Pediatric Cardiac Intensive Care Society 2014 Consensus Statement

Pharmacotherapies in Cardiac Critical Care

Sedation, Analgesia and Muscle Relaxant

Sarah Scarpace Lucas, PharmD, BCPS, FCSHP; Viviane G. Nasr, MD; Angelica J. Ng, PharmD, BCPS; Charlene Joe, PharmD; Meredyth Bond, PharmD; James A. DiNardo, MD

Disclosures

Pediatr Crit Care Med. 2016;17(S1):S3-S15. 

In This Article

Abstract and Introduction

Abstract

Objective: This article reviews pharmacotherapies currently available to manage sedation, analgesia, and neuromuscular blockade for pediatric cardiac critical patients.

Data Sources: The knowledge base of an expert panel of pharmacists, cardiac anesthesiologists, and a cardiac critical care physician involved in the care of pediatric cardiac critical patients was combined with a comprehensive search of the medical literature to generate the data source.

Study Selection: The panel examined all studies relevant to management of sedation, analgesia, and neuromuscular blockade in pediatric cardiac critical patients.

Data Extraction: Each member of the panel was assigned a specific subset of the studies relevant to their particular area of expertise (pharmacokinetics, pharmacodynamics, and clinical care) to review and analyze.

Data Synthesis: The panel members each crafted a comprehensive summary of the literature relevant to their area of expertise. The panel, as a whole, then collaborated to cohesively summarize all the available, relevant literature.

Conclusions: In the cardiac ICU, management of the cardiac patient requires an individualized sedative and analgesic strategy that maintains hemodynamic stability. Multiple pharmacological therapies exist to achieve these goals and should be selected based on the patient's underlying physiology, hemodynamic vulnerabilities, desired level of sedation and analgesia, and the projected short- or long-term recovery trajectory.

Introduction

Children in the cardiac ICU can suffer from pain, fear, and anxiety. Separation from family and home; the fear of machines and procedures; disruption of sleep, alarms, and noises are common reasons for anxiety in children requiring sedation.[1] The cause of pain can be surgical or can result from diagnostic and therapeutic procedures such as suctioning, position changes, and peripheral IV placement.[2] Management of pain and anxiety is challenging with the potential of harm secondary to under- and overtreatment. Undertreatment can result in behavioral and biochemical consequences, resulting in delayed healing and stress for the patients and the caregivers.[3,4] By contrast, overtreatment delays recovery, can cause tolerance, and possibly withdrawal upon discontinuation of therapy.[5]

Therefore, pain and sedation scales should be used routinely to provide an objective assessment while managing patients in the ICU. The COMFORT-Behavioral Scale[6,7] has been validated to assess both pain and sedation, whereas other scales such as the State Behavioral Scale have been validated to assess sedation only. These scales should be used on initiation of sedation or pain treatment, and after subsequent changes in dosing of the medications to determine appropriate management.

Maintaining ideal analgesia while at the same time promoting early extubation and ICU discharge can be difficult to achieve. Different algorithms and recommendations have been proposed for short- and long-term extubation goals in the ICU.[8–10] The decision to use a specific agent is also based on the patient's hemodynamic/respiratory status, the physiologic rationale, severity of the disease, the desired level of sedation, and the potential for adverse effect.

The World Health Organization's analgesic ladder classifies pain in three categories: mild, moderate, and severe. Nonopioids should be considered for children with mild to moderate pain or as an adjuvant agent for moderate to severe pain to reduce the need for opioids. Sedative agent may be used to keep a child comfortable and avoid excessive opioid exposure. Intermittent IV opioids and benzodiazepines could be used for minor bedside procedures or in mechanically ventilated children. However, continuous infusions of sedatives and analgesics such as dexmedetomidine, morphine, or midazolam may be more practical for long-term use. Propofol should be used only for procedural sedation and short-term sedation because of the risk for propofol infusion syndrome (PRIS).[11]

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