University Hospital of Wales Paediatric Intensive Care Unit Guideline Printed on Wed 23-jul-08
Search Site

Last updated June 6, 2017 12:44 PM

Referrals
0300 0300 789

PCCU
02920 744622

External links

Fax

02920 746443

logo

Noah's Ark Childrens Hospital for Wales
Heath Park
Cardiff
CF14 4XW
02920 747747


Sedation of children intubated for mechanical ventilation

Evidence

  1. Protocol driven sedation helps in reducing the duration of mechanical ventilation and the length of stay in paediatric intensive care. (1 & 2)
  2. Prolonged use of sedation and analgesia is associated with tolerance and withdrawal phenomena. There are also concerns about the physical and psychological well being of the patients.(3,4&5)
  3. Use of sedation assessment score and withdrawal assessment score helps in optimising sedation. Also helps in reducing the duration of sedation and the length of intensive care stay. In a PICU the tools would bring in consistency to the practice involving the multi-disciplinary team. At the same time it would empower bed side nurse to lead on sedation management.

Sedation practice in PCCU:

As a general rule the need for sedation is less in children who are very unwell and the doses are accordingly lower – regular as well as PRN bolus.

Under 6 months

Nurse led sedation strategy based on goals and targets set at the time of ward round and/or at the time of admission.

Perform Comfort scores every 4 hours to 6 hours and titrate sedation to achieve the desired sedation goal.

Initial bolus of Morphine 20 – 50 mcg/kg followed by an infusion of 10 – 40 mcg/kg/hr.

In infants who are not able to have enteral sedation or as rescue until oral sedation works, please use PRN boluses of morphine (20 to 50 mcg/kg)  and midazolam (50 to 100 mcg/kg)

Oral/enteral sedation:
There is evidence that Clonidine helps reduce the need for opioids and hence the incidence of withdrawal phenomena. Consider starting regular Clonidine if no contraindication.

Also start PRN Chloral Hydrate and/or Alimemazine if appropriate. Please see the appendix for doses.

Consider Midazolam infusion only following discussion with Consultant

Over 6 months

Initial bolus of Morphine 50-100 mcg/kg each of and Midazolam 50-100 mcg/kg followed by an infusion of Morphine 20 to 40 mcg/kg/hr and Midazolam of 50-100 mcg/kg/hr.

Set clear sedation goals and target sedation scores at the time of admission and daily ward rounds.

Nurse led sedation strategy based on goals and targets set at the time of ward round and/or at the time of admission. Perform COMFORT scores every 4 to 6 hours.

Increase the IV sedation to Morphine 40 mcg/kg/hr and Midazolam 200 mcg/kg/hr to optimise sedation, only if there is a contraindication to immediate use of regular clonidine and/or PRN Chloral Hydrate and Alimemazine.

Please see the appendix for doses. In children who are not able to have enteral sedation or as rescue until oral sedation works, please use PRN boluses of morphine (20 to 50 mcg/kg)  and midazolam (50 to 100 mcg/kg)

In patients who are on enteral feeds, consider use of oral sedation earlyChloral Hydrate, Clonidine and Alimemazine. This is to achieve the optimum sedation targets. Consider use of IV Clonidine ( 0.2  to 1 mcg/kg/hr, IV) if desired level of sedation is not achieved.

Weaning sedation on PCCU:

 

Refer to the flow chart.

 

Withdrawal syndrome:

Withdrawal phenomenon is a clinical syndrome that manifests after stopping or reversing a drug after prolonged exposure to that drug. It is a diagnosis of exclusion. Perform withdrawal scoring on all patients at least once every shift after initiation of sedation wean. (7) Ensure other causes have been ruled out before patient diagnosed with Withdrawal syndrome. (7&8).

Weaning of sedation after extubation:

Sedation weaning depends on the duration of ventilation and the medications used. It is informed by an assessment of withdrawal using the Withdrawal Assessment Tool (WAT 1). 

Duration of sedation 4 to 6 days

Once patient is extubated but shows evidence of withdrawal, convert the IV sedation to enteral/oral sedation, as per the calculation below and initiate a slow weaning regime. This should aim to reduce the sedatives – Oromorph and Lorazepam by 10 to 20% of the original dose every day. If patient was on IV sedation, without evidence of withdrawal, consider managing with Chloral Hydrate and Alimemazine.

Duration of sedation for ≥ 7 days

Use Clonidine to offset the need for Opioids during the wean; do not stop Clonidine abruptly.

Once patient is extubated, have a clear weaning plan based on withdrawal scores. Change the IV medications to oral/enterals as per the calculation below.

Wean one of two medications (Oromorph or Lorazepam ) on alternate days by 10%  to 20% of the original starting dose. When 50% of the original starting dose of Oromorph, start weaning Clonidine by 10 – 20% daily.

Once a small dose is reached, reduce frequency on alternate days.

Continue with regular withdrawal scores. If  any signs and symptoms of withdrawal occur :

 If withdrawal symptoms persist, increase the dose by 10% of the original pre-wean dose.

Converting Intravenous to Oral Sedation

IV Morphine to Oromorph Calculation  -
IV Morphine microgram/kg/hr x 24 x weight (Kg) = total daily dose of Oromorph to be given in 6 divided doses


IV Midazolam to Lorazepam Calculation  -  
IV Midazolam microgm/k/hour x 24 x weight in Kg  divided by 8 (conversion factor)  = total daily dose of Lorazepam. It is given in 3 divided doses (5)


Discharge from PCCU of a patient on weaning regime of sedation

Consider appropriateness of discharge to the ward based on resource and staffing competencies in the destination ward.

Have a clear weaning regime plan documented in the discharge letter and handover to the staff on the ward. It is a joint responsibility of the staff to ensure smooth transition of the patient with potential or ongoing withdrawal symptoms.   Ensure a copy of the Weaning regime plan as well as the WAT 1 assessment tool is handed over to the ward staff.

References

  1. Aitken LM, Bucknall T, Kent K, et al. Protocol directed sedation versus non-protocol directed sedation to reduce duration of mechanical ventilation in mechanically ventilated intensive care patients [Protocol]. Cochrane Database Syst Rev 2012;(4):CD009771.
  2. Vet NJ, Ista E, de Wildt SN, et al. Optimal sedation in pediatric intensive care patients: a systematic review. Intensive Care Med 2013;39:1524–34.
  3. Cammarano WB, Pittet JF, Weitz S, et al. Acute withdrawal syndrome related to the administration of analgesic and sedative medications in adult intensive care unit patients. Crit Care Med 1998;26:676–84.
  4. Fonsmark L, Rasmussen YH, Carl P. Occurance of withdrawal in critically ill sedated children. Crit Care Med 1999;27:196–9.
  5. Tobias JD. Tolerance, withdrawal, and physical dependency after long-term sedation and analgesia of children in the pediatric intensive care unit. Crit Care Med 2000;28:2122–32.
  6. Consensus guidelines on sedation and analgesia in critically ill children.

Playfor et al. Intensive Care Med (2006) 32:1125–1136

  1. Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals. Harris et al. Intensive Care Med (2016) 42:972–986
  2. Withdrawal symptoms in children after long-term administration of sedatives and/or analgesics: a literature review. “Assessment remains troublesome”

Intensive Care Med (2007) 33:1396–1406

 

Appendix

Oral/enteral sedation for children in PICU.
Please refer to BNFc for detailed information on contraindications, interactions and side effects.

  1. Chloral Hydrate

 

Dose: 30 – 50 mg/kg (maximum dose 1 g) 4- 6 hourly.

Side effects: Gastric irritation, vomiting and rarely rash

Unpleasant taste ! dilute if given orally

Relative contraindications:
Please reduce the dose in mild to moderate liver impairment and avoid in severe liver impairment
Avoid in severe renal impairment.

 

  1. Clonidine

Is an α2 agonist which is used as a sedative.
Use of clonidine for sedation in PICU has been shown to offset the need for opioid use in terms of the duration and the cumulative dosage for sedation.

Test dose: Initial dose of 1 microgm/kg to test for  hypotension.

Regular dose:  2 – 3 microgm/kg 8 hrly

Treatment cessation: Wean gradually as risk of rebound hypertensive crisis.

Absolute contraindication:
Brady arrhythmias or sick sinus syndrome

Use with caution (reduced dose ) in renal impairment.

  1. Alimemazine

 

Is a sedating antihistamine which is used as a third line enteral sedative

Dose: 1-2 mg/kg 8 hourly

Contraindications: Newborns, glaucoma (congenital eye disorders)  severe renal and hepatic impairments

Side effects: Rare -  severe movement disorders, angioedema and anaphylaxis.

 

Siva Oruganti June 2016

For Review June 2019