Sedation, Analgesia, and Neuromuscular Blockade: An Assessment of Practices From 2009 to 2016 in a National Sample of 66,443 Pediatric Patients Cared for in the ICU

Abstract

Objectives: To describe the pharmaceutical management of sedation, analgesia, and neuromuscular blockade medications administered to children in ICUs.

Design: A retrospective analysis using data extracted from the national database Health Facts.

Setting: One hundred sixty-one ICUs in the United States with pediatric admissions.

Patients: Children in ICUs receiving medications from 2009 to 2016.

Exposure/intervention: Frequency and duration of administration of sedation, analgesia, and neuromuscular blockade medications.

Measurements and main results: Of 66,443 patients with a median age of 1.3 years (interquartile range, 0-14.5), 63.3% (n = 42,070) received nonopioid analgesic, opioid analgesic, sedative, and/or neuromuscular blockade medications consisting of 83 different agents. Opioid and nonopioid analgesics were dispensed to 58.4% (n = 38,776), of which nonopioid analgesics were prescribed to 67.4% (n = 26,149). Median duration of opioid analgesic administration was 32 hours (interquartile range, 7-92). Sedatives were dispensed to 39.8% (n = 26,441) for a median duration of 23 hours (interquartile range, 3-84), of which benzodiazepines were most common (73.4%; n = 19,426). Neuromuscular-blocking agents were dispensed to 17.3% (n = 11,517) for a median duration of 2 hours (interquartile range, 1-15). Younger age was associated with longer durations in all medication classes. A greater proportion of operative patients received these medication classes for a longer duration than nonoperative patients. A greater proportion of patients with musculoskeletal and hematologic/oncologic diseases received these medication classes.

Conclusions: Analgesic, sedative, and neuromuscular-blocking medications were prescribed to 63.3% of children in ICUs. The durations of opioid analgesic and sedative medication administration found in this study can be associated with known complications, including tolerance and withdrawal. Several medications dispensed to pediatric patients in this analysis are in conflict with Food and Drug Administration warnings, suggesting that there is potential risk in current sedation and analgesia practice that could be reduced with practice changes to improve efficacy and minimize risks.

Figure 1:

Venn Diagram of Patients Receiving Non-Opioid Analgesic, Opioid Analgesic, Sedative and Neuromuscular Blockade Medications (N = 42,070)

Figure 2.

Non-Opioid Analgesic, Opioid Analgesic, Sedative and Neuromuscular Blockade Medications by Age

Figure 3

a – e. Patients Receiving Non-Opioid Analgesic, Opioid Analgesic, Sedative and Neuromuscular Blockade Medications for Diagnostic Categories (n = 39,514). Pairwise comparisons of the proportion of medication classes administered between each diagnostic group are significantly different (p<0.05). Pairwise comparisons are detailed in Supplemental Appendix 3. 1. P<0.05 for comparison of proportions in different diagnostic groups.

Figure 3

a – e. Patients Receiving Non-Opioid Analgesic, Opioid Analgesic, Sedative and Neuromuscular Blockade Medications for Diagnostic Categories (n = 39,514). Pairwise comparisons of the proportion of medication classes administered between each diagnostic group are significantly different (p<0.05). Pairwise comparisons are detailed in Supplemental Appendix 3. 1. P<0.05 for comparison of proportions in different diagnostic groups.

Figure 3

a – e. Patients Receiving Non-Opioid Analgesic, Opioid Analgesic, Sedative and Neuromuscular Blockade Medications for Diagnostic Categories (n = 39,514). Pairwise comparisons of the proportion of medication classes administered between each diagnostic group are significantly different (p<0.05). Pairwise comparisons are detailed in Supplemental Appendix 3. 1. P<0.05 for comparison of proportions in different diagnostic groups.

Figure 3

a – e. Patients Receiving Non-Opioid Analgesic, Opioid Analgesic, Sedative and Neuromuscular Blockade Medications for Diagnostic Categories (n = 39,514). Pairwise comparisons of the proportion of medication classes administered between each diagnostic group are significantly different (p<0.05). Pairwise comparisons are detailed in Supplemental Appendix 3. 1. P<0.05 for comparison of proportions in different diagnostic groups.