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Successful implementation of a pediatric sedation protocol for mechanically ventilated patients*

Deeter, Kristina H. MD; King, Mary A. MD, MPH; Ridling, Debra CCRN; Irby, Gretchen L. PharmD; Lynn, Anne M. MD; Zimmerman, Jerry J. MD, PhD, FCCM

doi: 10.1097/CCM.0b013e318206cebf
Clinical Investigations

Objective: To evaluate the effect of a nursing-driven sedation protocol for mechanically ventilated pediatric patients on duration of use of analgesic and sedative medications. We hypothesized that a protocol would decrease length of sedation use and decrease days of mechanical ventilation and length of stay.

Design: Retrospective cohort study with historical controls.

Setting: Thirty-one-bed tertiary care, medical-surgical-cardiac pediatric intensive care unit in a metropolitan university-affiliated children's hospital.

Patients: Children requiring mechanical ventilation longer than 48 hrs not meeting exclusion criteria.

Interventions: Before protocol implementation, sedation was managed per individual physician orders. During the intervention period, analgesia and sedation were managed by nurses following an algorithm-based sedation protocol based on a comfort score.

Measurements and Main Results: The observation group included consecutive patients admitted during the 12-month period before protocol education and implementation (n = 153). The intervention group included patients admitted during the 12 months following protocol implementation (n = 166). The median duration of total sedation days (intravenous plus enteral) was 7 days for the observation period and 5 days for the intervention period (p = .026). Specifically, the median duration of morphine infusion was 6 days for the observation period and 5 days for the intervention period (p = .015), whereas the median duration of lorazepam infusion was 2 days for the observation period and 0 days for the intervention period. After adjusting for severity of illness with the pediatric risk of mortality III (PRISM III) score, the Cox proportional hazards regression analysis demonstrated that at any point in time, patients in the intervention group were 23% more likely to be off all sedation (heart rate 0.77, p = .020). Additionally, the intervention group tended to be associated with fewer days of mechanical ventilation (heart rate 0.81, p = .060) and decreased pediatric intensive care unit length of stay (heart rate 0.81, p = .058), although these associations did not quite reach statistical significance.

Conclusion: A pediatric sedation protocol can significantly decrease days of benzodiazepine and opiate administration, which may improve pediatric intensive care unit resource utilization.

From the Departments of Pediatrics (KHD, MAK, DR, GLI, AML, JJZ) and Anesthesiology (AML), Seattle Children's Hospital University of Washington, Seattle, WA.

This study was supported, in part, by the National Institutes of Health.

The authors have not disclosed any potential conflicts of interest.

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© 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins