Practices related to assessment of sedation, analgesia and delirium among critical care pediatricians in Brazil / Práticas relacionadas à avaliação de sedação, analgesia e delirium entre pediatras intensivistas no Brasil

ABSTRACT Objective To understand the use of tools, protocols and comfort measures related to sedation/analgesia, and to screen the occurrence of delirium in pediatric intensive care units. Methods A survey with 14 questions was distributed by e-mail to Brazilian critical care pediatricians. Eight questions addressed physician and hospital demographics, and six inquired practices to assess sedation, analgesia, and delirium in pediatric intensive care units. Results Of 373 questionnaires sent, 61 were answered (16.3%). The majority of physicians were practicing in the Southeast region (57.2%). Of these, 46.5% worked at public hospitals, 28.6% of which under direct state administration. Of respondents, 57.1% used formal protocols for sedation and analgesia, and the Ramsay scale was the most frequently employed (52.5%). Delirium screening scores were not used by 48.2% of physicians. The Cornell Assessment of Pediatric Delirium was the score most often used (23.2%). The majority (85.7%) of physicians did not practice daily sedation interruption, and only 23.2% used non-pharmacological measures for patient comfort frequently, with varied participation of parents in the process. Conclusion This study highlights the heterogeneity of practices for assessment of sedation/analgesia and lack of detection of delirium among critical care pediatricians in Brazil.

RESUMO Objetivo Compreender o uso de ferramentas, protocolos e medidas de conforto relacionadas à sedação/analgesia, além de rastrear a presença de delirium em unidades de terapia intensiva pediátricas. Métodos Um inquérito com 14 questões foi distribuído, por meio de correio eletrônico, para médicos pediatras intensivistas brasileiros. Oito questões eram sobre os dados demográficos dos médicos e dos hospitais, e seis questões eram sobre as práticas na avaliação da sedação, analgesia e delirium em unidades de terapia intensiva pediátrica. Resultados Responderam ao inquérito 61 médicos dos 373 e-mails enviados (taxa de resposta de 16,3%). A maioria dos médicos era da Região Sudeste (57,2%) e 46,5% trabalhavam em hospitais públicos, sendo 28,6% sob administração direta do Estado. Dos respondedores, 57,1% utilizavam protocolos formais de sedação e analgesia, sendo a escala de Ramsay a mais utilizada (52,5%). Não utilizavam escores de rastreamento de delirium 48,2% dos médicos, e o Cornell Asssessment of Pediatric Delirium (23,2%) foi o mais utilizado. A maioria (85,7%) dos médicos não utilizou a prática da interrupção diária da sedação, e apenas 23,2% utilizavam medidas não farmacológicas para o conforto do paciente com frequência, com a participação heterogênea dos pais nesse processo. Conclusão Este estudo destaca a heterogeneidade nas práticas de avaliação da sedação/analgesia e insuficiência de rastreamento de delirium entre os intensivistas pediátricos brasileiros.

Sedación y analgesia en pacientes con asistencia ventilatoria mecánica en unidades de cuidados intensivos pediátricos de Argentina / Sedation and analgesia in patients on mechanical ventilation in pediatric intensive care units in Argentina

Introducción. Los niños en unidades de cuidados intensivos pediátricos (UCIP) están expuestos a padecer dolor, estrés y ansiedad debido a su enfermedad, el tratamiento o el ambiente. La adecuada sedación y analgesia son fundamentales para su cuidado, especialmente, en aquellos que requieren asistencia ventilatoria mecánica (AVM). Objetivo. Determinar la práctica habitual en la sedación y analgesia de los pacientes que requieren ARM en UCIP de Argentina. Material y métodos. Estudio descriptivo, transversal, multicéntrico, realizado a través de encuestas enviadas por correo electrónico. Resultados. Se encuestaron y respondieron 45 UCIP. El 18% (N= 8) utiliza un protocolo de sedoanalgesia de seguimiento estricto, mientras que el 58% (N= 26) siguen un protocolo "tácito" producto de la automatización en la práctica. Las drogas más utilizadas son el midazolam para sedación y fentanilo para analgesia. El 31% (N= 14) de las UCIP monitorizan la sedación con escalas de evaluación (Ramsay modificada y/o Comfort). El 4% (N= 2) realizan la interrupción diaria de la sedación en forma programada. En pacientes de difícil sedación, la dexmedetomidina es la droga más utilizada como coadyuvante. El 73% (N= 33) de las unidades utilizan bloqueantes neuromusculares ante indicaciones precisas, y un monitoreo clínico. El 20% (N= 9) de las UCIP tienen un protocolo de destete para la sedoanalgesia, la morfina y lorazepam son las drogas más frecuentemente utilizadas. Conclusión. Existe un bajo porcentaje de protocolización en la práctica habitual del manejo de la sedoanalgesia en pacientes con AVM en las UCIP encuestadas.

Introduction. Children in pediatric intensive care units (PICUs) are exposed to experiencing pain, stress and anxiety due to their disease, treatment or care setting. Adequate sedation and analgesia are key to their care, particularly in patients requiring mechanical ventilation (MV). Objective. To determine the usual practice in sedation and analgesia management in patients requiring MV in PICUs in Argentina. Material and methods. Descriptive, crosssectional, multi-center study conducted by means of e-mailed surveys. Results. A total of 45 PICUs were surveyed, 18% (N= 8) of which follow a sedation and analgesia protocol strictly, while 58% (N= 26) follow an "implied" protocol based on routine practice. The most commonly used drugs were midazolam, for sedation, and fentanyl, for analgesia. In 31% (N= 14) of the PICUs, sedation was monitored through assessment scales (modified Ramsay and/or Comfort scales). In 4% (N= 2) of units, daily, scheduled interruptions of sedation was implemented. In patients who are difficult to sedate, dexmedetomidine was the most commonly used adjuvant. In 73% (N= 33) of the units, neuromuscular blocking agents were used in compliance with precise guidelines and under clinical monitoring. In 20% (N= 9) of the PICUs there was a sedation and analgesia weaning protocol in place, and morphine and lorazepam are the most commonly used drugs. Conclusion. Only a low percentage of surveyed PICUs had a protocol in place for the routine management of sedation and analgesia in patients on MV.

Comparative study of dexmedetomidine, propofol, and midazolam for postoperative sedation following open heart surgery

Dexmedetomidine is a new, potent, and highly selective adrenoreceptor agonist. It has sedative-hypnotic, anxiolytic, analgesic, anesthetic-reducing and sympatholytic effects. Dexmedetomidine produced rapid and stable sedation in postsurgical ventilated patients, without significant respiratory or haemodynamic compromise, while maintaining a high degree of patient reusability and anxiety reduction. To study the different effects of Dexmedetomidine, in comparison to Propofol, and Midazolam for postoperative sedation in adult patients undergoing open heart surgery. Sixty patients, ASA physical status III-IV, aged 18-70 yr, with an ejection fraction > 45%, undergoing elective first time coronary artery bypass graft surgery [CABG], or single-valve replacement. All patients received a standardized fentanyl / sevoflurane anesthesia. During cardiopulmonary bypass 100 micro g/kg/min propofol was substituted for sevoflurane. Upon arrival to ICU, patients were randomized to three groups [n=20]: Group I [Dexmedetomidine] received dexmedetomidine 1 micro g/kg over 10-minute followed by infusion of 0.25-0.75 micro g/kg/hr. Group II [Propofol] received propofol 1mg/kg over 10-minute followed by infusion of 25-75 micro g/kg/min. Group III [Midazolam] received midazolam 0.1 mg/kg over 10-minute followed by infusion of 0.25-0.75 micro g/kg/min. Analgesia was provided with an infusion of morphine at 0.02 mg/kg/hr. Infusion rates were adjusted to maintain sedation within a predetermined range [Ramsay 2-4]. The infusion was terminated after six hours. Patients were weaned from mechanical ventilation when haemodynamic stability, haemostasis, normothermia and mental orientation were confirmed. Haemodynamic measurements and arterial blood gas tensions were recorded at specified times. The incidence of hypotension, hypertension, tachycardia, bradycardia, total dose of morphine, and the incidence of postoperative nausea, vomiting, and shivering were also recorded. There were no significant differences between the three groups for the time spent at each level of sedation, number of infusion rate adjustments, times to awakening and extubation and blood gases during weaning and after extubation [P=NS]. No patient in the three groups required tracheal reintubation. Dexmedetomidine treated patients required significantly lower dose of morphine during the first six hours after surgery 2.64 +/- 1.4 while in propofol 4.57 +/- 2.3 and in midazolam 5.12 +/- 2.8 [P<0.05]. Dexmedetomidine sedation was associated with a 25% incidence of bradycardia which was significantly higher than other two groups [P<0.05]. There were no other significant differences in haemodynamic values between the three groups. Postoperative shivering, nausea and vomiting occurred less frequently in dexmedetomidine group but without statistical significance [P >0.05]. It was concluded that, compared with a standard midazolam and propofol sedation regimens, dexmedetomidine 1 micro g/kg over a 10-minute period followed by an infusion of 0.2 5-0.7 5 micro g kg/hr, in selected cases, produced safe and clinically effective sedation, and relief of anxiety in patients recovering from cardiac surgery. It significantly reduced the analgesic requirements during the period of postoperative mechanical ventilation, without clinically apparent haemodynamic compromise, or respiratory depression after extubation