Successful implementation of a pediatric sedation protocol for mechanically ventilated patients.

Department of Pediatrics, Seattle Children's Hospital University of Washington, Seattle, WA, USA.
Critical care medicine (Impact Factor: 6.37). 01/2011; 39(4):683-8. DOI: 10.1097/CCM.0b013e318206cebf
Source: PubMed

ABSTRACT To evaluate the effect of a nursing-driven sedation protocol for mechanically ventilated pediatric patients on duration of use of analgesic and sedative medications. We hypothesized that a protocol would decrease length of sedation use and decrease days of mechanical ventilation and length of stay.
Retrospective cohort study with historical controls.
Thirty-one-bed tertiary care, medical-surgical-cardiac pediatric intensive care unit in a metropolitan university-affiliated children's hospital.
Children requiring mechanical ventilation longer than 48 hrs not meeting exclusion criteria.
Before protocol implementation, sedation was managed per individual physician orders. During the intervention period, analgesia and sedation were managed by nurses following an algorithm-based sedation protocol based on a comfort score.
The observation group included consecutive patients admitted during the 12-month period before protocol education and implementation (n = 153). The intervention group included patients admitted during the 12 months following protocol implementation (n = 166). The median duration of total sedation days (intravenous plus enteral) was 7 days for the observation period and 5 days for the intervention period (p = .026). Specifically, the median duration of morphine infusion was 6 days for the observation period and 5 days for the intervention period (p = .015), whereas the median duration of lorazepam infusion was 2 days for the observation period and 0 days for the intervention period. After adjusting for severity of illness with the pediatric risk of mortality III (PRISM III) score, the Cox proportional hazards regression analysis demonstrated that at any point in time, patients in the intervention group were 23% more likely to be off all sedation (heart rate 0.77, p = .020). Additionally, the intervention group tended to be associated with fewer days of mechanical ventilation (heart rate 0.81, p = .060) and decreased pediatric intensive care unit length of stay (heart rate 0.81, p = .058), although these associations did not quite reach statistical significance.
A pediatric sedation protocol can significantly decrease days of benzodiazepine and opiate administration, which may improve pediatric intensive care unit resource utilization.

  • Pediatric Critical Care Medicine 03/2014; 15(3):264-266. · 2.35 Impact Factor
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    European Journal of Intensive Care Medicine 06/2013; · 5.17 Impact Factor
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    ABSTRACT: The Sophia Observation withdrawal Symptoms scale is an instrument for screening benzodiazepine and opioid withdrawal syndrome in pediatric critical care patients. The objectives of this study were to establish cutoff scores and to test sensitivity to change. Second, risk factors for withdrawal syndrome were explored. Prospective observational study with repeated measures. Level IV ICU at a university children's hospital. A total of 154 children with median age 5 months (interquartile range, 0-42 mo) who received continuous infusion of benzodiazepines and/or opioids for 5 or more days. None. Nurses repeatedly applied the Sophia Observation withdrawal Symptoms scale and the Numeric Rating Scale withdrawal when children were weaned off benzodiazepines and opioids. The latter represents the nurse's expert opinion. We analyzed 3,754 paired assessments; the median number per child was 15 (interquartile range, 7-31) over a median of 5 days (interquartile range, 3-11 d). Sensitivity and specificity were 0.83 and 0.93, respectively, for the Sophia Observation withdrawal Symptoms scale cutoff score of 4 or higher against a Numeric Rating Scale-withdrawal score of 4 or higher. Sensitivity to change was determined by comparing 156 Sophia Observation withdrawal Symptoms scale assessments (n = 51 patients) before and after additional sedatives or opioids. Multilevel regression analysis showed a mean decline of 1.5 points (at score range 0-15) after intervention (p < 0.0001). Logistic regression analysis identified duration of preweaning of midazolam, duration of weaning of midazolam, duration of preweaning of morphine, duration of weaning of morphine, and number of additional sedatives/opioids as statistically significant risk factors for withdrawal syndrome in these children. The Sophia Observation withdrawal Symptoms scale is a valid tool with good psychometric properties to assess withdrawal symptoms in PICU patients.
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