Intensive Care Medicine

, Volume 32, Issue 8, pp 1125–1136

Consensus guidelines on sedation and analgesia in critically ill children

  • Stephen Playfor
  • Ian Jenkins
  • Carolyne Boyles
  • Imti Choonara
  • Gerald Davies
  • Tim Haywood
  • Gillian Hinson
  • Anton Mayer
  • Neil Morton
  • Tanya Ralph
  • Andrew Wolf
  • United Kingdom Paediatric Intensive Care Society Sedation
  • Analgesia and Neuromuscular Blockade Working Group
Special Article

Abstract

Objective

The United Kingdom Paediatric Intensive Care Society Sedation, Analgesia and Neuromuscular Blockade Working Group is a multi-disciplinary expert panel created to produce consensus guidelines on sedation and analgesia in critically ill children and forward knowledge in these areas. Sedation and analgesia are recognised as important areas of critical care practice and adult clinical practice guidelines in these fields remain amongst the most popular of those produced by the Society of Critical Care Medicine. However, similar clinical practice guidelines have not previously been produced for the critically ill paediatric patient.

Design

A modified Delphi technique was used to allow the Working Group to anonymously consider draft recommendations in three Delphi rounds with predetermined levels of agreement. This process was supported by a total of four consensus conferences. Once consensus had been reached, a systematic review of the available literature was carried out.

Outcome

A set of consensus guidelines was produced including 20 key recommendations, 10 relating to the provision of analgesia and 10 relating to the sedation of critically ill children. An evaluation of the existing literature supporting these recommendations is provided.

Conclusions

Multi-disciplinary consensus guidelines for maintenance sedation and analgesia in critically ill children have been successfully produced and are supported by levels of evidence (excluding sedation and analgesia for procedures and excluding neonates). The working group has highlighted the paucity of high-quality evidence in these important clinical areas and this emphasises the need for further randomised clinical trials in this area.

Keywords

Paediatric intensive care morphine fentanyl midazolam propofol withdrawal comfort 

References

  1. 1.
    Shapiro BA, Warren J, Egol AB, Greenbaum DM, Jacobi J, Nasraway SA, Schein RM, Spevetz A, Stone JR (1995) Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit: an executive summary. Crit Care Med 23:1596–1600PubMedCrossRefGoogle Scholar
  2. 2.
    Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, Chalfin DB, Masica MF, Bjerke HS, Coplin WM, Crippen DW, Fuchs BD, Kelleher RM, Marik PE, Nasraway SA Jr, Murray MJ, Peruzzi WT, Lumb PD; Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists (ASHP), American College of Chest Physicians (2002) Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 30:119–141PubMedCrossRefGoogle Scholar
  3. 3.
    Harbour R, Miller J (2001) A new system for grading recommendations in evidence based guidelines BMJ 323:334–336Google Scholar
  4. 4.
    Griffin JP, Myers S, Kopelke C, Walker D (1988) The effects of progressive muscular relaxation on subjectively reported disturbance due to hospital noise. Behav Med 14:37–42PubMedCrossRefGoogle Scholar
  5. 5.
    Labyak SE, Metzger BL (1997) The effects of effleurage backrub on the physiological components of relaxation: a meta-analysis. Nurs Res 46:59–62PubMedCrossRefGoogle Scholar
  6. 6.
    Richards KC (1998) Effect of a back massage and relaxation intervention on sleep in critically ill patients. Am J Crit Care 7:288–299PubMedGoogle Scholar
  7. 7.
    Stevenson JG, French JW, Tenckhoff L, Maeda H, Wright S, Zamberlin K (1990) Video viewing as an alternative to sedation for young subjects who have cardiac ultrasound examinations. J Am Soc Echocardiogr 3:488–490PubMedGoogle Scholar
  8. 8.
    Koch ME, Kain ZN, Ayoub C, Rosenbaum SH (1998) The sedative and analgesic sparing effects of music. Anesthesiology 89:300–306PubMedCrossRefGoogle Scholar
  9. 9.
    Bullock EA, Shaddy RE (1993) Relaxation and imagery techniques without sedation during right ventricular endomyocardial biopsy in pediatric heart transplant patients. J Heart Lung Transplant 12:59–62PubMedGoogle Scholar
  10. 10.
    Guzzetta CE (1989) Effects of relaxation and music therapy on patients in a coronary care unit with presumptive myocardial infarction. Heart Lung 18:609–616PubMedGoogle Scholar
  11. 11.
    Updike P (1990) Music therapy results for ICU patients. Dimens Crit Care Nurs 9:39–45PubMedCrossRefGoogle Scholar
  12. 12.
    Bolwerk CA (1990) Effects of relaxing music on state anxiety in myocardial infarction patients. Crit Care Nurs Q 13:63–72PubMedGoogle Scholar
  13. 13.
    Zimmerman L, Nieveen J, Barnason S, Schmaderer M (1996) The effects of music interventions on postoperative pain and sleep in coronary artery bypass graft (CABG) patients. Sch Inq Nurs Pract 10:153–170PubMedGoogle Scholar
  14. 14.
    Byers JF, Smyth KA (1997) Effect of a music intervention on noise annoyance, heart rate, and blood pressure in cardiac surgery patients. Am J Crit Care 6:183–191PubMedGoogle Scholar
  15. 15.
    Chan L (1998) Effectiveness of a music therapy intervention on relaxation and anxiety for patients receiving ventilatory assistance. Heart Lung 27:169–176CrossRefGoogle Scholar
  16. 16.
    White JM (1999) Effects of relaxing music on cardiac autonomic balance and anxiety after acute myocardial infarction. Am J Crit Care; 8:220–230PubMedGoogle Scholar
  17. 17.
    Playfor SD, Thomas DA, Choonara I (2000) Recall following Paediatric Intensive Care. Arch Dis Child; 83:445–448PubMedCrossRefGoogle Scholar
  18. 18.
    Stein-Parbury J, McKinley S (2000) Patients' experiences of being in an intensive care unit: A select literature review. Am J Crit Care; 9:20–27PubMedGoogle Scholar
  19. 19.
    Meyer TJ, Eveloff SE, Bauer MS, Schwartz WA, Hill NS, Millman RP (1994) Adverse environmental conditions in the respiratory and medical ICU settings. Chest; 105:1211–1216PubMedCrossRefGoogle Scholar
  20. 20.
    Aaron JN, Carlisle CC, Carskadon MA, Meyer TJ, Hill NS, Millman RP (1996) Environmental noise as a cause of sleep disruption in an intermediate respiratory care unit. Sleep 19:707–710PubMedGoogle Scholar
  21. 21.
    Freedman NS, Kotzer N, Schwab RJ (1999) Patient perception of sleep quality and etiology of sleep disruption in the intensive care unit. Am J Resp Crit Care Med 159:1155–1162PubMedGoogle Scholar
  22. 22.
    Agency UEP. 1974. Information on levels of environmental noise requisite to protect public health and welfare with an adequate margin of safety. US Government Printing Office, Washington, DC.Google Scholar
  23. 23.
    Chen HI, Tang YR (1989) Sleep loss impairs inspiratory muscle endurance. Am Rev Respir Dis 140:907–909PubMedGoogle Scholar
  24. 24.
    Schiffman PL, Trontell MC, Mazar MF, Edelman NH (1983) Sleep deprivation decreases ventilatory response to CO2 but not load compensation. Chest; 84:695–698PubMedCrossRefGoogle Scholar
  25. 25.
    Krachman SL, D'Alonzo GE, Criner GJ (1995) Sleep in the intensive care unit. Chest 107:1713–1720PubMedCrossRefGoogle Scholar
  26. 26.
    Horne JA (1985) Sleep function, with particular reference to sleep deprivation. Ann Clin Res 17:199–208PubMedGoogle Scholar
  27. 27.
    Brown R, Price RJ, King MG, Husband AJ (1989) Interleukin-1 beta and muramyl dipeptide can prevent decreased antibody response associated with sleep deprivation. Brain Behav Immun 3:320–330PubMedCrossRefGoogle Scholar
  28. 28.
    Merskey H, Bugduk N (1994) Classification of chronic pain. Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. 2nd ed. Seattle, WA: IASP Press.Google Scholar
  29. 29.
    Middleton C (2003) Understanding the physiological effects of unrelieved pain. Nurs Times 99:28–31PubMedGoogle Scholar
  30. 30.
    Epstein J, Breslow MJ (1999) The stress response of critical illness. Crit Care Clin; 15:17–33PubMedCrossRefGoogle Scholar
  31. 31.
    Lewis KS, Whipple JK, Michael KA, Quebbeman EJ (1994) Effect of analgesic treatment on the physiological consequences of acute pain. Am J Hosp Pharm 51:1539–1554PubMedGoogle Scholar
  32. 32.
    Gust R, Pecher S, Gust A, Hoffmann V, Bohrer H, Martin E (1999) Effect of patient-controlled analgesia on pulmonary complications after coronary artery-bypass grafting. Crit Care Med 27:2218–2223PubMedCrossRefGoogle Scholar
  33. 33.
    Desai PM (1999) Pain management and pulmonary dysfunction. Crit Care Clin 15:151–166PubMedCrossRefGoogle Scholar
  34. 34.
    Clark F, Gilbert HC (2001) Regional analgesia in the intensive care unit. Principles and practice. Crit Care Clin 17:943–966PubMedCrossRefGoogle Scholar
  35. 35.
    Tobias JD (1994) Continuous femoral nerve block to provide analgesia following femur fracture in a paediatric ICU population. Anaesth Intensive Care 22:616–618PubMedGoogle Scholar
  36. 36.
    Bosenberg A (2004) Pediatric regional anesthesia update. Paediatr Anaesth 14:398–402PubMedCrossRefGoogle Scholar
  37. 37.
    Birmingham PK, Wheeler M, Suresh S, Dsida RM, Rae BR, Obrecht J, Andreoni VA, Hall SC, Cote CJ (2003) Patient-controlled epidural analgesia in children: can they do it? Anesth Analg 96:686–691PubMedGoogle Scholar
  38. 38.
    McDonald AJ, Cooper MG (2001) Patient-controlled analgesia: an appropriate method of pain control in children. Paediatric Drugs 3:273–284PubMedCrossRefGoogle Scholar
  39. 39.
    Beaulieu P (1998) Age and opioid patient-controlled analgesia use. Anaesthesia 53:208PubMedGoogle Scholar
  40. 40.
    Monitto CL, Greenberg RS, Kost-Byerly S, Wetzel R, Billett C, Lebet RM, Yaster M (2000) The safety and efficacy of parent-/nurse-controlled analgesia in patients less than six years of age. Anesth Analg 91:573–579 PubMedCrossRefGoogle Scholar
  41. 41.
    Breau LM, Finley GA, McGrath PJ, Camfield CS (2002) Validation of the Non-communicating Children's Pain Checklist-Postoperative Version. Anesthesiology 96:528–535PubMedCrossRefGoogle Scholar
  42. 42.
    Grunau RV, Johnston CC, Craig KD (1990) Neonatal facial and cry responses to invasive and non-invasive procedures. Pain 42:295–305PubMedCrossRefGoogle Scholar
  43. 43.
    Stevens B, Johnston C, Petryshen P, Taddio A (1996) Premature Infant Pain Profile: development and initial validation. Clin J Pain 12:13–22PubMedCrossRefGoogle Scholar
  44. 44.
    Beyer JE, Denyes MJ, Villarruel AM (1992) The creation, validation, and continuing development of the Oucher: a measure of pain intensity in children. J Pediatr Nurs 7:335–346PubMedGoogle Scholar
  45. 45.
    Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB (1990) The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain 41:139–150PubMedCrossRefGoogle Scholar
  46. 46.
    Wong DL, Baker CM (1988) Pain in children: comparison of assessment scales. Pediatr Nurs 14:9–17PubMedGoogle Scholar
  47. 47.
    Chambers CT, Giesbrecht K, Craig KD, Bennett SM, Huntsman E (1999) A comparison of faces scales for the measurement of pediatric pain: children's and parents' ratings. Pain 83:25–35PubMedCrossRefGoogle Scholar
  48. 48.
    Berde CB, Sethna NF (2002) Analgesics for the treatment of pain in children. N Engl J Med 347:1094–1103PubMedCrossRefGoogle Scholar
  49. 49.
    Lynn A, Nespeca MK, Bratton SL, Strauss SG, Shen DD (1998) Clearance of morphine in postoperative infants during intravenous infusion: the influence of age and surgery. Anesth Analg 86:958–963PubMedCrossRefGoogle Scholar
  50. 50.
    Arnold JH, Truog RD, Orav EJ, Scavone JM, Hershenson MB (1990) Tolerance and dependence in neonates sedated with fentanyl during ECMO. Anesthesiology; 73:36–40Google Scholar
  51. 51.
    Katz R, Kelly HW, Hsi A (1994) Prospective study on the occurrence of withdrawal in critically ill children who receive fentanyl by continuous infusion. Crit Care Med 22:763–767PubMedCrossRefGoogle Scholar
  52. 52.
    Franck LS, Vilardi J, Durand D, Powers R (1998) Opioid withdrawal in neonates after continuous infusions of morphine or fentanyl during extracorporeal membrane oxygenation. Am J Crit Care 7:364–369Google Scholar
  53. 53.
    Egan TD, Lemmens HJ, Fiset P, Hermann DJ, Muir KT, Stanski DR, Shafer SL (1993) The pharmacokinetics of the new short-acting opioid remifentanil (GI87084B) in healthy adult male volunteers. Anesthesiology 79:881–892PubMedCrossRefGoogle Scholar
  54. 54.
    Tobias JD: Remifentanil (1998) Applications in the Pediatric ICU Population. Amer J Pain Manage 8:114–117Google Scholar
  55. 55.
    Korpela R, Korvenoja P, Meretoja OA (1999) Morphine-sparing effect of acetaminophen in pediatric day-case surgery. Anesthesiology 91:442–447PubMedCrossRefGoogle Scholar
  56. 56.
    Schug SA, Sidebotham DA, McGuinnety M, Thomas J, Fox L (1998) Acetaminophen as an adjunct to morphine by patient-controlled analgesia in the management of acute postoperative pain. Anesth Analg 87:368–372PubMedCrossRefGoogle Scholar
  57. 57.
    Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D, Sherman G (1998) The use of continuous IV sedation is associated with prolongation of mechanical ventilation. Chest 114:541–548PubMedCrossRefGoogle Scholar
  58. 58.
    Kress JP, Pohlman AS, O'Connor MF, Hall JB (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342:1471–1477PubMedCrossRefGoogle Scholar
  59. 59.
    Kress JP, Gehlbach B, Lacy M, Pliskin N, Pohlman AS, Hall JB (2003) The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med 168:1457–1461PubMedCrossRefGoogle Scholar
  60. 60.
    Randolph AG, Wypij D, Venkataraman ST, Hanson JH, Gedeit RG, Meert KL, Luckett PM, Forbes P, Lilley M, Thompson J, Cheifetz IM, Hibberd P, Wetzel R, Cox PN, Arnold JH; Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network (2002) Effect of mechanical ventilator weaning protocols on respiratory outcomes in infants and children: a randomized controlled trial. JAMA 288:2561–2568PubMedCrossRefGoogle Scholar
  61. 61.
    Devlin JW, Holbrook AM, Fuller HD (1997) The effect of ICU sedation guidelines and pharmacist interventions on clinical outcomes and drug cost. Ann Pharmacother 31:689–695PubMedGoogle Scholar
  62. 62.
    Saich C, Manji M, Dyer I (1999) Effect of introducing a sedation guideline on sedative costs per bed day. Br J Anaesth 82:792–793PGoogle Scholar
  63. 63.
    Mascia MF, Koch M, Medicis JJ (2000) Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care. Crit Care Med 28:2300–2306PubMedCrossRefGoogle Scholar
  64. 64.
    Ambuel B, Hamlett KW, Marx CM, Blumer JL (1992) Assessing distress in pediatric intensive care environments: The COMFORT Scale. J Pediatric Psychology 17:95–109CrossRefGoogle Scholar
  65. 65.
    Davidson AJ (2003) Depth of anaesthesia monitors in paediatric anaesthesia. In: John Keneally (eds). Australasian Anaesthesia 2003. Australian and New Zealand College of AnaesthetistsGoogle Scholar
  66. 66.
    De Deyne C, Struys M, Decruyenaere J, Creupelandt J, Hoste E, Colardyn F (1998) Use of continuous bispectral EEG monitoring to assess depth of sedation in ICU patients. Intensive Care Med 24:1294–1298PubMedCrossRefGoogle Scholar
  67. 67.
    Mychaskiw G, Heath BJ, Eichhorn JH (2000) Falsely elevated bispectral index during deep hypothermic circulatory arrest. Br J Anaesth 8:798–800CrossRefGoogle Scholar
  68. 68.
    Berkenbosch JW, Fichter CR, Tobias JD (2002) The correlation of the bispectral index monitor with clinical sedation scores during mechanical ventilation in the pediatric intensive care unit. Anesth Analg 94:506–511PubMedCrossRefGoogle Scholar
  69. 69.
    Crain N, Slonim A, Pollack MM (2002) Assessing sedation in the pediatric intensive care unit by using BIS and the COMFORT scale. Pediatr Crit Care Med 3:11–14PubMedCrossRefGoogle Scholar
  70. 70.
    Simmons LE, Riker RR, Prato BS, Fraser GL (1999) Assessing sedation levels in mechanically ventilated ICU patients with the bispectral index and the sedation-agitation scale. Crit Care Med 27:1499–1504PubMedCrossRefGoogle Scholar
  71. 71.
    Riker RR, Fraser GL, Simmons LE, Wilkins ML (2001) Validating the sedation-agitation scale with the bispectral index and visual analog scale in adult ICU patients after cardiac surgery. Intensive Care Med 27:853–858PubMedCrossRefGoogle Scholar
  72. 72.
    Playfor SD (2005) The use of bispectral index monitors in paediatric intensive care. Crit Care 9:25–26PubMedCrossRefGoogle Scholar
  73. 73.
    Ghoneim MM, Mewaldt SP (1990) Benzodiazepines and human memory: A Review. Anesthesiology 72:926–938PubMedCrossRefGoogle Scholar
  74. 74.
    de Wildt SN, de Hoog M, Vinks AA, van der Giesen E, van den Anker JN (2003) Population pharmacokinetics and metabolism of midazolam in pediatric intensive care patients. Crit Care Med 31:1952–1958PubMedCrossRefGoogle Scholar
  75. 75.
    Boulieu R, Lehmann B, Salord F, Fisher C, Morlet D (1998) Pharmacokinetics of midazolam and its main metabolite 1-hydroxymidazolam in intensive care patients. Eur J Drug Metab Pharmacokinet 23:255–258PubMedCrossRefGoogle Scholar
  76. 76.
    Shelly MP, Mendel L, Park GR (1987) Failure of critically ill patients to metabolise midazolam. Anaesthesia 42:619–626PubMedCrossRefGoogle Scholar
  77. 77.
    Hiller A, Olkkola KT, Isohanni P, Saarnivaara L (1990) Unconsciousness associated with midazolam and erythromycin. Br J Anaesth 65:826–828PubMedCrossRefGoogle Scholar
  78. 78.
    Playfor SD, Thomas DA, Choonara I, Collier J, Jarvis A (2001) Parental perceptions of comfort during mechanical ventilation. Paediatr Anaesth 11:99–103PubMedCrossRefGoogle Scholar
  79. 79.
    Ambrose C, Sale S, Howells R, Bevan C, Jenkins I, Weir P, Murphy P, Wolf A (2000) Intravenous clonidine infusion in critically ill children: dose-dependent sedative effects and cardiovascular stability. Br J Anaesth 84:794–796PubMedGoogle Scholar
  80. 80.
    Maze M, Tranquill W (1991) Alpha-2 agonists: defining their role in clinical anesthesia. Anesthesiology 74:581–605PubMedCrossRefGoogle Scholar
  81. 81.
    Parkinson L, Hughes J, Gill A, Billingham I, Ratcliffe J, Choonara I (1997) A randomized controlled trial of sedation in the critically ill. Paediatr Anaesth 7:405–410PubMedCrossRefGoogle Scholar
  82. 82.
    Vasile B, Rasulo F, Candiani A, Latronico N (2003) The pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome. Intensive Care Med 29:1417–1425PubMedCrossRefGoogle Scholar
  83. 83.
    Wolf A, Weir P, Segar P, Stone J, Shield J (2001) Impaired fatty acid oxidation in propofol infusion syndrome. Lancet 357:606–607PubMedCrossRefGoogle Scholar
  84. 84.
    Parke TJ, Stevens JE, Rice AS, Greenaway CL, Bray RJ, Smith PJ, Waldmann CS, Verghese C (1992) Metabolic acidosis and fatal myocardial failure after propofol infusion in children: five case reports. BMJ 305:613–616PubMedCrossRefGoogle Scholar
  85. 85.
    MCA/CSM Current problems in Pharmacovigilance (2001) 27:10Google Scholar
  86. 86.
    Hughes J, Gill A, Leach HJ, Nunn AJ, Billingham I, Ratcliffe J, Thornington R, Choonara I (1994) A prospective study of the adverse effects of midazolam on withdrawal in critically ill children. Acta Paediatr 83:1194–1199PubMedGoogle Scholar
  87. 87.
    Fonsmark L, Rasmussen Y, Carl P (1999) Occurrence of withdrawal in critically ill sedated children. Crit Care Med 27:196–199PubMedCrossRefGoogle Scholar
  88. 88.
    Kron RE, Finnegan LP, Kaplan SL, Litt M, Phoenix MD (1975) The assessment of behavioral change in infants undergoing narcotic withdrawal: comparative data from clinical and objective methods. Addict Dis 2:257–275PubMedGoogle Scholar
  89. 89.
    Green M, Suffet F (1981) The Neonatal Narcotic Withdrawal Index: a device for the improvement of care in the abstinence syndrome. Am J Drug Alcohol Abuse 8:203–213PubMedCrossRefGoogle Scholar
  90. 90.
    Tobias JD (2000) Tolerance, withdrawal, and physical dependency after long-term sedation and analgesia of children in the pediatric intensive care unit. Crit Care Med 28:2122–2132PubMedCrossRefGoogle Scholar
  91. 91.
    Maldonado R (1997) Participation of noradrenergic pathways in the expression of opiate withdrawal: biochemical and pharmacological evidence. Neurosci Biobehav Rev 21:91–104PubMedCrossRefGoogle Scholar
  92. 92.
    Carr DB, Todres ID (1994) Fentanyl infusion and weaning in the pediatric intensive care unit: Toward science-based practice. Crit Care Med 22:725–727PubMedCrossRefGoogle Scholar
  93. 93.
    Tobias JD (1999) Subcutaneous administration of fentanyl and midazolam to prevent withdrawal after prolonged sedation in children. Crit Care Med 27:2262–2265PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • Stephen Playfor
    • 1
  • Ian Jenkins
    • 1
  • Carolyne Boyles
    • 1
  • Imti Choonara
    • 1
  • Gerald Davies
    • 1
  • Tim Haywood
    • 1
  • Gillian Hinson
    • 1
  • Anton Mayer
    • 1
  • Neil Morton
    • 1
  • Tanya Ralph
    • 1
  • Andrew Wolf
    • 1
  • United Kingdom Paediatric Intensive Care Society Sedation
    • 1
  • Analgesia and Neuromuscular Blockade Working Group
    • 1
  1. 1.Paediatric Intensive Care UnitRoyal Manchester Children's HospitalManchesterUK

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