Abstract
Background Critically ill paediatric patients often require complex medical procedures as well as invasive testing and monitoring, which can be painful and distressing, necessitating the administration of analgesia and sedation to reduce stress response.1 Achieving the optimal combination of adequate analgesia and appropriate sedation can be challenging in a patient population with a wide spectrum of ages, sizes and developmental stages.2 We propose to review the appropriateness of analgesia and sedation prescribing in a large tertiary paediatric intensive care unit (PICU).
Aims
Identify the most commonly prescribed sedatives and analgesics in the PICU.
Assess compliance with the Trust’s PICU pain and sedation guidelines.3
Identify reasons for deviations from the PICU pain and sedation guidelines.
Methods Prospective data was collected between October and November 2022. 50 patients were selected at random and included in the study. For all patients, their demographics, reason for admission, diagnosis, weight, medication, administration route, formulation, doses, length of sedation and analgesia, daily sedation and pain scores were documented on Microsoft Excel (Version 1808). Most commonly prescribed sedatives and analgesics were identified by reviewing prescription charts using the electronic prescribing system: IntelliSpace Critical Care and Anaesthesia (ICCA, Version H.02.02)). Compliance with the guideline was achieved by reviewing the prescribed agents against the approved guideline3 and calculating the cumulative dose of the prescribed sedatives and analgesics, using ICCA. Patients’ medical notes were thoroughly reviewed to identify reasons for deviations from the guideline. Reasons for deviations were reviewed and confirmed by a Specialist Registrar and a Senior PICU Pharmacist.
Results The most commonly prescribed analgesics and sedatives were morphine and clonidine. 94% (47/50) of patients received morphine and 75% (38/50) received clonidine during their PICU admission. Morphine and clonidine were also administered for the longest duration with morphine being administered for an average of 55.4 hours, and clonidine for an average of 61.9 hours. 76% (38/50) of patients were prescribed and administered analgesics and sedation in accordance with the Trust guidelines. Of the 24% (12/50) of patients that were not treated in accordance with the guideline, 75% (9/12) were identified as appropriate deviations from the guideline. Appropriate reasons for deviating from the guideline included; ‘propofol administered for intubation’, ‘patient admitted with status epilepticus’, and ‘propofol administered to assess neurology’.
Conclusion This study demonstrated that the majority of patients admitted to the PICU received analgesia and sedation as per Trust guidance. With a great proportion of patients receiving morphine and clonidine as first line agents, which is stipulated in the guideline. For most patients that received sedation and analgesia outside of the Trust guidance, reasons for deviating from the guidance were reasonable and appropriately documented. Despite this, a few inappropriate deviations from the Trust guidance were present, indicating that further education and training to the medical and nursing team is needed to re-iterate the importance of prescribing as per Trust guidelines (when deemed appropriate).
References
Egbuta C, Mason KP. Current state of analgesia and sedation in the pediatric intensive care unit. J Clin Med 2021;10:1847.
Smith HAB, Besunder JB, Betters KA, et al. Society of critical care medicine clinical practice guidelines on prevention and management of pain, agitation, neuromuscular blockade, and delirium in critically ill pediatric patients with consideration of the ICU environment and early mobility. Pediatric Critical Care Medicine 2022;23:e74–e110.
Perkins J, Procopiuc L. Paediatric Critical Care: Pain and Sedation Guidelines. Version 1.0. Guy’s and St Thomas’ NHS Foundation Trust, 2021.
