RAMB - Julho 2016

otta

606

ssoc

ras

2016; 62(6):602-609

and treatment.

57-59

Tobias et al., in 2000, proposed a treat-

ment based on the conversion of midazolam to loraze-

pam and fentanyl to methadone, through the relation

between potency and half-life, with slow weaning based

on weakly reductions of 20% of its dose.

Bowens et al.

compared the weaning of opioids with low and high dos-

es of methadone, showing no difference between the two

approaches.

Other studies demonstrated the imple-

mentation of a protocol for the management of absti-

nence syndrome reduces the time and dosage of those

drugs, while the WAT-1 scale has a good performance eval-

uating abstinence.

62-66

Fernandez-Carrión et al. showed

that reductions of 10% in the doses of methadone every

day implied in no increase in the incidence of signs and

symptoms of abstinence, needs of morphine rescue ther-

apy, or excess sedation.

Some other studies show that

daily reductions of 5-10% in the doses used between 5

and 10 days did not demonstrate adverse effects, sug-

gesting that a faster approach on weaning leaded to a

decrease in length of stay, without any increase in mor-

bidity.

55,57

Oschman et al. show that the use of other

drugs is possible in the treatment of abstinence, such as

dexmedetomidine and clonidine.

Delirium

Delirium represents an acute cerebral dysfunction, char-

acterized by an altered mental state and behavior. Ac-

cording to the Diagnostic and Statistical Manual of

Mental Disorders (DSM-5) definition, diagnostic crite-

ria for delirium include: disruption of attention and

consciousness, accompanied by cognitive impairment

(memory, orientation, language, and perception) that

cannot be explained by other previous neurocognitive

disturbances; this develops in hours or days, frequent-

ly with fluctuations throughout the day and worsening

during nighttime, and there is evidence that these ef-

fects result from clinical conditions or treatment (in-

fection, cancer, metabolic or endocrine alterations, use

of sedatives). Delirium can be either hypoactive (apathy,

slowed speech, lethargy; a condition with poorer prog-

nosis), hyperactive (agitation, emotional fluctuation,

hallucinations) or mixed. It is associated with worse

outcomes, longer length of stay, more cognitive impair-

ment and higher mortality rates in adults up until three

times higher than the general population, along 6

months of observation.

4,68-70

The prevalence in adults is well established, varying

from 45 to 87% of the patients in ICUs.

69,70

In pediatrics,

there are still few studies, with some of then showing a

prevalence of 4-29%.

4,70

Risk factors for delirium, in adults, include the well-

-documented use of midazolam, which became less and less

used in this population of patients, leading to the use of

dexmedetomidine and propofol as sedative agents. Besides

this, immobilization, long length of stay, alterations on

sleep-awake cycle, lack of present companions, infection,

presence of invasive devices are also described as risk fac-

tors for the development of delirium.

In the pediatric

population, Silver et al.,

in a prospective study, described

some risk factors, such as: previous alterations on mental

status (p<0.0001), necessities of oxygen therapy (p<0.0001),

use of mechanical ventilation (p<0.0001), profound seda-

tion (p<0.0001), pre-scholar age group (p=0.007).

The early recognition of delirium is shown to be es-

sential, in virtue of the high mortality and morbidity as-

sociated with it. So, the use of evaluation scales every 8

to 12 hours is recommended.

4,68-70

In pediatrics, there is

still no consensus regarding the best method. Options

include the p-CAM (pediatric Confusion Assessment

Method), derived from the CAM scale, for children old-

er than 5 years of age, and the CAP-D (Cornell Assess-

ment Pediatric Delirium tool) for children between 0-18

years old.

4,68,70,72

iscussion

Promotion of comfort and lowering of anxiety, fear, and

anguish is part of the daily routine of a pediatric intensive

care physician. The use of an excessive dosage of sedatives

and analgesics leads to worse outcomes, with longer peri-

ods of immobilization, more sleep-awake cycle disturbanc-

es and delirium, increase in time of mechanical ventilation

and hospital length of stay, higher treatment costs.

The use of analgesia and sedation scales is well doc-

umented, favoring a better communication within the

multidisciplinary team, better choice of medication when

taking into account the pharmacokinetic and pharma-

codynamics of the drugs, their interaction with different

age groups and pathologies. In addition, avoiding exces-

sive sedation and analgesia promotes ideal mild sedation,

causing the patient to remain calm, responsive to stimuli,

and comfortable under mechanical ventilation.

In the initial management, analgesia with the use of

strong opioids, like fentanyl, and with mild sedation, is

preconized. After adequate analgesia, the use of sedative

agents should be taken into account, avoiding, if possi-

ble, the use of benzodiazepines, as it was shown to lead

to negative outcomes in delirium and increased morbid-

ity/mortality. The use of other therapeutic agents, such

as dexmedetomidine, clonidine, propofol (if possible),

and ketamine, is indicated.