Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit

Abstract

Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.

Keywords: PICU; PICU-acquired complications; analgesia; critically ill pediatric patient; delirium; sedation; withdrawal.

Figure 1

An updated analgosedation approach (left) versus a traditional benzodiazepine-based sedation regimen (right). Republished with permission of NANCY INTERNATIONAL LTD SUBSIDIARY AME PUBLISHING COMPANY, from Sedation strategies in children with pediatric acute respiratory distress syndrome (PARDS), Rosenberg, L. and Traube, C., Annals of Translational Medicine, Vol 7, No 19, 2019; permission conveyed through Copyright Clearance Center, Inc [185].