Incidence of over-sedation, under-sedation and pain in prolonged ventilated patients in Pediatric critical care
CCCF ePoster library. Sampaio T. Oct 2, 2017; 198115; 23
Dr. Tatiana Sampaio
Dr. Tatiana Sampaio
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Incidence of over-sedation, under-sedation and pain in prolonged ventilated patients in Pediatric critical care

Sampaio, Tatiana Z.A.L. 1,2; Fitzgibbons, Colleen 1; Cole-Hartgerink, Jessica 1 ;Larmer, Erin 1; Dhanani, Sonny 1,2


1. Division of Intensive Care, Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Canada

2. Division of Intensive Care, Department of Pediatrics, University of Ottawa, Ottawa, Canada

Introduction: Sedation and analgesia are used to manage ventilated pediatric patients comfortably and safely. However, over-sedation can cause complications including prolonged mechanical ventilation[1] and Iatrogenic Withdrawal Syndrome (IWS).[2] Under-sedation puts patients at risk for unplanned extubation and agitation[3]. The use of standardized sedation and analgesia assessments can reduce under and over-sedation.[4] In our center, the protocol for sedation and analgesia titration relies on set targets for: State Behavioral Scale (SBS)[5] and Comfort B scale (CBS)[6], respectively. The way targets are ordered and met will affect quality of care. This project was part of a large initiative to decrease IWS incidence in our unit.
Objectives: (1) To determine the frequency of over-sedation, under-sedation and pain in pediatric patients intubated for longer than 5 days (2) to identify how the targets for SBS and CBS are ordered and how frequently.

Methods: This quality assurance project utilized data from a retrospective chart review that included patients intubated and ventilated for 5 or more days aged from birth to 18 years old from February 2015 to January 2016. Patients with a tracheostomy, ECMO, hemodialysis, and patients that died before sedation wean were excluded. Presence of under-sedation (US) was defined by SBS>0, presence of over-sedation (OS) was defined as SBS<-1 and presence of pain as CBS > 17[4]. The targets for sedation and analgesia were collected daily and categorized as first order set, second order set, third order set and fourth order set.
Results: 45 patients were included. The median age was 23 months (IQR 3.5-138), 40% of patients had a respiratory illness, 42% had a pre-existing condition, their PELOD-2 [7]score median was 5 (IQR: 4, 7). All but 1 patient experienced OS in some point of their time ventilated. Only 4 patients did not experience US or pain during the days that they were ventilated. Figure 1 shows the percentage of patients that experienced over-sedation or under-sedation per days after intubation. A total of  454 ventilation days were analyzed in this chart review 252 (55.5%) there was documented over-sedation,181(39.9%) under-sedation and 165 (36.3%) pain. 93.3% of patients had at least one set of SBS and MCS targets ordered, 77.8% in the first day of admission, and 60% had targets orders reviewed once. Table 1 attached is showing the targets of SBS and CBS ordered ranging from-1 to -2 and 8 to 14 respectively.
Conclusions: This study showed that patients in our institution were frequently over-sedated, reflecting targets that were ordered in lower ranges than those recommended by literature[4], which enabled over-sedation. MD orders of sedation and analgesia were identified as a root cause for over-sedation and consequently IWS. Simple and easy changes in documentation and daily bedside safety checklist were established in order to optimize use of sedation and analgesia and decrease complications related to over and under-sedation.

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