Analgesia, sedation, and delirium in pediatric surgical critical care

https://doi.org/10.1053/j.sempedsurg.2019.01.006Get rights and content

Abstract

The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.

Introduction

Analgesia, sedation, and delirium are complex topics that intertwine during the management of critically ill surgical patients. The administration of analgesic and sedative agents to reduce pain and anxiety comes with side effects that may include delirium and withdrawal.1 On the other hand, inadequate pain control and increased anxiety may also lead to delirium.2, 3 In recent years, there has been an increased emphasis within the critical care and surgical communities on the relationship between analgesia, sedation, and anxiolysis and important outcomes such as mortality, the duration of mechanical ventilation, and intensive care length of stay.4, 5

Section snippets

Significance

Pain control in post-operative patients is an essential component of recovery.6 Uncontrolled post-operative pain has been associated with both negative physiological and psychological outcomes in children and adults.7, 8, 9, 10, 11 Decreased immune responses, poor sleep, decreased physical function, anxiety, chronic persistent post-surgical pain (CPSP), and future psychiatric problems are all associated with poorly controlled pain.8,12, 13, 14, 15 Despite many advances in pain management, the

Significance

Sedation in critically ill pediatric patients is an essential component of care. Sedation aids in recovery by reducing agitation, protecting indwelling/intravenous catheters and drains, allowing invasive procedures, and aiding synchronization with mechanical ventilation. While the need for sedation is well understood amongst providers, optimal levels of sedation are only achieved 50% of the time.73

Optimal sedation is defined as a state in which the patient is somnolent, is responsive to the

Significance

Delirium is a well described phenomenon in the intensive care population. It is defined as a disturbance in attention, awareness, and cognition over a short period of time that is not explained by a pre-existing neurocognitive disorder or a decreased level of arousal attributed to a medical condition, intoxication, withdrawal, or a medication side effect.111 The occurrence of delirium in adult ICU patients has been reported to affect 16–89% of patients and is more common in the elderly and in

Summary

In critically ill, post-operative, pediatric patients, analgesia, sedation, and delirium represent complex yet extremely important aspects of care. While the literature is diverse and expanding for adults, studies concerning best practices in children are lacking. Appropriate pain control, optimal sedation, and the identification and treatment of delirium in the intensive care environment reduces morbidity and mortality. Indeed, the proper management of these conditions may be just as critical

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