Monitoring sedation in the critically ill child

Psychometric analysis of subjective sedation scales used for critically ill paediatric patients

AIMS

This study evaluated the psychometric properties of subjective sedation scales using one psychometric scoring system to identify the appropriate scale that is most suitable for clinical care practice.

BACKGROUND

A number of published sedation assessment scales for paediatric patients are currently used to attempt to achieve a moderate depth of sedation to avoid the undesirable effects caused by over- or undersedation. However, there has been no systematic review of these scales.

SEARCH STRATEGY

We searched the Cochrane Library, PubMed, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, etc., to obtain relevant articles. The quality of the selected studies was evaluated according to the Consensus-based Standards for the Selection of Health Measurement Instruments checklist.

INCLUSION CRITERIA

Articles that had been published or were in press and discussed the psychometric properties of sedation scales were included. The population comprised critically ill infants and non-verbal children ranging in age from 0 to 18 years who underwent sedation in an intensive care unit.

FINDINGS

Data were independently extracted by two investigators using a standard data extraction checklist: 43 articles were included in this review, and 13 sedation scales were examined. The quality of the psychometric evidence for the Comfort Scale and Comfort Behaviour Scale was 'very good', with the Comfort Scale having a higher quality (total weighted scores, Comfort Scale = 17·3 and Comfort Behaviour Scale = 15·5).

CONCLUSIONS

We suggest that the scales be systematically and comprehensively tested in terms of development method, reliability, validation, feasibility and correlation with clinical outcome. The Comfort Scale and Comfort Behaviour Scale are useful tools for measuring sedation in paediatric patients.

RELEVANCE TO CLINICAL PRACTICE

Nursing staff should choose one subjective sedation scale that is suitable for assessing paediatric patients' depth of sedation. We recommend the Comfort Scale and Comfort Behaviour Scale as optimal choices if the clinical environment permits.

ABCB1 genotype is associated with fentanyl requirements in critically ill children

BackgroundThe gene ABCB1 encodes p-glycoprotein, a xenobiotic efflux pump capable of transporting certain opioids, including fentanyl. ABCB1 genotype has been previously associated with patient opioid requirements and may influence fentanyl dosing requirements in critically ill children.MethodsA diagnostically diverse cohort of 61 children who received a fentanyl infusion while admitted to the pediatric intensive care unit (PICU) were included in this study. We examined associations between fentanyl requirements, pain and sedation scores, serum fentanyl levels, and ABCB1 genotype.ResultsPatients with the AA allele at ABCB1 locus rs1045642 received less fentanyl compared with patients with the AG or GG allele. A multivariable model demonstrated that patients with the AA allele received 18.6 mcg/kg/day less fentanyl than patients with either the AG or GG allele (95% confidence interval -33.4 to -3.8 mcg/kg/day; P=0.014). Incorporating race in this model demonstrated a similar association, but did not reach the threshold for multiple testing.ConclusionABCB1 genotype rs1045642 AA is associated with fentanyl administration in this cohort of children admitted to the PICU, likely because of decreased expression and activity of p-glycoprotein. Prospective evaluation of the influence of ABCB1 in sedative-analgesia administration in critically ill children is warranted.

Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version

In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the “Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care”. Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade “A” (strong recommendation), Grade “B” (recommendation) and Grade “0” (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.

The efficacy of the COMFORT score and pain management protocol in ventilated pediatric patients following cardiac surgery

BACKGROUND AND OBJECTIVES

An optimal scoring system for pain assessment in pediatric intensive care is necessary to determine the efficacy of analgesics. We assess the COMFORT scale in postoperative ventilated children and study the effect of pain and sedation protocols on their outcomes.

PATIENTS AND METHODS

We included postoperative ventilated patients. The unit-based pain management protocol was used. The assessment of the COMFORT and FLACC scales was performed by 2-nurses at 2-h intervals on the day of surgery and at 4-h intervals during the first 2-postoperative days or until the patient was ex-tubated. The patients' outcomes were compared with age-matched and RACHS score matched patients prior to the application of the pain protocol.

RESULTS

One-hundred-ten prospective patients were included. The mean age and weight was 24 months and 9.8 ± 8.4 kg, respectively. There was a weak, statistically significant correlation between the COMFORT and FLACC scales, with a range of (r = 0.01-0.7). The COMFORT scale demonstrated good internal consistency, with a Cronbach's alpha of 0.75. The mean ventilation days were 1.3 ± 3, with a mean ICU and hospital stay of 5 ± 5 and 10 ± 9 days, respectively. The 110 patients were compared to 50 retrospective matching patients. The prospective group demonstrated statistically less ventilation days, ICU stay time and hospital stay time, with P-values of 0.0004, 0.001 and 0.0003, respectively.

CONCLUSION

The COMFORT scale is a valuable and reliable pain assessment tool for use in postoperative ventilated pediatric patients. The implementation of a pain and sedation protocol decreased the incidence of withdrawal and the duration of mechanical ventilation as well as ICU and hospital stays.

Sedation monitoring during open muscle biopsy in children by Comfort Score and Bispectral Index - a prospective analysis

BACKGROUND

Open muscle biopsies in children are generally performed under general anesthesia. Alternatively, deep sedation and analgesia may be required.

OBJECTIVES

The aim of our study was to compare the Bispectral Index (BIS) and Comfort Score (CS) with respect to their clinical significance for sedation/analgesia in children undergoing open muscle biopsy.

METHODS

Thirty pediatric patients subjected to open muscle biopsy for diagnosis of their underlying disease were prospectively enrolled. Sedation/analgesia was performed in all patients using remifentanil and propofol. The patients were simultaneously monitored using the CS and BIS.

RESULTS

All sedations and muscle biopsies were performed uneventfully. The CS and BIS were significantly correlated (R = 0.589; P < 0.01). Receiver operating characteristic (ROC) analysis revealed an area under the curve (AUC) of 0.918 with a maximum cut-off point of BIS 70.5 (sensitivity 0.9; specificity 0.785) for adequate sedation. Sensitivity of 100% was achieved at BIS 60. Accordingly, all patients with BIS ≤60 had CS within the target range of 10-14. The BIS showed substantial intra- and interindividual variability (30 points and 58 points, respectively) during sedation, whereas CS varied only within close ranges during sedation. In 25 patients, sedatives were reduced according to low BIS values (<60). No unintended anesthesia awareness was noted during the study period.

CONCLUSION

Bispectral Index provides an additional helpful tool to guide sedation/analgesia in minor surgical procedures in children. BIS values ≤60 correlated with sufficient depth of sedation and prevented unintended awareness. Additionally, BIS measurement allowed for distinct regulation of depth of sedation without prolonged sedation/analgesia due to unintended overdose.

Assessment of pain in critically ill children. Is cutaneous conductance a reliable tool?

PURPOSE

The purpose of this study is to assess the usefulness and accuracy of skin conductance (SC) as a tool to evaluate the level of sedation and pain in pediatric critical patients during painful procedures and to compare it with hemodynamic variables, clinical scales, and bispectral index (BIS).

MATERIALS AND METHODS

This is a prospective observational study in 61 critical children undergoing invasive procedures. Hemodynamic data (heart rate and arterial blood pressure), clinical scales punctuation (Ramsay, COMFORT, and numeric rating pain scales), BIS, and the number of fluctuations of SC per second were collected before, during, and at the end of the procedure.

RESULTS

The mean age of the patients was 42.9 (range, 1 month to 16 years). Seventy-two point six percent were postcardiac surgery patients. Nonmuscle-relaxed patients showed a moderate increase in heart rate (P = .02), numeric rating pain scales (P = .03), and Ramsay scale (P = .002). The number of fluctuations of SC per second increased significantly during the procedure (basal, 0.1; maneuver, 0.2; P = .015), but it never reached the level considered as pain or stress nor did it precede clinical scales or BIS. None of the variables studied showed a significant change during the procedure in muscle-relaxed patients.

CONCLUSIONS

Skin conductance was not found to be more sensitive or faster than clinical scales for the assessment of pain or stress in critical children undergoing painful procedures. Skin conductance was not useful in muscle-relaxed children.

Nurse perception of Bispectral Index monitoring as an adjunct to sedation scale assessment in the critically ill paediatric patient

BACKGROUND

Reliability of clinical scales and haemodynamic variables for assessing sedation depth in critically children is limited, particularly for those receiving neuromuscular blocking agents (NMBAs).

OBJECTIVE

To introduce and integrate the use of Bispectral Index (BIS) monitoring as adjunct to sedation scale assessment in intubated mechanically ventilated Paediatric Intensive Care Unit (PICU) patients.

METHODS

Quality improvement intervention including: BIS education for all PICU nurses; 8-week implementation of BIS monitoring guided by Paediatric BIS Sedation Protocol; evaluation by convenience sample of nurses (n=17).

MEASUREMENTS

15-Item survey assessing perceptions of BIS attributes was given to nurses after first 4 BIS encounters; nurse comments and project coordinator observations were recorded.

FINDINGS

Survey data (intermediate reliability and nurse attitude ratings and low ratings on other attributes; little change over time) revealed nurses' reservations about the usefulness of BIS as an adjunct to sedation scales, but qualitative data indicated that they valued BIS for assessing sedation depth in children receiving NMBAs.

CONCLUSIONS

Post-intervention, BIS monitoring was adopted in PICU for children receiving NMBAs. One year later, this practice is sustained, and the percentage of BIS-monitored patients has increased. Guidelines addressing the use of BIS in patients not receiving paralytics are needed.

A review of the utility of EEG depth of anaesthesia monitors in the paediatric intensive care environment

OBJECTIVES

This paper aims to bring together current evidence regarding the use of depth of anaesthesia monitors (DoAM) as objective measures of sedation for paediatric intensive care (PIC) patients.

BACKGROUND

Delivering appropriate dosages of sedative agents, to individual PIC patients, is important to reduce the many risks of over- or under-sedation. Although based on adult anaesthesia, DoAMs could offer increased objectivity to the titration of sedative agents for children in PIC. This article synthesises the current available evidence from studies investigating DoAM use in the PIC environment.

METHOD

Literature regarding DoAM use in PIC was reviewed, from 1996 and August 2011, after EMBASE, PubMed, CINAHL and ProQuest Dissertation & Theses Database were searched using key search terms.

FINDINGS

Fourteen original research articles addressing sedation assessment using DoAMs in PIC were identified. The main findings were that DoAMs generally have a moderate or poor correlation with sedation scores and their performance varies in varying clinical settings. DoAMs do not make reliable conclusions about depth of sedation of individual PIC children, and can be influenced by children's age.

CONCLUSION

Evidence to support DoAMs in the PIC setting is currently not sufficient to advocate their routine use in clinical practice.