Sedation and Analgesia in Pediatric Cardiac Critical Care

Viviane G. Nasr, MD; James A. DiNardo, MD

Disclosures

Pediatr Crit Care Med. 2016;17(S1):S225-S231. 

In This Article

Abstract and Introduction

Abstract

Objectives: This review will focus on the pharmacokinetics (with an emphasis on the context-sensitive half-time), pharmacodynamics, and hemodynamic characteristics of the most commonly used sedative/hypnotic, analgesic, and IV anesthetics used in cardiac intensive care. In addition, the assessment of pain and agitation and withdrawal will be reviewed.

Data Source: MEDLINE, PubMed.

Conclusions: Children in the cardiac ICU often require one or more components of general anesthesia: analgesia, amnesia (sedation and hypnosis), and muscle relaxation to facilitate mechanical ventilation, to manage postoperative pain, to perform necessary procedures, and to alleviate fear and anxiety. Furthermore, these same children are often vulnerable to hemodynamic instability due to unique underlying physiologic vulnerabilities. An assessment of hemodynamic goals, postoperative procedures to be performed, physiologic vulnerabilities, and the intended duration of mechanical ventilation should be made. Based on this assessment, the optimal selection of sedatives, analgesics, and if necessary, muscle relaxants can then be made.

Introduction

Children in the ICU undergo painful interventions, often require mechanical ventilation, and are exposed to multiple strangers while separated from their caregivers and their normal environment. Some and often all three components of general anesthesia: analgesia, amnesia (sedation and hypnosis), and muscle relaxation must be administered to children in the cardiac ICU (CICU). Managing their pain, fear, and anxiety and maintaining hemodynamic stability is challenging. Both under-treatment and over-treatment can have deleterious effects. Under-treatment can result in delayed healing and stress for the patient and the caregivers, whereas overtreatment can cause tolerance and possibly withdrawal upon discontinuation of therapy, delay recovery, and induce cardiopulmonary instability.[1–3] An assessment of hemodynamic goals, postoperative procedures to be performed such as tube/line removal and chest closure, cardiopulmonary status, physiologic vulnerabilities, and the intended duration of mechanical ventilation should be made. Based on this assessment, the projected trajectory for each patient can be determined. Intelligent choices regarding use of sedatives, analgesics, and if necessary, muscle relaxants can then be made. Since no one drug can provide analgesia, sedation, and muscle relaxation, the use of multiple agents is necessary. With the large choice of agents available, practitioners should understand the mechanism of action, pharmacokinetic profile, and advantages and disadvantages of each agent that may be used, as well as the hemodynamic profile of the individual patient.

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