Correspondence Address:
Dr. Suresh Kumar Angurana
Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh
India

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Sedation and analgesia are important in critically ill children undergoing mechanical ventilation as they reduce child's agitation and anxiety, improve the harmonization of the child with mechanical ventilator, reduce the risk of unplanned extubation, and make mechanical ventilation a less painful experience.[1] However, unnecessary and prolonged administration of sedation and analgesia may lead to tolerance, dependence, and iatrogenic withdrawal syndrome (IWS).[2],[3] The choice of sedation and analgesia varies from person to person and center to center. The availability, ease of administration, the familiarity of the treating team, and patient-related factors also determine the choice of sedation and analgesia.

Recent clinical practice guidelines by the Society of Critical Care Medicine on the prevention and management of pain, agitation, neuromuscular blockade, and delirium among critically ill children issued 44 recommendations (14 strong and 30 conditional) and five good practice statements.[3] For the assessment of adequate analgesia, these guidelines recommended to use either the Faces, Legs, Activity, Cry, and Consolability or COMFORT-B scales among noncommunicative critically ill children; and suggested to use self-report by using the Visual Analog Scale, Numeric Rating Scale, Oucher Scale, or Wong-Baker Faces pain scale among critically ill children ≥6 years who can communicate. For assessment of adequate sedation, it was recommended to use the COMFORT-B Scale or the State Behavioral Scale and suggested use of the Richmond Agitation-Sedation Scale among mechanically ventilated children. It was also suggested to assign a target depth of sedation using a validated sedation assessment tool at least once a day and protocolized sedation in all critically ill children undergoing mechanically ventilated children.[3] The alpha 2-agonists have been suggested as the primary sedative in critically ill children undergoing mechanical ventilation. In those with suboptimal sedation depth, the addition of ketamine as the adjunct sedative agent has been suggested. It was recommended to use dexmedetomidine as a primary sedative agent in critically ill postoperative cardiac surgical children with expected early extubation and to decrease the risk of tachyarrhythmias. Continuous propofol infusion has been suggested for short-term sedation (<48 h) during the peri-extubation period to facilitate the weaning of other sedatives and analgesics before extubation. For treating moderate-to-severe pain, intravenous opioids have been recommended in critically ill children.[3] These guidelines also recommended the use of either the Withdrawal Assessment Tool 1 or the Sophia Observation Scale for the assessment of IWS due to opioid or benzodiazepine withdrawal in critically ill children. It has been suggested to treat opioid-related IWS with opioid replacement therapy and benzodiazepine-related IWS with benzodiazepine replacement therapy to attenuate symptoms, irrespective of their preceding dose and/or duration. Furthermore, it has been suggested to use standardized protocol for sedation/analgesia weaning to reduce the duration of sedation taper and attenuate the emergence of IWS.[3]

Despite the availability of these guidelines, there is wide variability in the usage of sedation and analgesia worldwide. Moreover, the data on the usage and adequacy of sedation and analgesia among mechanically ventilated children from India is limited to a few studies[4],[5],[6] with no formal guidelines.

Jose et al.[7] in this issue of the journal reported prospective data of 35 children aged 1–12 years who were mechanically ventilated for >24 h about the choice and adequacy (using the University of Michigan Sedation Scale [UMSS]) of sedation. This study was conducted in a 5-bedded pediatric intensive care unit (PICU) for 21 months (October 2019 to June 2021). The average duration of mechanical ventilation was 79.8 h (2793 h/35). Jose et al.[7] demonstrated that midazolam and fentanyl were commonly used drug combinations (48.5%, n = 17), followed by fentanyl alone (40%, n = 14). UMSS ranges from 0 to 4, and a score of 1–3 was taken as adequate sedation. Adequate sedation, oversedation, and undersedation accounted for 87.1%, 7.9%, and 5% of the total duration of mechanical ventilation, respectively. Irrespective of the primary diagnosis, illness severity, or type of agent/s used (midazolam and fentanyl or fentanyl alone), children spent most of the time in adequate sedation. Undersedation was common in children with mild disease severity and those ventilated for respiratory conditions, whereas oversedation was more in children with higher severity of illness and those ventilated for polytrauma. IWS was noted in 28.5% (n = 10) children, and 11.4% (n = 4) had severe IWS. In children with IWS, there was a statistically nonsignificant trend toward a higher percentage of time spent in oversedation as compared to those without IWS.[7]

The study by Jose et al.[7] is an important contribution to the literature from India regarding sedation and analgesia among critically ill children receiving mechanical ventilation. However, a very small sample size and single-center participation are its major limitations. The rate of IWS was quite high (28.5%) in this study despite the short average duration of mechanical ventilation and sedation (just over 3 days). Although the prevalence of IWS following the administration of opioids and/or benzodiazepines among critically ill children has been reported as high as 87%.[8],[9],[10] Furthermore, the authors have not mentioned about the rates of delirium, the usage of neuromuscular blockers, and about the treatment used for IWS.

As initiation of sedation and analgesia in critically ill children undergoing mechanical ventilation is important, the protocolized weaning of sedation and analgesia, bundled benzodiazepine-sparing sedation analgesia, extubation readiness, PICU liberation bundle, and early mobilization (PICU up) are also equally important. These interventions are feasible and safe even in PICU of resource-limited settings and can have a beneficial impact on short-and long-term outcomes among critically ill children.[11],[12],[13]

Pediatric intensivists from India are entrusted with the urgent need for documentation of the practice of the utilization of sedation and analgesia among critically ill mechanically ventilated children, their adequacy, and the prevalence of IWS and delirium. Furthermore, custom-made guidelines are needed for Indian setup, which are suitable for both public and private health-care settings depending on the availability of drugs, ease of usage, and local needs.

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