PICU Clinical Pathway for Sedation/Analgesia
in the Invasively Mechanically Ventilated Child
- Related Pathways
PICU Sedation/Analgesia in the Mechanically Ventilated Child
- Exclusion Criteria
- Continuous neuromuscular blockade infusions
- Lacking invasive airway
- Requiring active thermoregulation device
- Status epilepticus
- Cessation of neurologic function
- End of life/comfort care
Monitoring
SBS ≤ Goal: Over Sedated
SBS > Goal: Under Sedated
- If sustained or < goal for 8 hrs
- Consider weaning infusion by 10–20%
Medically ready for extubation in the next 24 hrs
Intubated (Titrating)
Extubated (Weaning)
High-Risk Criteria for Withdrawal
- Seizure disorders
- Hemodynamically significant congenital heart disease
- Pulmonary hypertension
- Prior history of weaning difficulty or withdrawal
- Sedation duration < 5 days
- No high-risk criteria present
- Sedation duration ≥ 5 days
- High-risk criteria present
Turn off sedation prior to extubation
Monitor, treat withdrawal symptomsTitrate sedation to desired level of wakefulness
Extubation
Wean Opioid, Benzodiazepine Infusions to IV Conversion Threshold
- Perform WAT-1 before starting infusion wean
- Monitor, treat withdrawal symptoms
- Rescue doses for withdrawal while weaning
| Medication | Goal IV Threshold |
|---|---|
| Fentanyl | 2.5 mcg/kg/hr |
| Morphine | 0.1 mg/kg/hr |
| Hydromorphone | 0.015 mg/kg/hr |
| Midazolam | 0.15 mg/kg/hr |
Tolerating Enteral Medications
- IV to enteral:
NOT Tolerating Enteral Medications
Wean IV sedationEnteral Regimen Wean
Opioids and BenzodiazepinesMonitor pain, withdrawal symptoms, and mental status
- Treat pain if present
- Rescue doses for withdrawal while weaning
- Consider decreasing opioid/benzodiazepine or skipping scheduled dose if somnolent
Evidence
- Successful Implementation of a Pediatric Sedation Protocol for Mechanically Ventilated Patients
- Efficacy of Sedation Regimens to Facilitate Mechanical Ventilation in the Pediatric Intensive Care Unit: A Systematic Review
- Evaluation of IV to Enteral Benzodiazepine Conversion Calculations in a Pediatric Intensive Care Setting
- Delirium and Mortality in Critically Ill Children: Epidemiology and Outcomes of Pediatric Delirium
- Benzodiazepines and Development of Delirium in Critically Ill Children: Estimating the Causal Effect
- 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients