu- The hazard ratio represents the likelihood at and total sedation (IV plus enteral) than
sion and exclusion criteria, age, sex, diagnosis, any point in time that a child in the interven- patients in the observation group. For the
Pediatric Risk of Mortality III (PRISM III) tion group (as compared with the observation primary outcome, the intervention group
group) would be on a given therapy. All sta- (as compared with the observation group)
score (22), LOS, duration of MV, IV sedation
tistical tests were two-sided. Data were ana- was 23% more likely to be off all sedation
including medication and duration, enteral se-
lyzed by using STATA 10 (Stata, College Sta-
dation including medication and duration, (heart rate 0.77, 95% confidence interval:
tion, TX).
and whether or not the patient had undergone 0.61– 0.96, p ⫽ .020). For secondary anal-
surgery. Total days of sedation (reported in yses, the intervention group tended to be
tables as IV plus enteral) included the IV in- RESULTS
associated with fewer days of MV (heart
fusions received during hospitalization in Patients. Two hundred eighty-five pa- rate 0.81, p ⫽.060) and PICU LOS (heart
addition to any oral benzodiazepines or opi- tients met inclusion criteria during the rate 0.81, p ⫽ .058), although these as-
ates given on a scheduled basis while admit- observation period. After exclusions were sociations did not quite reach statistical
ted or prescribed at discharge. Outpatient significance (Table 3).
made, 153 patient charts were analyzed
medications were tracked with our elec- The rate of unplanned extubations
(Fig. 3). The records of 325 consecutive
tronic records system for refills, and outpa-
patients meeting inclusion criteria dur- during each study period was also retro-
tient physician notes were reviewed to de-
ing the intervention period were re- spectively reviewed and summarized. In
termine exact length of time required for
weaning medications (typically oral mor- viewed, and data from 166 patients were 2007, during the observation period,
phine, methadone, or lorazepam). There ultimately analyzed after review for ex- there were 13 documented unplanned ex-
were only a small number of patients who clusion criteria. The demographics of tubations out of 4,003 ventilator days (an
required outpatient weaning, and all of both groups were similar (Table 1) as average of 0.32 events per 100 ventilator
these records were available for review to were reasons for study exclusion. There days). During the first year of protocol
confirm date of cessation of weaning medi- were 30 patients in the intervention implementation, there were 11 un-
cation (most followed by the cardiac, trans- group that would have met criteria to be planned extubations out of 4,737 ventila-
plant, or oncology services). During the in- placed on the SCCP but were excluded by tor days (average of 0.23 events per 100
tervention period, we also reviewed charts the ordering physician due to preference ventilator days). The national benchmark

Crit Care Med 2011 Vol. 39, No. 4 685

Table 1. Comparison of baseline characteristics by intervention group decreased the duration of both opiate and
benzodiazepine continuous infusions as
Observation Group Intervention Group
well as total duration of sedative expo-
Demographic (n ⫽ 153) (n ⫽ 166)
sure. As found in previous adult studies, a
Age (yrs) multidisciplinary team approach was suc-
Mean (SD) 3.0 (5.0) 2.6 (4.7) cessfully used to create a sedation proto-
Median (interquartile range) 0.5 (0.1–3.1) 0.4 (0.1–1.7) col that empowers intensive care nurses
Gender to safely administer and titrate continu-
Male 85 (56%) 88 (53%)
Female 68 (44%) 78 (47%)
ous infusions of opiates and benzodiaz-
Diagnostic category epines for critically ill children. When we
Surgical (%) 105 (69%) 108 (65%) accounted for the potential confounding
Medical (%) 48 (31%) 58 (35%) effect of severity of illness as measured by
Pediatric risk of mortality III score PRISM III score, our data suggest that a
Mean (SD) 6.9 (5.5) 6.2 (4.8)
Median (interquartile range) 6 (3–10) 5 (3–9) pediatric sedation protocol very likely can
also decrease duration of MV and ICU
LOS. Importantly, we found no increase
Table 2. Comparison of days of pediatric intensive care unit therapy by intervention group in the rate of unplanned extubations. We
found that dexmedetomidine use fell by
Observation Group Intervention Group approximately 50% in our study popula-
Variable (Days) (n ⫽ 153) (n ⫽ 166) pa tion, suggesting that children required
fewer alternative sedation therapies while
Morphine infusion
Mean (SD) 9.9 (11.0) 7.0 (6.3) on the SCCP; however, this would need
Median (IQR) 6 (4–12) 5 (3–9) .015 future study to verify. We also found no
Lorazepam infusion association between dexmedetomidine
Mean (SD) 6.6 (11.2) 1.6 (3.7) use and total sedation days (our primary
Median (IQR) 2 (0–7) 0 (0–2) ⬍.001
outcome measure) in patients on the
Total sedation (intravenous ⫹ enteral)b
Mean (SD) 15.9 (19.6) 11.6 (12.6) SCCP.
Median (IQR) 7 (4–22) 5 (3–17) .026 The positive changes seen in our unit
Mechanical ventilation are likely a result of many factors: Imple-
Mean (SD) 8.1 (9.0) 6.3 (5.4) mentation of a nursing-driven protocol,
Median (IQR) 5 (3–9) 5 (3–7) .155
Pediatric intensive care unit length of stay education of the healthcare team with
Mean (SD) 13.1 (13.3) 10.4 (7.7) respect to the medications used for pain
Median (IQR) 9.5 (5.4–15.2) 8.2 (5–13.2) .302 and sedation, and a growing awareness of
the importance of reducing unnecessary
IQR, interquartile range. sedation. This is a single center study in a
a
p values are calculated via Wilcoxon’s rank sum test; btotal sedation days are defined as total days teaching hospital; our protocol may not
of sedative medications, including all routes (intravenous and enteral) as well as all locations (in the
be easily translatable to other PICUs. The
intensive care unit, the pediatric ward, and home).
SCCP was designed to meet the needs of
our unit and was created with input from
Table 3. Cox proportional hazards regression model to assess the effect of intervention group on
our nursing staff and from specialists uti-
duration of therapy, after adjustment for severity of illness
lizing our services. Similar centers will
Variable (Days) Hazard Ratio (95% Confidence Interval) p likely need to construct individual proto-
cols to meet their own needs.
Total sedation (intravenous ⫹ enteral) 0.77 (0.61–0.96) .020 We encountered many challenges in
Mechanical ventilation 0.81 (0.65–1.01) .060 developing our protocol. In reviewing
Pediatric intensive care unit length of stay 0.81 (0.64–1.01) .058
published protocols, we found that many
centers use different medication algo-
rithms for pain and anxiety. As discrimi-
(http://mmp-bench.com) during these midine use (yes/no) and total sedation nation of pain and anxiety in children is
time periods was 0.65 accidental extuba- days (median) in the observation group difficult, we instead decided to focus on a
tions per 100 days. These data include all (dexmedetomidine yes: 12 days vs. dex- single “comfort” protocol to address both
ventilated patients admitted to our ICU, medetomidine no: 6 days, p ⫽ .018). We variables with titration guided by a com-
including those patients meeting criteria found no association between dexmedeto- fort scale. The Seattle PICU Comfort Tool
for this study. midine use and total sedation days in the was developed at our institution, has
Lastly, we collected data on dexme- intervention group (dexmedetomidine been in use in the ICU for approximately
detomidine use during our study period. yes: 5 days vs. dexmedetomidine no: 5 10 yrs, and thus was well known to staff.
Dexmedetomidine was used in 74 of 153 days, p ⫽ .244). Although this tool is not a nationally val-
patients (48%) in the observation group idated scoring system, it was derived
and only 40 of 166 patients (25%) in the DISCUSSION from the adult Ramsay sedation tool (23)
intervention group during some point in and developed as part of a quality im-
the course of their ICU therapy. We found Implementation of a nursing-driven provement project with inter-rater reli-
a strong association between dexmedeto- pediatric sedation protocol significantly ability testing completed before use. An-

686 Crit Care Med 2011 Vol. 39, No. 4

other challenge in developing the SCCP prove staff satisfaction through use of lowing discharge from the ICU should be
was to standardize sedation provided to standardization and guidelines (27, 28). studied in a prospective fashion.
both our medical and surgical patients Patient deaths during each time pe-
with a single algorithm in an effort to riod were excluded in this study to fur- CONCLUSION
decrease risk of error given that nurses ther describe a change in the total days of
may work in both the medical/surgical sedation, MV, and LOS. Median PRISM III The development and implementation
and cardiac ICUs. After much collabora- score for patients who expired in the ob- of a pediatric comfort protocol that ad-
tive discussion, we chose to utilize mor- servation group was 16.5 and for the in- dresses analgesia and sedation is feasible
phine as the primary sedation agent for tervention group was 11. Many of these and safe. Initiation of this quality im-
all patients on the protocol. The Seattle patients required extracorporeal life sup- provement protocol significantly de-
Children’s team of anesthesiologists, in- port or a paralytic infusion thereby re- creased exposure of critically ill children
tensivists, and pharmacists collabora- moving them from protocol inclusion. to analgesic and sedative medications
Many others were found to have fatal with an associated reduction in days of
tively adopted the use of morphine years
malignancies, failed bone marrow or MV and ICU LOS. The key components of
ago due to its analgesic and sedative
solid organ transplants, or inoperable this protocol include the use of a consis-
properties, its pediatric safety and efficacy
cardiac conditions. Deaths were reviewed tent comfort metric, nursing education
profile, relatively slow development of
by authors and circumstances found to be and empowerment, and forced, scheduled
tachyphylaxis, and its cost-effectiveness.
similar between groups. Although it is assessments with defined responses.
Common concerns regarding histamine re-
lease with morphine has been shown to be impossible to know without further re-
less problematic with infusions (24, 25). view and alternative study design, there ACKNOWLEDGMENTS
Use of morphine and lorazepam for long- was no documentation discovered in
The authors would like to thank Tel-
term sedation has also been supported by these charts implicating the method of
len Bennett, Lin DiGennaro, Lauraine
recent consensus guidelines (8). sedation as a contributing factor to death.
Heer, and John Salyer for their assistance
Particularly when dosing is high, wean- with technical aspects of this study and
ing of long-term sedation can require days Limitations manuscript preparation.
to months, and this may prolong duration
We cannot generalize our results to
of MV and hospitalization (26). Children REFERENCES
the critically ill child with neurologic dis-
may be sent home on oral analgesic/
ease or the child who is so ill as to require 1. Jenkins I: The provision of analgesia and
sedative medications and weaning proto-
extracorporeal life support or go on to die sedation in the PICU: Current practice and
cols that create risk for patient and family
as those populations were excluded from recent advances. Paediatr Anaest 2002; 12:
safety concerns. A key component of the
our study. Specifically, another agent 837– 839
SCCP is a rapid attainment of comfort with
such as fentanyl may be preferable for 2. Jacobs JR, Reves JG, Glass PS: Rationale and
bolus dosing and titration of the infusion, technique for continuous infusions in anes-
patients who have severe hemodynamic
but with subsequent mandatory assess- thesia. Int Anesthesiol Clin 1991; 29:23–38
compromise or who require frequent
ment every 4 hrs and reduction of the in- neurologic exams, and we did not test the 3. Buck ML, Blumer JL: Opioids and other an-
fusion recommended every 12 hrs once the efficacy of morphine in these popula-
algesics. Adverse effects in the intensive care
patient is comfortable. In this way, patients unit. Crit Care Clin 1991; 7:615– 637
tions. Our retrospective design and use of 4. Mehta S, Burry L, Fischer S, et al: Canadian
are slowly, but steadily, weaned from seda- historical controls is another important
tion before extubation. survey of the use of sedatives, analgesics, and
limitation to our study as practice and neuromuscular blocking agents in critically
Aside from minimizing sedation dura- patient populations may change over ill patients. Crit Care Med 2006; 34:374 –380
tion, we have also demonstrated how a time. A retrospective design was deemed 5. Anand KJ, Ingraham J: Pediatric. Tolerance,
pediatric ICU sedation protocol can de- necessary as the research team felt that dependence, and strategies for compassion-
crease days of MV and ICU LOS, although attempting to train only half of our entire ate withdrawal of analgesics and anxiolytics
our data in these regards did not quite healthcare team in an effort to randomize in the pediatric ICU. Crit Care Nurse 1996;
reach statistical significance given the to different arms of a study would not be 16:87–93
small nature of this single-center study. 6. Kollef MH, Levy NT, Ahrens TS, et al: The use
feasible in our unit and would lead to
This decrease in utilization of scarce pe- of continuous i.v. sedation is associated with
contamination of results during the in- prolongation of mechanical ventilation.
diatric medical resources may impart a tervention phase. Unfortunately, our ret- Chest 1998; 114:541–548
large cost savings to the patient, the hos- rospective electronic chart review was 7. Tobias JD: Tolerance, withdrawal, and physical
pital, and society. Further prospective also not adequate to capture total milli- dependency after long-term sedation and anal-
study with large numbers of subjects uti- grams of sedatives and narcotics admin- gesia of children in the pediatric intensive care
lizing pediatric tools for assessment of istered daily. It is possible that even unit. Crit Care Med 2000; 28:2122–2132
delirium and posttraumatic stress disor- though the total days of sedative admin- 8. Jacobi J, Fraser GL, Coursin DB, et al: Clin-
der along with long-term follow-up of istration decreased, the actual amount ical practice guidelines for the sustained use
neurodevelopmental effects is needed to of sedatives and analgesics in the critically ill
(in milligrams) of these medications may
adult. Crit Care Med 2002; 30:119 –141
fully answer such questions. From a hos- have increased as has been reported by
9. Loepke AW: Developmental neurotoxicity of
pital perspective, we hope to improve safe other investigators using similar protocols sedatives and anesthetics: A concern for neo-
patient flow through the ICU, decrease (19). Total amount of drug exposure (in natal and pediatric critical care medicine?
costs related to sedation, decrease costs milligrams), incidence of withdrawal symp- Pediatr Crit Care Med 2010; 11:217–226
related to complications in the ICU or toms and delirium (29), and number of 10. Fredriksson A, Pontén E, Gordh T, et al: Neo-
ward related to drug exposure, and im- children requiring weaning regimens fol- natal exposure to a combination of N-methyl-

Crit Care Med 2011 Vol. 39, No. 4 687

 D-aspartate and gamma-aminobutyric acid tensive care unit: A systematic review. Pedi- Controlled sedation with alphaxalone-
type A receptor anesthetic agents potentiates atr Crit Care Med 2009; 10:246 –255 alphadolone. BMJ 1974; 2:656 – 659
apoptotic neurodegeneration and persistent 17. Black J: The Toyota Way to Healthcare Ex- 24. Warner MA, Hosking MP, Gray JR, et al:
behavioral deficits. Anesthesiology 2007; 107: cellence. Chicago, IL, Health Administration Narcotic-induced histamine release: A com-
427– 436 Press, 2008 parison of morphine, oxymorphone, and fen-
11. Creeley CE, Olney JW: The young: Neuroapo- 18. Kress JP, Pohlman AS, O’Connor MF, Hall JB: tanyl infusions. J Cardiothorac Vasc Anesth
ptosis induced by anesthetics and what to do Daily interruption of sedative infusions in crit- 1991; 5:481– 484
about it. Anesth Analg 2010; 110:442– 448 ically ill patients undergoing mechanical ven- 25. Doenicke A, Moss J, Lorenz W, et al: Intra-
12. Brook AD, Ahrens TS, Schaiff R, et al: Effect tilation. N Engl J Med 2000; 342:1471–1477 venous morphine and nalbuphine increase
of a nursing-implemented sedation protocol 19. de Wit M, Gennings C, Jenvey WI, et al: histamine and catecholamine release with-
on the duration of mechanical ventilation. Randomized trial comparing daily interrup- out accompanying hemodynamic changes.
Crit Care Med 1999; 27:2609 –2615 Clin Pharmacol Ther 1995; 58:81– 89
tion of sedation and nursing-implemented
13. Kress JP, Pohlman AS, Hall JB: Sedation and 26. Randolph AG, Wypij D, Venkataraman ST, et
sedation algorithm in medical intensive care
analgesia in the intensive care unit. Am J al: Effect of mechanical ventilator weaning
unit patients. Crit Care Med 2008; 12:R70
Respir Crit Care Med 2002; 166:1024 –1028 protocols on respiratory outcomes in infants
20. Curley MA, Harris SK, Fraser KA, et al: State
14. Girard TD, Kress JP, Fuchs BD, et al: Efficacy and children: A randomized controlled trial.
Behavioral Scale: A sedation assessment in-
and safety of a paired sedation and ventilator JAMA 2002; 288:2561–2568
weaning protocol for mechanically ventilated strument for infants and young children sup- 27. Arias-Rivera S, Sánchez-Sánchez Mdel M,
patients in intensive care (Awakening and ported on mechanical ventilation. Pediatr Santos-Díaz R, et al: Effect of a nursing-
Breathing Controlled Trial): a randomised Crit Care Med 2006; 7:107–114 implemented sedation protocol on weaning
controlled trial. Lancet 2008; 371:126 –134 21. Ambuel B, Hamlett KW, Marx CM, Blumer outcome. Crit Care Med 2008; 36:2054 –2060
15. Playfor S, Jenkins I, Boyles C, et al: Consen- JL: Assessing distress in pediatric intensive 28. Clemmer TP, Spuhler VJ: Developing and
sus guidelines on sedation and analgesia in care environments: the COMFORT scale. gaining acceptance for patient care proto-
critically ill children. Intensive Care Med J Pediatr Psychol 1992; 17:95–109 cols. New Horiz 1998; 6:12–19
2006; 32:1125–1136 22. Pollack MM, Patel KM, Ruttimann UE: 29. Smith HA, Fuchs DC, Pandharipande PP, et
16. Hartman ME, McCrory DC, Schulman SR: PRISM III: An updated Pediatric Risk of Mor- al: Delirium: An emerging frontier in the
Efficacy of sedation regimens to facilitate tality score. Crit Care Med 1996; 24:743–752 management of critically ill children. Crit
mechanical ventilation in the pediatric in- 23. Ramsay MA, Savege TM, Simpson BR, et al: Care Clin 2009; 25:593– 614, x

688 Crit Care Med 2011 Vol. 39, No. 4