The purpose of this video is to provide general information and education about the care of
a critically ill child.
It is in no way a substitute for the independent decision-making and judgment by a qualified
health care professional.
The information contained in this video should not be used to make a diagnosis or to overrule
the advice of a qualified health care provider, nor should it be used to provide advice for
emergency medical treatment.
Sedating the Intubated Patient by Dr. Monica Kleinman.
Please note that in this video, we will be following the guidelines used at Boston Children's
Hospital.
Some of this information may need to be modified based on the equipment, guidelines, and practices
in place in your institution.
Hello.
My name is Dr. Monica Kleinman.
I'm a pediatric intensivist in the Division of Critical Care Medicine at Children's Hospital
Boston.
And today I'm going to be talking about the use of sedation and analgesia for the intubated
pediatric patient.
What we're going to do here is describe how we take care of children on a ventilator at
Children's Hospital Boston, and talk about some of the principles of sedation and analgesia.
Namely, the goals of providing sedation and analgesia to facilitate care, the choice of
medications, the regimen of medications to provide depending on the course of the child's
illness, and then how to transition to the point that the child can be extubated once
the underlying disease has resolved.
Once an infant or child has respiratory failure requiring intubation, the use of mechanical
ventilation is facilitated by sedation and analgesia in order to maintain the child's
comfort and safety.
This discussion is going to be about the use of sedation and analgesia in the intubated
patient in the pediatric ICU.
The goals of sedating and providing anagelsia to a child who's receiving mechanical ventilation
are several.
The main goal is comfort, and comfort is a combination of analgesia, anxiolysis, and
amnesia.
And then the second main goal is safety, which is to facilitate the care of the patient--
be that providing positive pressure ventilation to facilitate gas exchange, suctioning, or
other treatments for which the child needs to be relaxed and cooperative.
Remember that medications are only part of providing sedation and analgesia for the intubated
child.
Whenever possible, one should use environmental techniques like keeping the lights in the
room low, keeping the sound in the room decreased, providing swaddling or other means that are
age appropriate to increase the child's comfort, and using other non-pharmacologic techniques
like distraction techniques for the child who might be somewhat awake, but who is still
at risk of becoming uncooperative.
Also consider reversible causes of discomfort-- things like hypercarbia, agitation from uncomfortable
sensations like urinary retention or skin breakdown can all make the infant harder to
keep comfortable, but from a cause that isn't a lack of medications, but is something that
could potentially be corrected.
Also your choice of medications and your regimen of medications can be influenced by the child's
underlying condition.
Certainly a child who's otherwise healthy and neurologically normal, who needs to be
intubated and ventilated is going to require a different medication regimen than a child
who perhaps has some significant preexisting neurologic problems.
Initial Considerations.
The general approach is fourfold-- to anticipate the trajectory of illness meaning, is this
child going to be intubated and ventilated for hours, days, or potentially even weeks?
To define the comfort goals-- that is to say, how sedated and comfortable do I need this
child to be in order to safely take care of him or her?
To choose medications based on what's available in your facility and based on the child's
underlying condition, and then to continuously adjust your sedation regimen, so that you
are keeping the sedation comfort goal that you have already set, or reassessing the comfort
goal as the child's condition changes.
In terms of the trajectory of illness, in the short-term, one is going to be looking
for things like post-operative or post-procedural situations where the need for intubation and
mechanical ventilation can be predicted to be finite.
So a child who's just had surgery, who may need to remain intubated and ventilated overnight
clearly is going to have just a short-term course of mechanical ventilation and is going
to need a different regiment than a child who has say, suffered a head injury in a motor
vehicle accident and is anticipated to be on the ventilator for many days.
The other group of patients who may require just a short course of mechanical ventilation
are those with reversible conditions-- things like, toxic ingestion or prolonged seizure
in which one expects the child is only going to be temporarily in need of ventilation and
not need ventilation for more than a day or two.
Longer-term-- those children who have a critical illness, sepsis, acute lung injury, severe
trauma are ones who one can predict are going to be on the ventilator for more than a day
or two, and therefore, your sedation plan is going to be altered because of that child's
anticipated trajectory.
And we usually divide those into the acute phase of the illness and then the recovery
phase of the illness or the maintenance phase of the illness where in the acute phase you're
still doing ongoing resuscitation and the child's vital signs and vital functions have
not yet stabilized.
And the comfort goal may be different than that child who's recovering from pneumonia
or recovering from motor vehicle accidents, and whom you're trying to gradually allow
them to be more wakeful over time.
Any patient who is intubated, ventilated and receiving chemical paralytics should be treated
with sedatives and analgesics with the assumption that they are uncomfortable.
And the assessment of that patient can be challenging, but we'll discuss it a little
bit more when we talk about how to set a sedation goal.
Comfort Goal.
The suggestion, when one is trying to define the comfort goals for an individual patient,
is to try to use some sort of standardized score-- something that everybody can understand.
It doesn't necessarily have to be something that's terribly complicated.
But it should be a score that describes what condition you would like the patient in, ideally.
So in an ideal world, you'd like the youngster to, perhaps, sleep when undisturbed, wake
when stimulated, but quickly fall back asleep when no longer stimulated.
And that might be the ideal description, for the typical child on a ventilator.
However, there are some patients who are going to need to be more sedated than that, in order
to be safe or in order to be comfortable.
So for instance, the child with increased intracranial pressure may need to be kept
at a more significant level of sedation and analgesia, so as to avoid changes in intracranial
pressure that could be harmful.
Likewise, a child who may have some sort of neuromuscular disease, and who is quite weak
and not in danger of self-extubating or dislodging tubes or lines, might not need as heavy a
level of sedation-- enough to reduce anxiety and prevent any pain, but not so much that
you're helping to keep them restrained in the bed, and avoid dislodgment of tubes and
lines.
So certain things, like patients who are known to have a difficult airway, patients with
intracranial pressure increases, and patients with conditions like pulmonary hypertension
are ones in which you may wish a more significant level of sedation and analgesia, so that changes
in their physiology don't cause major problems for vital functions.
The key with this is to reassess frequently.
The goal that you set on a Monday may be different than the goal that you need for Tuesday or
Wednesday.
And so it's a process of continually trying to understand where the child is in their
trajectory of illness, in the course of their illness, and then what the best goal is for
their sedation.
One score that we've used is the State Behavioral Score, which describes children at different
levels of sedation-- everywhere from comatose and unresponsive, to a child who can be awake,
and calm, and cooperative, to a child who's thrashing and uncomfortable-- which is, typically,
not a goal that we would set.
But this is a score that has been published, and has been used with success, in our ICU,
to help the clinical team come up with a plan for the day, and a common goal that nurses
and physicians can use to say, we'd like to keep the patient in this relative zone of
comfort.
Medications.
In terms of the medications that might be used for a typical patient who is intubated
and ventilated, we use a combination of narcotics and benzodiazepines.
Different narcotics are available in different areas of the world.
At our facility, the standard choices are morphine for analgesia and midazolam for comfort
and for anxiolysis and amnesia, but this could be other benzodiazepines or other narcotics,
depending on what is available and what you're comfortable using in your own unit.
The need for chemical paralysis really depends on the patient's condition.
A patient who is chemically paralyzed is one where you're going to have a more challenging
time assessing comfort.
Patients who are chemically paralyzed are going to display discomfort, usually in their
vital signs.
So you'll see autonomic changes with tachycardia and hypertension in a patient who is chemically
paralyzed, but who is uncomfortable.
And we, as I said before, assume that they are in pain, assume that they are uncomfortable
when they have changes in vital signs with mild stimulation.
And we'll use that score standard to assess whether or not that patient is uncomfortable,
and to adjust medications when they are chemically paralyzed.
Pupillary reaction has been used by people to try to determine whether a child is well-sedated
or not.
It may not be as reliable as vital sign changes are, and so one should use all the information
in deciding whether a paralyzed patient is in need of more sedation or analgesia.
The major principle once you've started medications is to titrate, that is adjust to your comfort
goal.
And so if you've described your goal for the child, calm, not agitated, may briefly wake
to noxious stimuli, but easily falls back asleep and sleeps when undisturbed, the people
at the bedside can then adjust the medications to target that particular comfort level that
you've described.
For patients who are going to be intubated only for a short-term period of time, we will
generally use intermittent doses of medication.
So, a bolus dose of a narcotic alternating with a bolus dose of a benzodiazepine, whether
we think the child's mostly suffering from pain or needs sedation.
And since many of these patients who are on the short term pathway for their course of
intubation, because many of them are post-operative, we oftentimes will favor using narcotics because
we believe there's post-operative pain involved.
For a child who is here with respiratory failure or asthma, it's less likely that their reaction
to being intubated is going to be one of pain and more likely that it's going to be agitation
and anxiety, and there we might favor using more midazolam or benzodiazepine.
For patients who are going to be intubated for a longer period of time, typically more
than two days, we will initiate continuous infusions of narcotics and benzodiazepines
with the idea of trying to avoid swings in level of comfort and provide a continuous
background.
And then on top of that, as needed, we'll provide extra boluses of medication to either
get the patient to a better level of sedation quickly, if needed, or to pre-medicate before
a noxious stimulation, like suctioning.
And so we call those rescue or procedural boluses.
So the child who's on a continuous infusion may be fine as long as you're not touching
them, but if they need a procedure done, may need some extra medication.
Or, if they are becoming tolerant to the medication dose that they had yesterday, they may need
that infusion increased and, while you're waiting for that to take effect, may need
a bolus of medication to keep them safe and comfortable.
We will try to avoid adding other agents to that basic mix of narcotics and benzodiazepines,
unless we have really maximized those drugs, or if we start seeing toxic side effects that
limit our raising them further.
And if we do have to add extra agents, we try very hard to do that one at a time, thoughtfully,
based on why we think the child is still not able to tolerate the endotracheal tube, whether
it's an issue of disturbed sleep cycles, whether it's an issue of pain, whether it's an issue
of significant tolerance to medications because of prior exposure.
We'll try to tailor our extra agents to those factors.
Of course, the hope is that while the child is on the ventilator and you have titrated
the medications to keep them comfortable and safe, that in the meantime your treatment
of the underlying problem is helping them to get better.
And therefore, one needs to be prepared to transition the child to extubation.
This can be another challenge, because by necessity the child needs to go from a fairly
sedated and calm state to a more awake state so that they can have the endotracheal tube
removed and be able to protect the airway and breathe comfortably.
And so this is very much art more than science, and requires very good communication among
the caregivers at the bedside.
The first thing to consider is that as the child's improving, that child may not need
to have as significant a level of sedation as when you were initially resuscitating the
child.
And so fluctuations in levels of awakeness, in heart rate and blood pressure may be much
better tolerated when they are in the recovery phase from their illness.
So allowing them to be more awake and resetting your goal for the level of sedation is the
first step.
And then, adjusting the medications to basically the minimum effective dose that you need to
keep the child comfortable should be your goal.
Extubation concerns.
For patients who are intubated for less than five to seven days who recover in that period
of time and who have been getting narcotics and benzodiazepines-- when their disease has
improved to the point that they meet our criteria for safely extubating them, then we'll consider
stopping those medications all at once and, when the child is adequately awake, which
may take minutes to hours, removing the endotracheal tube.
For patients who have been on those medications for longer than five to seven days, there's
a much greater risk of acute withdrawal if those medications are abruptly stopped.
And so instead, we would wean them in a gradual fashion so that, once the child is awake enough,
we know we can remove the endotracheal tube.
But we can also leave on some medication so that they won't experience withdrawal symptoms.
Of course, this is just a general guideline.
There are patients who've been intubated for three or four days on medication who will
exhibit withdrawal signs if you abruptly stop.
There are patients who've been intubated for 10 days who won't.
And so we tend to be conservative and, if something looks like withdrawal, treat it
as withdrawal, and practice weaning medications rather than stopping them if the patient's
been medicated for more than a week.
Withdrawal.
Withdrawal is another condition that, if you use a standardized assessment tool, it can
be helpful in describing the child's level of discomfort, agitation, sweatiness, et cetera,
that's making you think this is withdrawal.
And we use a standardized tool called the WAT score, which is Withdrawal Assessment
Tool, that has criteria for the various signs of withdrawal.
And all children who've been on benzodiazepines and narcotics for a significant period of
time, as you lower them, will start to experience some mild signs of withdrawal.
The goal is not to eliminate that completely, but to make it tolerable for the child.
And so we will discuss, as a care team, what degree of symptoms we'll tolerate in the child
who's being weaned from narcotics and benzodiazepines.
And if they reach a point that those symptoms are excessive, we will either provide some
rescue doses of medication or we'll slow down the rate at which we're weaning from those
sedatives.
And as long as the child is awake and breathing after extubation, we will expect that they'll
need some time in order to have these medications reduced without having a lot of side effects
from their exposure.
Summary.
So in summary, the child who has been intubated for respiratory failure from a number of conditions
will primarily need your treatment for the underlying condition, but while doing so,
we need to maintain comfort and safety while they are on the mechanical ventilator.
And for a child who's intubated for just a brief period of time after surgery or following
an ingestion or something that's likely to be very temporary, one can use intermittent
doses of medication, usually a narcotic and a benzodiazepine combination in order to achieve
comfort and safety.
And that comfort safety goal can be described using a standard sedation score or by descriptive
information, such as a child who is calm and cooperative or a child who really doesn't
respond when noxious stimulation is applied.
For a child who's going to be intubated for a longer period of time, for instance a child
with severe lung disease or who's had a head injury, then your level of sedation is likely
going to need to be more continuous, and providing infusions of medications to keep a more constant
level of sedation is appropriate with extra doses when needed for procedures, or when
the child appears uncomfortable.
And then certain conditions, may drive you to keep the child calmer and more sedate than
others.
Things like intracranial hypertension, patient with a difficult airway, or a patient with
pulmonary hypertension may not tolerate agitation and you may wish to have them more deeply
sedated.
Of course ultimately, those patients who cannot tolerate any movement in order to be ventilated
or safely taken care of may need chemical paralysis.
And if that's the case, one needs to have a low threshold for providing additional sedation
and analgesia assuming that pain and agitation are present based on vital signs when the
child is stimulated.
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