Postoperative Sedation and Analgesia After Pediatric Liver Transplantation

Trends in sedation-analgesia practices in pediatric liver transplant patients admitted postoperatively to the pediatric intensive care unit: An analysis of data from the pediatric health information system (PHIS) database

BACKGROUND

Children admitted to the pediatric intensive care unit (PICU), after liver transplantation, frequently require analgesia and sedation in the immediate postoperative period. Our objective was to assess trends and variations in sedation and analgesia used in this cohort.

METHODS

Multicenter retrospective cohort study using the Pediatric Health Information System from 2012 to 2022.

RESULTS

During the study period, 3963 patients with liver transplantation were admitted to the PICU from 32 US children's hospitals with a median age of 2 years [IQR: 0.00, 10.00]. 54 percent of patients received mechanical ventilation (MV). Compared with patients without MV, those with MV were more likely to receive morphine (57% vs 49%, p < .001), fentanyl (57% vs 44%), midazolam (45% vs 31%), lorazepam (39% vs. 24%), dexmedetomidine (38% vs 30%), and ketamine (25% vs 12%), all p < .001. Vasopressor usage was also higher in MV patients (22% vs. 35%, p < .001). During the study period, there was an increasing trend in the utilization of dexmedetomidine and ketamine, but the use of benzodiazepine decreased (p < .001).

CONCLUSION

About 50% of patients who undergo liver transplant are placed on MV in the PICU postoperatively and receive a greater amount of benzodiazepines in comparison with those without MV. The overall utilization of dexmedetomidine and ketamine was more frequent, whereas the administration of benzodiazepines was less during the study period. Pediatric intensivists have a distinctive opportunity to collaborate with the liver transplant team to develop comprehensive guidelines for sedation and analgesia, aimed at enhancing the quality of care provided to these patients.

Optimizing Sedation Management to Promote Early Mobilization for Critically Ill Children

Achieving successful early mobilization for the intubated, critically ill child is dependent on optimizing sedation and analgesia. Finding the fine balance between oversedation and undersedation can be challenging. The ideal is for a child to be lucid and interactive during the daytime and demonstrate normal circadian rhythm for sleep with rest at night. Being alert during the day facilitates active participation in therapy including potential ambulation, while decreasing the risk of delirium during mechanical ventilation. An active state during the day with frequent mobilization promotes restorative sleep at night, which brings with it multiple benefits for healing and recovery. Indeed, this ideal may not be physiologically feasible given a child's critical illness and trajectory, but defining it as the "gold standard" for early mobilization provides a consistent goal for the pediatric intensive care unit (PICU) hospitalization. As such, goal-directed, patient-specific sedation plans are integral to creating a culture of mobility in the PICU. We review currently available sedation strategies for mechanically ventilated children for successful implementation of early mobilization in the PICU, as well as pharmacologic considerations for specific classes of sedative-analgesics.