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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
607
The use of daily interruption of sedation and spon-
taneous breathing test are also more established in the
pediatric population, with a decrease in the duration of
ventilatory support and length of ICU stay, without an
increase in the numbers of accidental tracheal extubation
and loss of invasive devices.
The diagnosis of delirium is still difficult in the pe-
diatric setting and there are few randomized studies on
this topic. Its recognition is increasingly taken into ac-
count and pediatric intensive care physicians must be
alert to prevent it. The use of scales is recommended, such
as the recent p-CAM, CAP-D and sp-CAM. The use of pre-
ventive measures, including early passive or active mobi-
lization, promotion of a good sleep-awake cycle, light and
noise control, and the constant presence of family mem-
bers, must be adopted in the pediatric ICU.
More and more pediatric ICUs should adopt such mea-
sures and interventions in order to provide better manage-
ment of analgesia and sedation for the patients, control-
ling morbidity and mortality, with the use of protocols.
This protocol must include the management of an-
algesia and sedation, as well as the use of assessment scales
such as FLACC, numeric and visual scales for pain and
COMFORT-Behavior for sedation, by the nursing staff
every 4 hours, instituting mild sedation, first with anal-
gesic control, the with the use of sedatives, based on the
scales’ assessment; promote the use of daily interruption
with spontaneous breathing test every day in patients in
conditions for it; monitoring and treating abstinence syn-
drome with WAT-1 and the use of methadone and loraz-
epam, with fast weaning, in 5 to 10 days and daily reduc-
tions of its doses; assess and treat delirium, adopting
non-pharmacological measures, such as early mobiliza-
tion, promotion of the sleep-awake cycle, video and mu-
sical therapy, presence of family members, and the use of
delirium assessment tools.
C
onclusion
Offering perfect analgesia and sedation in pediatrics is
still a controversy. There is a concern regarding the con-
sequent over-sedation caused by high doses of sedatives
and analgesics, which slow metabolism and clearance, im-
pacting duration of mechanical ventilation and hemody-
namic stability. However, the institution of therapy guid-
ed by protocols and assessment scales is necessary to
prevent excessive or suboptimal use of sedatives, which
leads to an increase in the duration of mechanical venti-
lation support, accidental tracheal extubation, abstinence
and delirium. To reach this objective, a multidisciplinary
approach is essential.
R
esumo
Importância do uso de protocolos para manejo da analge-
sia e sedação em unidade de terapia intensiva pediátrica
Introdução:
analgesia e sedação são elementos necessá-
rios no cuidado do paciente em UTI, com o objetivo de
promover controle de dor, angústia, agitação e evitar per-
da de dispositivos, extubação acidental e melhora da sin-
cronia do paciente com a ventilação mecânica. No entan-
to, o excesso dessas medicações ocasiona um aumento de
morbidades e mortalidade. O manejo ideal depende da
adoção de medidas clínicas e farmacológicas, guiadas por
escalas e protocolos.
Objetivo:
revisão da literatura sobre principais aspectos
da analgesia e sedação, síndrome de abstinência e
delirium
em unidade de terapia intensiva pediátrica, mostrando a
importância do uso de protocolos no manejo dos pacien-
tes criticamente enfermos.
Método:
artigos publicados nos últimos 16 anos, nas pla-
taformas PubMed, Lilacs e Cochrane Library, com os ter-
mos analgesia, sedação, síndrome de abstinência, nível
leve de sedação, interrupção diária da sedação e unidade
de terapia intensiva.
Resultados:
foram selecionados 76 artigos relevantes
para descrever a importância da utilização do protocolo
de sedação e analgesia, preconizando um nível leve de se-
dação, com uso de escalas de avaliação, interrupção diá-
ria e aplicação de teste de respiração espontânea. Essas
medidas evidenciam uma diminuição no tempo de ven-
tilação mecânica, no tempo de internação hospitalar, o
controle da síndrome de abstinência e
delirium
, sem im-
plicar em maior risco de morbimortalidade.
Conclusão:
apesar da falta de estudos controlados e
randomizados em pediatria, o uso de protocolo, otimi-
zando um nível leve de sedação, determina uma menor
morbidade.
Palavras-chave:
pediatria, unidade de terapia intensiva,
analgesia, sedação, interrupção diária da sedação, síndrome
de abstinência,
delirium
.
R
eferences
1.
Keogh SJ, Long DA, Horn DV. Practice guidelines for sedation and analgesia
management of critically ill children: a pilot study evaluating guideline
impact and feasility in the PICU. BMJ Open. 2015; 5(3):e006428.
2. Vet NJ, Ista E, Wildt SN, van Dijk M, Tibboel D, Hoog M. Optimal sedation
in pediatric intensive care patients: a systematic review. Intensive Care Med.
2013; 39(9):1524-34.
3.
Hughes CG, Girard TD, Pandharipande PP. Daily sedation interruption
versus targeted light sedation strategies in ICU patients. Crit Care Med.
2013; 41(9):S39-45.