Sedation is a mainstay of therapy for critically ill children. Although necessary in the care of the critically ill child, sedative drugs are associated with adverse effects, such as disruption of circadian rhythm, altered sleep, delirium, potential neurotoxicity, and immunosuppression. Optimal approaches to the sedation of the critically ill child should include identification of sedation targets and sedation interruptions, allowing for a more individualized approach to sedation. Further research is needed to better understand the relationship between critical illness and sedation pharmacokinetics and pharmacodynamics, the impact of sedation on immune function, and the genetic implications on drug disposition and response.
Key points
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Sedation is a mainstay of therapy for critically ill children. Drugs of many classes are available to sedate children cared for in the PICU, and are used in various combinations to achieve the desired effect.
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Although necessary in the care of the critically ill child, sedative drugs are associated with adverse effects, such as disruption of circadian rhythm, altered sleep, delirium, potential neurotoxicity, and immunosuppression.
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Optimal approaches to the sedation of the critically ill child should include identification of sedation targets and sedation interruptions, allowing for a more individualized approach to sedation.
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Further research is needed to better understand the relationship between critical illness and sedation pharmacokinetics and pharmacodynamics, the impact of sedation on immune function, and the genetic implications on drug disposition and response.
In 2006 the consensus guidelines on sedation and analgesia in critically ill children was published, providing guidance for sedative use in the pediatric intensive care unit (PICU). This guidance included statements supporting the assessment of sedation level using validated sedation scales, specifying that the “desired level of sedation should be identified for each patient and should be regularly reassessed” and “doses of sedative agents should be titrated to produce the desired level of sedation.” In addition, the concepts of tolerance and withdrawal were detailed, with the recommendation for medication tapering after 7 days of therapy. These overarching concepts to sedation in the PICU still hold true a decade later. However, recent changes in knowledge about potentially deleterious effects of sedative medications in combination with addition of newer medications, such as dexmedetomidine, suggest that previous guidance in 2006 may not apply today.
In 2016, the Pediatric Cardiac Intensive Care Society 2014 consensus statement “Pharmacotherapies in Cardiac Critical Care: Sedation, Analgesia and Muscle Relaxant” was published. Analgesic guidance for morphine, fentanyl, remifetanil, ketamine, and methadone was provided. In addition, guidance on the benzodiazepines midazolam, lorazepam, and diazepam was also given. Dexmedetomidine was highlighted in this statement, with an in-depth review of its pharmacokinetics and dynamics, and its potential as an antiarrhythmic especially in this setting. In conclusion, it was stated that sedation should be tailored to the individual needs of the patient.
This article provides an overview of the various drug classes that are used in the sedation of the critically ill child, and details regarding select drugs within each class. Analgesics, or medications that provide relief from pain, are also included because these agents are often included as sedation adjuncts regardless of whether there is an indication to treat pain. Afterward, an overview of concepts and issues surrounding sedation in the PICU is discussed, providing the reader with the current state of knowledge and areas that require additional scientific inquiry.
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