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Consensus guidelines on sedation and analgesia in critically ill children

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Abstract

Objective

The United Kingdom Paediatric Intensive Care Society Sedation, Analgesia and Neuromuscular Blockade Working Group is a multi-disciplinary expert panel created to produce consensus guidelines on sedation and analgesia in critically ill children and forward knowledge in these areas. Sedation and analgesia are recognised as important areas of critical care practice and adult clinical practice guidelines in these fields remain amongst the most popular of those produced by the Society of Critical Care Medicine. However, similar clinical practice guidelines have not previously been produced for the critically ill paediatric patient.

Design

A modified Delphi technique was used to allow the Working Group to anonymously consider draft recommendations in three Delphi rounds with predetermined levels of agreement. This process was supported by a total of four consensus conferences. Once consensus had been reached, a systematic review of the available literature was carried out.

Outcome

A set of consensus guidelines was produced including 20 key recommendations, 10 relating to the provision of analgesia and 10 relating to the sedation of critically ill children. An evaluation of the existing literature supporting these recommendations is provided.

Conclusions

Multi-disciplinary consensus guidelines for maintenance sedation and analgesia in critically ill children have been successfully produced and are supported by levels of evidence (excluding sedation and analgesia for procedures and excluding neonates). The working group has highlighted the paucity of high-quality evidence in these important clinical areas and this emphasises the need for further randomised clinical trials in this area.

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Authors and Affiliations

  1. Paediatric Intensive Care Unit, Royal Manchester Children's Hospital, Hospital Road, M27 4HA, Manchester, UK

    Stephen Playfor, Ian Jenkins, Carolyne Boyles, Imti Choonara, Gerald Davies, Tim Haywood, Gillian Hinson, Anton Mayer, Neil Morton, Tanya Ralph & Andrew Wolf

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  1. Stephen Playfor
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  2. Ian Jenkins
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United Kingdom Paediatric Intensive Care Society Sedation

Analgesia and Neuromuscular Blockade Working Group

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Correspondence to Stephen Playfor.

Additional information

This article is discussed in the editorial available at: http://dx.doi.org/10.1007/s00134-006-0191-9

Financial support received: none.

Conflict of interest: none.

Appendix: Summary of recommendations

Appendix: Summary of recommendations

  1. 1.

    All critically ill children have the right to adequate relief of their pain. (grade of recommendation = D)

  2. 2.

    Any correctable environmental and physical factors causing discomfort should be addressed alongside the introduction of pharmacological agents. (grade of recommendation = D)

  3. 3.

    A normal pattern of sleep should be encouraged. Attention should be paid to lighting, environmental noise and temporal orientation of patients. (grade of recommendation = D)

  4. 4.

    Pain assessment should be performed regularly by using a scale appropriate to the age of the patient and routinely documented. The level of pain reported by the patient must be considered the current standard of analgesia. (grade of recommendation = C)

  5. 5.

    Patients who cannot communicate should be assessed for the presence of pain-related behaviours and physiological indicators of pain. (grade of recommendation = D)

  6. 6.

    A therapeutic plan for analgesia should be established for each patient and regularly reviewed. (grade of recommendation = D)

  7. 7.

    Continuous intravenous infusions of morphine or fentanyl are recommended for relief of severe pain. (grade of recommendation = C)

  8. 8.

    Non-steroidal anti-inflammatory drugs or paracetamol may be used as adjuncts to opioids in certain patients. (grade of recommendation = D)

  9. 9.

    Local and regional anaesthetic techniques should be considered. (grade of recommendation = D)

  10. 10.

    A patient controlled analgesia (PCA) device may be useful in older children. (grade of recommendation = D)

  11. 11.

    Adequate analgesia should be provided to all critically ill children regardless of the need for sedation. (grade of recommendation = D)

  12. 12.

    The level of sedation should be regularly assessed and documented using a sedation assessment scale, wherever possible using a validated scoring system such as the COMFORT scale. (grade of recommendation = B)

  13. 13.

    The desired level of sedation should be identified for each patient and should be regularly reassessed. (grade of recommendation = D)

  14. 14.

    Doses of sedative agents should be titrated to produce the desired level of sedation. (grade of recommendation = D)

  15. 15.

    Midazolam is the recommended agent for the majority of critically ill children requiring intravenous sedation. It should be given by continuous infusion. (grade of recommendation = C)

  16. 16.

    Clonidine given by continuous intravenous infusion may be used as an alternative sedative agent to midazolam. (grade of recommendation = D)

  17. 17.

    Propofol should not be used to provide continuous sedation in critically ill children. (grade of recommendation = C)

  18. 18.

    Early use of enteral sedative agents is recommended. (grade of recommendation = B)

  19. 19.

    The use of clinical guidelines for sedation is recommended. (grade of recommendation = C)

  20. 20.

    The potential for opioid and benzodiazepine withdrawal syndrome should be considered after 7 days of continuous therapy. When subsequently discontinued, the doses of these agents may need to be routinely tapered. (grade of recommendation = D)

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Playfor, S., Jenkins, I., Boyles, C. et al. Consensus guidelines on sedation and analgesia in critically ill children. Intensive Care Med 32, 1125–1136 (2006). https://doi.org/10.1007/s00134-006-0190-x

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