RAMB - Julho 2016

otta

604

ssoc

ras

2016; 62(6):602-609

and pediatric. Mansouri P et al. demonstrated a decrease

of 3 days in ICU stay with the use of protocols and scales

for analgesia and sedation.

According to Larson EG et al.,

the use of scales improves communication within the mul-

tidisciplinary team, and thus the therapeutic plan and pa-

tient management.

Only one recent study, by Curley

MAW et al.

showed that the use of protocol did not alter

the duration of mechanical ventilation, but with a com-

plex relation between pain, agitation, and alertness, and

a lower use of medication, with no more adverse events.

As already described by Harris J et al.,

the FLACC

scale and the Multidimensional Assessment of Pain Scale

(MAPS) are indicated to evaluate pain in critically ill chil-

dren. There is no clear literature recommendation on the

frequency on which these scales should be applied, which

depends on the therapeutic goals and the clinical state of

the patient.

4,10-16,23

Merkel SI et al. created the FLACC scale in 1997

for

children aged from 2 months to 7 years in a post-surgical

setting.

The name FLACC is an acronym of five catego-

ries: Face, Legs, Activity, Cry, Consolability. Each catego-

ry scores 0 to 2 points, totaling 10 points. The resulting

score correlates with the degree of pain: 0 for no pain or

comfortable; 1-3 for mild pain; 4-6 for moderate pain; and

7-10 for intense pain.

11,19

The use of the FLACC scale was

posteriorly extended and various studies showed that its

use is reproducible and feasible in many age groups, clin-

ical settings, and cognitive states. As evaluated by Malvi-

ya S et al.

the FLACC scale can be individualized for use

in children with altered cognitive states.

Nilsson S et al.

showed that FLACC scale is adequate for children between

5 and 16 years of age.

Voepel-Lewis T et al. validated the

use of FLACC in intensive care units, with a good correla-

tion with numeric 0-10 scales.

The scale was translated

and validated for use in Portuguese language.

After the non-pharmacological measures have been

adopted and the most adequate scale has evaluated the pa-

tients, we shall initiate the pharmacological treatment of

pain. The choice of drug depends on the degree of pain of

the patient, given by the scale and its clinical condition. In

cases of mild pain, is indicated the use of non-opioid an-

algesics, like acetaminophen and – with care in the pediat-

ric setting – nonsteroidal anti-inflammatory drugs (NSAIDs),

such as ketorolac. In moderate pain, association of a weak

opioid, such as tramadol, is recommended. In intense pain,

the use of strong opioids is indicated, such as morphine,

fentanyl, and methadone. Adjuvant medications, includ-

ing gabapentin and carbamazepine, can also be used.

9,10,25

In intensive care units, intravenous opioids are con-

sidered the first line of drugs for the treatment of pain.

Recently, studies showed that the use of opioids consti-

tute the primary regimen for analgesia/sedation in

ICU.

9,10,21

Fentanyl is the most used opioid, being used by

66% of the intensive care physicians, as shown by Kud-

chadkar SR et al.,

due to a lower incidence of side effects

when compared to morphine.

21,26

Management of sedation/agitation

Patients admitted to intensive care units present some de-

gree of discomfort, physical or psychic distress, sometimes

requiring the use of sedatives, especially those in mechani-

cal ventilation. Reaching optimal/mild sedation is ideal,

avoiding oversedation or subdoses, each with its own ad-

verse reactions.

1,2,4

As described by Hughs CG et al., profound

sedation along the first 24 hours is associated to an increase

of 12 hours (p=0.0001) of mechanical ventilation; increase

in 10% of in-hospital mortality (p=0.01) and 8% in 180 days

mortality (p=0.03). The use of protocols of sedation, mild

sedation, daily interruption with spontaneous breathing

test is recommended in order to decrease ventilatory needs,

hospitalization time and cognitive impairment.

2-4,9,10,27-33

The

implementation of the mnemonic ABCDE bundle program

(Awakening and Breathing coordination, attention to the

Choice of sedation, Deliriummonitoring, and Early mobil-

ity and Exercise) in adults showed success in providing less

days of mechanical ventilation (p=0.04) and in lowering de-

lirium incidence (p=0.004).

The use of sedation scales is useful and recommended

to reach mild sedation, which is considered ideal. The pa-

tient must be calm, responsive to stimuli, comfortable in

the mechanical ventilation.

4,9,10

Hughes et al. demonstrat-

ed that the use of mild sedation promotes a decrease in ven-

tilatory support time in nearly 2.6 days (p=0.02), reduction

of ICU stay in 3 days (p=0.03), without increase in acciden-

tal tracheal extubation and needs of re-intubation.

The use of sedation scales is yet difficult to implement

in ICUs, with a study by Hudchadkar et al. showing that

scales are routinely used in only 42% of the American pe-

diatric ICUs.

Nevertheless, its use is recommended as an

attempt to reduce the duration of mechanical ventilation,

length of ICU and hospital stay.

2,22,23,27

In pediatrics, in

1992, Ambuel et al. developed a method to evaluate seda-

tion in ventilated patients, the COMFORT scale, which

aggregates six behavioral and two physiological param-

eters. However, the two physiological parameters (blood

pressure and heart rate) were excluded to avoid confound-

ing the evaluation and a new scale was validated, the

COMFORT Behavior scale,

30-32

which is the scale recom-

mended (level A evidence) for management and evalua-

tion of sedation in pediatrics, used every 4 to 8 hours, as