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I
mportance
of
the
use
of
protocols
for
the
management
of
analgesia
and
sedation
in
pediatric
intensive
care
unit
R
ev
A
ssoc
M
ed
B
ras
2016; 62(6):602-609
603
nence syndrome and delirium, thus increasing the cost
of hospitalization. For better management of these pa-
tients, the use of scales and protocols of analgesia and se-
dation, associated with mild sedation and daily interrup-
tion, is associated with lower use and shorter duration of
sedation, mechanical ventilation, and length of hospital
and ICU stay (as described by the Society of Critical Care
Medicine – SCCM).
1-4
O
bjective
The objective is to review the main aspects of sedation
and analgesia in pediatric intensive care units, including
the use of scales for patient management, daily interrup-
tion, adequate level of sedation, abstinence syndrome,
and delirium. In the end, to promote the use of protocols,
with the main aspects to lower the use of sedatives through
the use of sedation and analgesia scales, improving mul-
tidisciplinary communication and lowering hospital and
length of ICU stay.
M
ethod
We conducted a review of the medical literature of the last
16 years (2000–2016) utilizing PubMed, Lilacs, and the
Cochrane Library with the following terms: sedation, an-
algesia, mild sedation, daily interruption, child, intensive
care medicine. The most relevant articles on sedation and
analgesia in ICU, use of sedation/analgesia scales, daily
interruption, abstinence, and delirium published in Eng-
lish and Portuguese were included. The papers selected
for this review included one meta-analysis, six systematic
reviews, 20 narrative reviews, six guidelines, nine prospec-
tive randomized studies, three cohort studies, three case
series, one case-control study, three clinical trials, eight
scale validation studies, six prospective observation stud-
ies, eight cross-sectional studies, two letters to the editor.
R
esults
Management of the patient in the pediatric intensive care unit
While the use of adequate sedation and analgesia reduce
the response to stress and improve clinical and psycholog-
ical outcomes, a subdose of these drugs would lead to pain,
discomfort, possible accidental extubation, and loss of de-
vices. Overdose, in the other hand, would lead to a need
for longer duration of mechanical ventilation, increased
hospital and ICU length of stay, tolerance, abstinence, and
delirium. To reach an ideal level of sedation, we should use
other measures for better patient comfort. Such measures,
known as non-pharmacological, are essential, helping on
the management of patients and on the reduction of agi-
tation, of unfavorable cognitive outcomes – such as dis-
ruptions of the sleep-wake cycle and delirium. Non-phar-
macological strategies should be carried out and checked
every time since the admission to the unit.
1,2,4-7
Among the non-pharmacological measures are min-
imization of noise in the unit – which must be as silent as
possible; utilization of adequate luminosity to promote
an adequate sleep-awake cycle – through less light during
nighttime; promoting time to rest and sleep to maintain
a circadian orientation; concentrating, as much as possi-
ble, the procedures on daytime; keeping the patient in a
comfortable position, with the use of cushions, for exam-
ple; stimulating the presence of companions; maintain-
ing good communication between everyone and the med-
ical team. The use of video-therapy and music-therapy are
also procedures to promote comfort to these patients.
1,2,4-7
Management of pain/sedation
The International Association for the Study of Pain defines
pain as a sensorial and emotional, unpleasant experience,
associated with an actual or potential lesion to tissues. In
the ICU, we can distinguish between two types of pain: (1)
acute pain, including procedure and post-operative pain;
and (2) prolonged pain – which is pain caused by a disease
(like peritonitis, mechanical ventilation, tubes and drains
etc.), with predictable beginnings and endings.
4,8,9
In spite of being a subjective parameter, all teams
must be prepared to recognize and treat pain, because re-
sponse to pain stress promotes an increase in endoge-
nous catecholamine, leading to arteriolar vasoconstric-
tion, worsening of tissue perfusion and reduction of
tissue pO
2
; hypercatabolic state, lipolysis, hyperglycemia;
and increased infection risk. So, identifying and treating
pain adequately requires attention and precise therapeu-
tic interventions.
9,10
Recent studies demonstrate that the use of scales to
improve recognition of pain and its pharmacological and
non-pharmacological management is crucial. A self-re-
port made by the patient is considered the gold-standard
method to measure an intervention on pain. This can be
done through numerical (a graduation of pain from 0 –
without pain – to 10, unbearable pain) and visual scales
(numbers or faces). However, such methods are not al-
ways useful in children, because of age, neurological dys-
function or lack of adequate communication due to the
presence of endotracheal tube and mechanical ventila-
tion.
4,9,10
Scales were developed and validated due to the-
ses difficulties, and their use is now well established for
the evaluation and intervention on pediatric pain.
9-18
The implementation of scales has already shown to be
plausible and effective on intensive care units, both adult