RAMB - Julho 2016

130 / 139

Motta E et al.
602 Rev Assoc Med Bras 2016; 62(6):602-609
REVIEW ARTICLE
Importance of the use of protocols for the management of
analgesia and sedation in pediatric intensive care unit
Emiliana Motta1*, Michele Luglio 2, Artur Figueiredo Delgado3, Werther Brunow de Carvalho4
1Assistant Physician at the Pediatric Intensive Care Unit (PICU), Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HC-FMUSP), São Paulo, SP, Brazil
2Clinical Preceptor at the PICU, Instituto da Criança, HC-FMUSP, São Paulo, SP, Brazil
3Professor, Habilitation (BR: Livre-docência), Department of Pediatrics, FMUSP. Coordinator of the PICU, Instituto da Criança, HC-FMUSP, São Paulo, SP, Brazil
4Full Professor of Intensive Care/Neonatology, Department of Pediatrics, FMUSP, São Paulo, SP, Brazil
Summary
Study conducted at Instituto da Criança,
Hospital das Clínicas, Faculdade de
Medicina, Universidade de São Paulo
(HC-FMUSP), São Paulo, SP, Brazil
Article received: 6/29/2016
Accepted for publication: 7/26/2016
*Correspondence:
Centro de Terapia Intensiva Pediátrica
Address: Av. Dr. Enéas de Carvalho
Aguiar, 647, 4 o andar
São Paulo, SP – Brazil
Postal code: 05403-000
Introduction: Analgesia and sedation are essential elements in patient care in
the intensive care unit (ICU), in order to promote the control of pain, anxiety
and agitation, prevent the loss of devices, accidental extubation, and improve
the synchrony of the patient with mechanical ventilation. However, excess of
these medications leads to rise in morbidity and mortality. The ideal manage-
ment will depend on the adoption of clinical and pharmacological measures,
guided by scales and protocols.
Objective: Literature review on the main aspects of analgesia and sedation, absti-
nence syndrome, and delirium in the pediatric intensive care unit, in order to show
the importance of the use of protocols on the management of critically ill patients.
Method: Articles published in the past 16 years on PubMed, Lilacs, and the
Cochrane Library, with the terms analgesia, sedation, abstinence syndrome, mild
sedation, daily interruption, and intensive care unit.
Results: Seventy-six articles considered relevant were selected to describe the im-
portance of using a protocol of sedation and analgesia. They recommended mild
sedation and the use of assessment scales, daily interruptions, and spontaneous
breathing test. These measures shorten the time of mechanical ventilation, as
well as length of hospital stay, and help to control abstinence and delirium, with-
out increasing the risk of morbidity and morbidity.
Conclusion: Despite the lack of controlled and randomized clinical trials in the
pediatric setting, the use of protocols, optimizing mild sedation, leads to de-
creased morbidity.
Keywords: pediatrics, intensive care unit, analgesia, sedation, daily interruption,
abstinence syndrome, delirium.
Introduction
Intensive care hospitalization exposes the patient to pain
and a series of stressful events that can cause it. Analge-
sia and sedation are key elements fundamental to the
care of these critically ill patients, especially those on
mechanical ventilation. The main indications to these
medications are: to better manage pain, anxiety, and ag-
itation; promote amnesia; facilitate synchrony with the
mechanical ventilation; avoid loss of catheters and en-
dotracheal tube; and reduce cellular metabolism.1-4 How-
ever, in spite of helping to manage these conditions, it is
still difficult to reach adequate level of sedation and an-
algesia, avoiding excesses and subdose. An ideal level of
sedation is described as an estate on which the patient
is sleepy, responding to environmental stimuli, without
risks and excessive movements. In this condition, the
child is conscious, with spontaneous breathing and com-
fortable in the mechanical ventilation, tolerating other
intervention. However, practice has shown that exces-
sive sedation, often driven by fear of loss of devices and
accidental tracheal extubation, results in increased du-
ration of mechanical ventilation in days, longer length
of stay in the intensive care unit (ICU) and overall hos-
pital stay, cerebral dysfunction, drug tolerance, absti-