Analgesia and Sedation in pediatric intensive care unit

Analgesia and Sedation in pediatric intensive care unit Volakli E, Sdouga M Treating children in an intensive care unit aims at the reversal of physiologic derangement of their organism while caring for comfortable physical and psychological environment. Any correctable environmental and physical factors causing discomfort should be addressed before the introduction of effective analgesia and sedation by pharmacological means; a normal schedule for sleep is desirable, and attention should be paid to the provision of feeding and hydration, lighting, environmental noise and the temporal orientation of the patients. All critically ill children have the right to adequate pain relief. Once adequate analgesia has been achieved, additional sedation may be required by some children. The aims of sedation are to reduce anxiety and distress of the child, and to allow for better tolerance of therapeutic and diagnostic procedures. Monitoring the level of analgesia and sedation will help to avoid both over and under treatment. There is no ideal method that will evaluate analgesia and sedation in all critically ill children. Pain scales according to child age should be used routinely, whereas the COMFORT scale is considered to be the most suitable clinical sedation scale for use in critically ill children requiring mechanical ventilation. Rather than seeking an ideal drug, strategies of drug administration that focus attention on principles of sedative pharmacology in critical illness should be utilized, and all sedation techniques must be patientfocused and individualized to patient needs through the utilization of Analgo-Sedation algorithms. INTRODUCTION Intensive Care Unit (ICU) is an unpleasant environment and while pain is often the root cause of distress experienced by the patient, anxiety, dyspnoea, delirium and sleep deprivation may be additive or synergistic. Factors that provoke these components of distress include underlying medical conditions, acute Pediatric Intensive Care Unit, Ippokratio General Hospital , Thessaloniki, Greece The Greek E-Journal of Perioperative Medicine 2012; 10:7-36 (ISSN 1109-6888) www.anesthesia. gr/ejournal Eλληνικό Πeριοδικό Πeριeγχeιρητικής Ιατρικής 2012; 10:7-36 (ISSN 1109-6888) www.anesthesia. gr/ejournal 8 ©2012 Society of Anesthesiology and Intensive Medicine of Northern Greece ©2012 Eηαιρeία Αναιζθηζιολογίας και Eνηαηικής Ιαηρικής Βορeίοσ Eλλάδος medical/surgical illness, and “routine” critical care practices like mechanical ventilation, the presence of indwelling catheters and tubes, iatrogenic illness, medication side effects, turning and suctioning, and excessive light and noise [1]. Important goals in the management of the critically ill patients include prevention and relief of suffering and distress and the provision of safe and effective care that leads to optimal outcome. Administration of sedatives and analgesics is a cornerstone for optimizing patient comfort and minimizing distress, particularly for patients on mechanical ventilation, yet it may lead to unintended consequences including adverse drug effects and delayed recovery from critical illness [2]. Effective analgesia and sedation in critically ill children includes caring for both their physiccal and psychological comfort. Any correctable environmental and physical factors causing discomfort should be addressed before the introduction of pharmacological agents; a normal sleep schedule should be attained, and attention should be paid to the provision of feeding and hydration, lighting, environmental noise, and the temporal orientation of the patients. All critically ill children have the right to adequate pain relief. Once adequate analgesia has been achieved, additional sedative agents may be required by some children. The aims of sedation are to reduce anxiety and distress of the child, and to allow for better tolerance of therapeutic and diagnostic procedures. Facilitation of mechanical ventilation is particularly important when less physiological ventilator modes as controlled ventilation or high frequency oscillatory ventilation are applied. Further benefits of sedation may include reduced metabolic rate and oxygen demand, enhance analgesia, a less disrupted sleep pattern, and reduced patient recall of unpleasant interventions. It is also well recognized that insufficient sedation is a risk factor for inadvertent self-extubation [3]. A variety of pharmacologic factors “conspire” to increase the likelihood of excessive and/or prolonged sedative effect in a patient who is critically ill, which include altered pharmacokinetic and pharmacodynamic characteristics with prolonged administration, altered protein binding and volume status, and end-organ dysfunction. Therefore, all sedation techniques must be patient-focused and individualized to patient needs. This goal directed approach improves patient outcome and reduces the use of sedative drugs. With pain being central to ICU discomfort, current sedation strategies for critically ill adults are based on “analgo-sedation” providing analgesia first and adding sedation as required. Deep sedation with or without muscle relaxants is rarely indicated, and it is associated with a hiThe Greek E-Journal of Perioperative Medicine 2012; 10:7-36 (ISSN 1109-6888) www.anesthesia. gr/ejournal Eλληνικό Πeριοδικό Πeριeγχeιρητικής Ιατρικής 2012; 10:7-36 (ISSN 1109-6888) www.anesthesia. gr/ejournal 9 ©2012 Society of Anesthesiology and Intensive Medicine of Northern Greece ©2012 Eηαιρeία Αναιζθηζιολογίας και Eνηαηικής Ιαηρικής Βορeίοσ Eλλάδος gher incidence of delirium and death [2, 4]. On the ground of better patient outcome by using lighter sedation in ICU, it is worth trying to explore whether an analogous practice could be used safely in pediatric intensive care patients as well. The objective of this article is to present a review of published data regarding analgesia and sedation in the pediatric intensive care unit (PICU).