Journal of Anesthesia and Surgery
A Practical Guide to Sedation and Analgesia in Paediatric Intensive Care Unit (ICU)
- 1Specialist Anaesthesiology; NMC Hospital Dubai Investment Park, Dubai, UAE
- 2Specialist Anaesthesiology, Al
GahroudHospital, Dubai, UAE
- 33Consultant Anaesthesiologist, Al Zahra Hospital, Sharjah, UAE
Dr. Surjya Prasad Upadhyay, Specialist Anaesthesiology, NMC Hospital Dubai, Investment Park, Dubai, UAE, E-mail: firstname.lastname@example.org
Upadhyay, S.P., et al. A Practical Guide to Sedation and Analgesia in Paediatric Intensive Care Unit (ICU). (2017) J Anesth Surg 4(1): 1- 6.
© 2017 Upadhyay, S.P. This is an Open access article distributed under the terms of Creative Commons Attribution 4.0 International License.
KeywordsSedation; Paediatric Intensive Care; Analgesia
All critically ill children have the right to adequate relief of their pain Correctable physical and environmental factors causing discomfort should be addressed using non-pharmacologic interventions before the initiation of pharmacologic interventions. The choice of sedative-analgesic agent and its initial dose are selected on the basis of several factors such
Appropriate sedation and analgesia are essential components of care in the treatment of critically ill child in paediatric intensive care unit (ICU) especially those with mechanical ventilation. The main indications for sedation analgesia in ICU includes[2-4].
• improving patient comfort by reducing anxiety, pain and agitation,
• to facilitate aggressive ICU therapy (mechanical ventilation, invasive procedure)
• to avoid accidental removal of medical devices (endotracheal tube, invasive line)
• to decrease cellular metabolism
Most clinicians provide sedatives and analgesics according to their professional experience based on the patient’s estimated need for sedation without proper monitoring and frequent re-evaluation that may contribute to adverse outcomes and complications. Both
Sedation challenges in
Unlike adult ICU,
Figure 1: Overlap of
Identify the cause of distress: One should try to find out the cause of the distress and address the root cause. Common causes of distress in
Anxiety: Unfamiliar atmosphere, stranger
Pain: There can be many
Delirium: It is an acute and potentially reversible impairment of cognitive and consciousness that often fluctuate in severity that can’t be better accounted for by another pre-existing neurocognitive disorder. Delirium has been described in infant below one year of age as well. Delirium symptoms are similar in adults and
Iatrogenic withdrawal syndrome (IWS): Prolonged administration of sedative-analgesic particularly opioid and benzodiazepine may
Nonpharmacological strategies: Non-pharmacologic strategy should be complementary as they act as an adjunct to pharmacological agents, reduces the requirement of
Pharmacologic intervention: The sedation in ICU can be best described in three phase, initiation, maintenance and weaning phase. The goal and approach vary from patient to patient, response to interventions and clinical conditions. Loading dose
Initiation and selection of agent: Adequate Analgesia should be provided to all critically
Table 1: Aetiology of distress and choice of sedative-analgesic in Paediatric ICU.
|Etiology of distress||Choice of drugs|
|Pain||Opioid, non-opioid analgesics, Local and regional blocks|
|Separation / strange Anxiety|
|Drug withdrawal syndromes||Benzodiazepine, dexmedetomidine|
|Intubated, mechanical ventilation||Combination of analgesic, sedative with or without relaxant|
Sedation and analgesia Goal: The ideal sedative-analgesic goal is for the patient to be awake and comfortable with minimal to no distress, however, some patients may require deeper level of sedation for optimal management (eg. patients on ventilator; head injury, ARDS). Scoring system has been designed to make evaluation for pain, depth of sedation and delirium assessment. The scoring systems are more useful
Assessment of pain: Routine pain assessment in systemic way using standardized, validated measure is considered as the foundation of effective pain management for any patient, regardless of age, condition or setting. Children as young as three years can
Table 2: Commonly used pain scoring system in
|Name||Recommended age group||Description|
|CRIES pain scale||0-6 month||Includes 5 points with 0-2 score for each point; Crying, Respiration, Increase in vital signs,
|Behavioral/ physiological scale eg FLACC||0-7 years||Evaluate 5 point (0-2 score) age-
||Above 3 years||Useful for preschool children, limited utility in subpopulation (cognitive impairment, mechanical ventilation)|
|Above 3 years||Simple scoring tool used for pain discrimination, self-report faces scale for acute pain. Six line-drawn faces range from no pain to worst pain with assigned numerical value and word description (no hurt, hurt little, hurt a bit, hurt a whole lot etc) to each face.|
|Multidimensional Assessment of Pain Scale (MAPS)||0-3 years/ cognitively impaired children||Incorporate behavioral and physiological indicators; has been validated in young infant and children, cognitively impaired/ ventilated Yes|
Sedation assessment in Paediatric ICU: Proper assessment of adequate sedation should be used concomitantly with routine pain assessment. Sedation in ICU is a dynamic process; sedative dose should be titrated to fluctuating level of sedation which is stimulus dependent. The degree of sedation requirement varies from patient to patient according to the underlying clinical condition and nature of required therapeutic, invasive or investigative procedures. Many paediatric ICU is until using either adult sedation scale (Ramsay, Richmond sedation score) or scales not specifically designated to evaluate sedation (eg
Table 3: Common
|Scoring system||Age group||General description|
|State Behavioral Scale||6 week to 6 years||Six-dimension scoring tools (-3 to 2 scoring system based on patient’s response to voice then touch and then noxious stimuli) derived from state/
|Penn State Children’s Sedation Algorithm||Children younger than 18 years||Six-item scoring tool (level 1-6) that defined target goals of sedation related to the amount of ventilator support required. Used for sedated/
|COMFORT and COMFORT-behavioural Scale||Children younger than 18 years||The most extensively used and validated tool.
Comfort scale has eight domains and includes physiological variable heart rate and blood pressure and does not include crying where as comfort
|Hartwig Sedation Scale||1 month to 5 years||Five-domain scoring tool that assesses motor response, mimic ability,
The best evaluated and validated clinical score system are the COMFORT and COMFORT-behaviour scale, which are also used to assess both pain and sedation. However, these are not useful for patients on
Neurophysiological monitoring: Children who are mechanically ventilated and pharmacologically paralysed, monitoring of depth of sedation, level of pain and presence of delirium is challenging. In this subgroup of patients, neurophysiological monitoring technique such as bispectral index (BIS) or auditory-evoked potentials can be utilised. BIS monitoring uses electroencephalographic (EEG) signals and analysed these signals through a complex Fourier transformation to give a numerical value ranging from 0 to 100, where 0 is no neurological activity and 100 is fully awake patient. These
Drug and dosing: The choice of drug and dosing depends on many factors like
Table 4: Dosing of commonly used analgesic and sedative.
|Drugs||Dose||Onset||Indication / Comments|
|Fentanyl||IV bolus 1-2
infusion: 1-10 mcg/kg/hr
|Morphine||IV bolus 0.1-0.2 mg/kg PRN Q1 hr
|5-10 min||Sedative and analgesics for
Analgesia 0.5-6 mcg/kg/hr
sedation 6-12 mcg/kg/hr
|Midazolam||Oral -0.5 - 0.75 mg/kg
iv 0.15-0.3 mg.kg
|2-5 min||May cause initial hypotension on bolus dose.
|Lorazepam||Iv: loading dose 0.02-0.06 mg/kg.
Infusion: 0.02-0.1 mg/kg/hr
|5-20 min||Longer acting benzodiazepine, action similar to midazolam. limited clinical experience in
|Propofol||Loading dose 1-2 mg/kg
infusion: 0.5-3 mg/kg/hr
|Dexmedetomidine||Loading dose -1mcg/kg over 10-15 min
infusion- 0.2-0.7 mcg.kg/hr
|5-10 min||Central sympatholytic; IV bolus associated with hypertension/hypotension; associated with rebound hypertension; increased accumulation in liver failure|
|Ketamine||Loading dose-1-2 mg/kg
|1-2 min||Strong analgesic and sedative, reduces opioid requirements, may cause hypertension, increased in intracranial pressure, emergence delirium and can accumulate in hepatic failure.|
|Thiopental||Iv loading 3-5 mg/kg
infusion: 1-5 mg/kg/hr
|30 sec||Not ideal for prolong use in ICU, may have a role in refractory status epilepticus. Losing the popularity because of propofol.|
A current literature consistently supports the use of the minimum possible level of sedation. There
• Intermittent small bolus doses without increasing the basal infusion rate.
• Daily interruption of sedation until the child is awake and
• Sedation Holidays or sedation vacation: Similar to daily interruption of sedative-analgesic, but instead of daily affair it is done on
• Cycling of sedative-analgesics.
• Central nervous system (CNS): agitation, restless, seizure, hallucination, psychosis, etc
• Autonomic features: vomiting, tachycardia, hypertension, fever.
• Cardiovascular: tachycardia, hypertension, arrhythmias.
• Respiratory: hyperventilation; desaturation
Commonly used strategies to reduce the withdrawal syndrome start with efforts to reduce the total doses of benzodiazepine and opioids administered in paediatric ICU by using appropriate assessment scale and greater use of non-pharmacological intervention to reduce pharmacological sedation.
Weaning from ICU sedation: When pharmacological sedation is no longer necessary; a
• Rate of reduction sedative/ analgesic should be individualised based on indication of sedation, duration of sedation.
• Analgesia first followed by sedation is the norm when we start sedation in ICU. The reverse is applicable in weaning process; sedation is
• Abrupt discontinuation: acceptable if the sedative-analgesic agents have been administered for a short duration (less than 5 days). It may also be appropriate in patients who have received sedative-analgesic for an extended period and are deeply sedated from prolonged accumulation of medication.
• Gradual withdrawal: A gradual reduction of 10 - 25% per day may be most appropriate strategy for patients who have received more than 7 days of sedation and exhibits evidence of tachyphylaxis with increasing dosage required over time to achieve the same level of sedation.
• Switching one drug from another to prevent the development of tolerance and accumulation of one particular group of medications. Best example is of intravenous dexmedetomidine to facilitate opioid and benzodiazepine withdrawal[24,25].
Conclusion and Recommendation
Non-pharmacologic interventions are essential and often complementary to pharmacologic sedative analgesics and should be considered irrespective of
- 1. Tobias, J.D. Tolerance, withdrawal, and physical
dependencyafter long-term sedation and analgesia of children in pediatric intensive care unit. (2000) Crit Care Med 28(6): 2122-2132.
- 2. Bavdekar, S.B., Mahajan, M.D., Chandu, K.V. Analgesia and sedation in paediatric intensive care unit. (1999) J Postgrad Med 45(3): 95-102.
- 3. Mehta, S., McCullagh, I., Burry, L. Current sedation practices: lessons learned from international surveys. (2009) Crit Care Clin 25(3): 471–488.
Playfor, S.D., Thomas, D.A., Choonara, I. Sedation and neuromuscular blockade in paediatric intensive care: a review of current practice in the UK. (2003) Paediatr Anaesth 13(2):147–151.
- 5. Selbst, S.M. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics 105(4): 864-865.
- 6. Aitken, L.M., Bucknall, T., Kent, K., et al. Protocol directed sedation versus non-protocol directed sedation to reduce duration of mechanical ventilation in mechanically ventilated intensive care patients. (2012) Cochrane Database Syst Rev (4): CD009771.
- 7. Vet, N.J., Ista, E., de Wildt, S.N., et al. Optimal sedation in pediatric intensive care patients: a systematic review. (2013) Intensive Care Med 39(9): 1524–1534.
- 8. Loepke, A.W. Developmental neurotoxicity of sedatives and anesthetics: a concern for neonatal and pediatric critical care medicine? (2010) Pediatr Crit Care Med 11(2): 217–226.
Playfor, S., Jenkins, I., Boyles, C., et al. Consensus guidelines on sedation and analgesia in critically ill children. (2006) Intensive Care Med 32(8): 1125–1136.
- 10. Mason, K.P. Challenges in paediatric procedural sedation: political, economic, and clinical aspects. (2014) Br J Anaesth 113 (
- 11. Harris, J., Ramelet, A.S., van Dijk, M., et al. Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals. (2016) Intensive Care Med 42(6): 972–986.
- 12. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5) Washington, DC. (2013).
- 13. Silver, G.H., Kearney, J.A., Kutko, M.C., et al. Infant delirium in pediatric critical care settings. (2010) Am J Psychiatry 167(10): 1172–1177.
- 14. Silver, G., Traube, C., Gerber, L.M., et al. Pediatric delirium and associated risk factors: a single-center prospective observational study. (2015) Pediatr Crit Care Med 16(4): 303–309.
- 15. Schieveld, J.N., Leroy, P.L., van Os, J., et al. Pediatric delirium in critical illness: phenomenology, clinical correlates and treatment response in 40 cases in the pediatric intensive care unit. Intensive Care (2007) Med 33(6): 1033-1040.
- 16. Katz, R., Kelly, H.W., His, A. Prospective study on the occurrence of withdrawal in critically ill children who receive fentanyl by continuous infusion. (1994) Crit Care Med 22(5): 763–767.
- 17. Fontaine, D.K.
Non pharmacologicmanagement of patient distress during mechanical ventilation. (1994) Crit Care Clin 10(4): 695-708.
- 18. Keogh, S.J., long, D.A., Horn, D.H. Practice guidelines for sedation and analgesia management of critically ill children: a pilot study evaluating guideline impact and feasibility in the PICU. (2015) BMJ Open 5(3): e006428.
- 19. Franck, L.S., Bruce, E. Putting pain assessment into practice: Why is it so painful? (2009) Pain Res Manag 14(1): 13-20.
- 20. Shruti, B.P., John, P.K. "Sedation and Analgesia in the Mechanically Ventilated Patient". (2012) Am J Respir Crit Care Med 185(5): 486-497.
- 21. Wiatrowski, R., Norton, C., Giffen, D. Analgosedation: Improving patient Outcomes in ICU Sedation and Pain Management. (2016) Pain Manag Nurs 17(3): 204-217.
- 22. Kollef MH, Levy NT, Ahrens TS, et al. The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation. (1998) Chest 114(2): 541-548.
Playfor, S.D. Analgesia and sedation in critically ill children. (2008) Contin Educ Anaesth Crit Care Pain 8(3): 90-94.
- 24. Maccioli, G.A. Dexmedetomidine to facilitate drug withdrawal. (2003) Anesthesiology 98: 575-577.
- 25. Multz, A.S. Prolonged dexmedetomidine infusion as an adjunct in treating sedation-induced withdrawal. (2003) Anesth Analg 96(4): 1054-1054.