ORIGINAL ARTICLE
Year : 2023 | Volume
: 7 | Issue : 1 | Page : 1--7
Sedation and analgesia practices of pediatric intensivists in Saudi Arabia
Mohammed Ali Bakhsh1, Mohamed Osman M. Humoodi2, Abdullah M Alzahrani1, Sara M Osman2, Razan Babakr2, Nada Townsi2, Maha A Azzam1,
1 Department of Pediatrics, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs; King Abdullah International Medical Research Centre; Department of Pediatrics, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
2 Department of Pediatrics, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs; King Abdullah International Medical Research Centre, Jeddah, Saudi Arabia
Correspondence Address:
Mohamed Osman M. Humoodi
Department of Pediatrics, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Jeddah
Saudi Arabia
Abstract
Background: Sedation practices in pediatric intensive care units (PICUs) vary significantly worldwide. This study aimed to explore the current sedation and analgesia practices among paediatric intensivists in Saudi Arabia. Methods: This web-based survey was conducted among pediatric intensive care physicians in Saudi Arabia. The survey investigated the participating PICUs, physicians' demographic data, and sedation/analgesia practices. Results: Of the 160 physicians included, the response rate was 67% (n = 108). Of the 100 participants who provided location information, 51% (n = 51) were from the central region of Saudi Arabia. Approximately two-thirds of the participants were consultants, and 48.1% had >10 years of experience. Most respondents practised in general PICUs and routinely assessed sedation and analgesia levels. The COMFORT-Behavior and Face, Legs, Activity, Cry, and Consolability scales were popular (42.6%). More than half of the respondents (52/98) did not practice daily sedation interruption. Furthermore, 78.3% of the respondents assessed patients for withdrawal, whereas only 25% used delirium screening scores. Infusions were preferred over interrupted doses to provide comfort for mechanically ventilated patients. The first-choice infusions were midazolam for sedation and fentanyl for analgesia. Dexmedetomidine was preferred when a third agent was required. Sedation protocols were used by 41.2% of the respondents and were mainly physician-led (75.2%). Various nonpharmacological measures were used to provide patient comfort, and parents often participated in their application. Conclusions: The practice of sedation varies significantly between pediatric intensivists, and formal assessment for delirium is infrequently done in PICUs in Saudi Arabia.
How to cite this article:
Bakhsh MA, M. Humoodi MO, Alzahrani AM, Osman SM, Babakr R, Townsi N, Azzam MA. Sedation and analgesia practices of pediatric intensivists in Saudi Arabia.Saudi Crit Care J 2023;7:1-7
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How to cite this URL:
Bakhsh MA, M. Humoodi MO, Alzahrani AM, Osman SM, Babakr R, Townsi N, Azzam MA. Sedation and analgesia practices of pediatric intensivists in Saudi Arabia. Saudi Crit Care J [serial online] 2023 [cited 2023 Jun 4 ];7:1-7
Available from: https://www.sccj-sa.org/text.asp?2023/7/1/1/372681 |
Full Text
Introduction
Stress in critically ill patients can be attributed to fear, anxiety, and pain. It delays recovery and prolongs the pediatric intensive care unit (PICU) stay.[1] Anxiety and pain are caused by several factors in the PICU environment, including separation from parents, monitoring devices and mechanical ventilators, and various invasive procedures.[2] Providing adequate sedation and analgesia to critically ill, ventilated patients plays a significant role in maintaining comfort. Adequate sedation is the level at which patients remain comfortable and asleep but can easily be awakened.[3] Undersedation increases distress and may cause adverse events such as unplanned extubation, displacement of devices, posttraumatic stress disorders, and impaired development.[4] In contrast, oversedation delays recovery and is associated with prolonged ventilation and extubation failure.[2] It may induce medication tolerance and lead to withdrawal syndrome.[5],[6],[7]
Achieving appropriate levels of sedation and analgesia is challenging. Several scales and scores have been developed to assess comfort and sedation.[8] Protocols and guidelines are used in some units to titrate medications, achieving adequate sedation and patient comfort.[9],[10],[11] Unfortunately, one medication cannot be recommended for use in all patients. Each sedative or analgesic medication has characteristic adverse effects; therefore, medicines should be selected carefully according to the individual patient and clinical scenario.[12],[13] In addition to medications, nonpharmacological measures are used to provide comfort and decrease the need for medications. However, the efficacy and safety of these measures require further evaluation.[13]
Differentiating pain, anxiety, and delirium in the PICU is challenging due to age-related communication limitations and the patients' critical status.[14] Therefore, delirium scales are utilised to diagnose this confusional state early and determine the appropriate treatment. Sedation and analgesia methods used to comfort patients vary significantly between PICUs worldwide.[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24] Few studies have investigated pediatric sedation practices in the Middle Eastern and North African regions. Accumulating more data will help improve patient care and ensure the comfort of PICU patients.
This study aimed to understand the current sedation and analgesia practices and medication preferences among critical care paediatricians in Saudi Arabia. We hypothesize that the sedation and analgesia methods used for critically ill and ventilated PICU patients in Saudi Arabia are diverse and that a minority of intensivists use delirium assessment tools.
Methods
This study is a web-based survey conducted among physicians providing care for PICU patients in Saudi Arabia. The Institutional Review Board Ministry of National Guard – Health Affairs approved the study (study number RJ20/193/J). All participants provided written informed consent when submitting their survey responses.
After a literature review, an electronic questionnaire with 31 items was constructed using Google forms (https://docs.google.com/forms) with the following search words: sedation, practice, analgesia, pediatric intensive care, and survey. The questions were mainly closed-ended. For testing and validation, a group of pediatric intensivists in the western region of Saudi Arabia was invited to participate in the survey. The changes to improve the wording and clarity of the questions were made based on their comments. The first part of the questionnaire included questions regarding the demographics of the PICUs and the practising physicians. In contrast, the second part addressed sedation/analgesia assessment tools, medications, administration routes, protocols, and nonpharmacological comfort measures. Finally, the clinical scenarios of critically ill, ventilated pediatric patients were provided to explore the sedation and analgesia preferences of pediatric general and cardiac intensivists.
The survey was electronically distributed in January 2021 via professional groups of general and cardiac pediatric intensivists in Saudi Arabia. Based on nonprobability sampling, 160 participants were invited to answer the questionnaire. Three reminders were sent over 2 weeks before the survey was closed. Participation in the survey was voluntary and anonymous, and no compensation was provided. Respondents consented to be included in the study. As some participants returned incompletely answered questionnaires, the denominator for each question was calculated separately. Each question provided data regarding a specific study topic and was assessed independently. Frequencies and proportions were calculated for each categorical variable using the Statistical Product and Service Solutions software version 23.0 (IBM Corp., Armonk, NY, USA).
Results
Overall, 108 of 160 pediatric intensivists practising in 26 different PICUs in Saudi Arabia participated in the survey (response rate = 67.5%). The surveys returned as incomplete (n = 16, 14.8%) were included in the study. Although the questionnaire was distributed to PICUs in all the regions of Saudi Arabia, more than half of the respondents who provided their location (51 of 100; 51%) were from the central region.
Most participants were consultants (n = 73; 67.6%), and nearly half (n = 52; 48.1%) reported more than 10 years of experience. Pediatric intensivists working in general PICUs were 53.7% of the study population (n = 58). Of the 26 participating units, 11.5% (n = 3) had ≥20 beds, and half (n = 13; 50%) had subspecialty training programs. A clinical pharmacist attended the rounds 3–7 days/week in 34% (n = 9) of the PICUs [Table 1].{Table 1}
Using validated tools for the routine monitoring of pain and sedation was reported by 85.9% (92 of 107) of the respondents. The Face, Legs, Activity, Cry, Consolability (FLACC) Scale was the most frequently used tool for pain assessment (n = 32; 29.6%), followed by the numeric rating scale (n = 14; 13.0%). The COMFORT-Behavior (COMFORT-B) scale (n = 30; 27.8%) and COMFORT sedation score (n = 24; 22.2%) were the most used scores to assess the level of sedation. The scales used to assess pain and sedation are summarized in [Figure 1].{Figure 1}
Over half of the participants (53 of 97; 54.6%) did not use protocols to modify the dosing of sedatives or analgesics. Most protocols (37 of 51, 72.5%) were physician-led. Only 26.9% (46 of 98) of the pediatric intensivists practised daily interruption of sedation. Regular monitoring for withdrawal during the dose reduction or cessation of sedatives and analgesics was reported by 78.3% (72 of 92) of respondents. The Withdrawal Assessment Tool-1 was the most commonly used instrument (39 of 92; 42.2%).
Most participants (76 of 99; 76.7%) did not routinely use delirium scores. However, the Pediatric Confusion Assessment Method for the Intensive Care Unit was the most popular assessment tool (11 of 99; 11.1%). The use of withdrawal and delirium assessment tools is summarized in [Figure 2] and [Figure 3].{Figure 2}{Figure 3}
The preferred sedatives were midazolam and dexmedetomidine as infusions and chloral hydrate intermittently [Table 2]. Continuous analgesia was induced using fentanyl, dexmedetomidine, and morphine infusions. Acetaminophen and ketamine were the most popular adjunct analgesics [Table 3].{Table 2}{Table 3}
To ensure adequate sedation and comfort of ventilated patients after painful procedures or surgeries, most general PICU physicians reported starting with a continuous infusion of fentanyl (96 of 106; 90.6%). The most common second infusion to add, if required, was midazolam (n = 75; 70.6%). Most chose fentanyl as the first infusion for hemodynamically unstable ventilated patients (n = 65; 61.3%). Midazolam was preferred (n = 40; 37.7%) when a second infusion was required.
For the ventilated postcardiac surgery patients, fentanyl was selected as the first infusion (66 of 105; 62.9%) and midazolam (44 of 105; 41.9%) as an add-on. Starting an infusion over intermittent dosing for postoperative ventilated patients was preferred by both general (90 of 98; 91.8%) and cardiac (79 of 95; 83.2%) intensivists. Dexmedetomidine (42 of 97; 43.3%) was the preferred agent when a third infusion was required. Propofol infusion was rarely used [Table 2].
The nonpharmacological comfort measures used in PICUs in Saudi Arabia included recitation of the Holy Quran (62 of 107; 57.4%), being held by a nurse or caregiver (n = 57; 52.8%), watching television and videos (n = 47, 43.5%), and using a soother or pacifier (n = 45; 41.7%) [Supplementary Figure 1].[INLINE:1]
Discussion
This survey explored sedation practices in 26 PICUs in Saudi Arabia. Pain and sedation levels were routinely monitored using different tools, including the COMFORT-B score. However, using a written sedation and analgesia protocol to titrate and adjust medications was uncommon. Withdrawal scores were assessed in most units. Although delirium is a common complication in PICUs, only one-fourth of the participating intensivists reported using delirium assessment tools. There was a wide variation in medication choices. However, the most commonly used drugs were midazolam for sedation and fentanyl for analgesia. Dexmedetomidine was the preferred third agent in difficult-to-sedate patients.
Diverse sedation practices have been reported in PICUs around the world. A study conducted in Canada reported significant variations in assessment tools, medications, and nonpharmacological methods.[14] A Japanese paper also reported considerable practice diversity and the rarity of using protocols and withdrawal and delirium assessment tools.[25] In Brazil, the sedation methods have been reported as heterogeneous, with the uncommon use of delirium detection methods.[26] A large retrospective study of PICUs in the United States reported the use of 83 different medications, several of which were prescribed against Food and Drug Administration warnings.[27]
Evaluating the intensity of pain and agitation using appropriate scales is essential for optimizing analgesia and sedation.[8],[28] Our survey showed a satisfactory adherence to the routine assessment of sedation and analgesia. A previous study reported that 84% of paediatric intensivists in Canada use sedation and analgesia scales.[14] In a multicenter international study conducted by Kudchadkar et al., 70% of respondents reported using scales to assess sedation.[18]
Several validated tools are currently available to assess pain and agitation in critically ill children. The COMFORT-B and FLACC scales were the most commonly used tools to assess sedation and analgesia levels in this study. The COMFORT-B scale is a validated assessment tool for sedation levels in children, suitable for intubated and nonintubated patients.[29],[30],[31] It is more accurate and easier to use than the COMFORT scale,[24] which may account for its popularity among PICU physicians in Saudi Arabia. However, a variety of tools are used to assess sedation worldwide. In Canada, the most commonly used tools were the COMFORT (41%) and COMFORT-B (15%) scales.[14] In a multicenter study conducted by Kudchadkar et al., the most popular tools included the COMFORT scale (37%), State Behavioral Scale (24%), and the Ramsay Scale (18%).[18] The COMFORT scale has been reported as a preferable tool for assessing sedation levels in several studies.[18],[21],[23]
Sedation protocols have been a topic of interest in recent years. The Randomized Evaluation of Sedation Titration for Respiratory Failure trial revealed that implementing sedation protocols was achievable, reduced the need for sedatives and analgesics, and improved patients' wakefulness and comfort. However, the duration of ventilation was not shortened, and more episodes of pain and agitation were documented.[32] Only 27% of respondents to an international survey used sedation protocols,[18] and only 36% of respondents to a Canadian study used sedation and analgesia protocols.[14] Approximately one-third of the participants used sedation protocols, mainly physician-led. The low implementation rate of sedation protocols may be related to PICU patient heterogeneity and the diversity of the managed diseases. The infrequent implementation of such protocols may indicate the need for future high-quality studies investigating the feasibility and efficacy of sedation and analgesia protocols.
Sedation holidays were routinely used by almost half of the respondents in this survey. The use of continuous sedative infusions for intubated and ventilated patients may result in deep sedation and prolonged mechanical ventilation.[33] The daily interruption of sedation improves wakefulness. Therefore, in adults, it results in earlier extubation, shorter intensive care unit stay, and a higher 1-year survival rate.[34],[35]
According to our survey, continuous sedative infusions were preferred to intermittent boluses during mechanical ventilation. The most commonly utilised continuous infusions were fentanyl and midazolam. Dexmedetomidine was mainly used as an add-on medication for difficult-to-sedate patients. Benzodiazepines are independently associated with an increased incidence of delirium;[31],[36] therefore, they may not be the best option for sedating critically ill paediatric patients. In contrast, dexmedetomidine may reduce the number of ventilation days and the need for opioids; therefore, its use has increased in recent years.[37],[38] The unpopularity of dexmedetomidine as a first-line sedative in this study may be related to its higher cost, use restrictions, and relatively limited research investigating its risks versus benefits.
The responses to this survey showed that withdrawal scores are commonly used, similar to Canadian paediatric intensivists' sedation practices.[14] However, the majority of respondents did not use assessment tools for delirium. Delirium is an important complication of PICU stay and is associated with significant adverse outcomes. Paediatric delirium is underdiagnosed, especially in young, critically ill children.[39] The multidisciplinary European Society of Paediatric Neonatal Intensive Care guidelines recommended routine delirium assessments using validated paediatric tools.[40] However, only one-fourth of the respondents to this survey assessed delirium, highlighting a gap in patient assessment. Kudchadkar et al. also identified the absence of routine delirium assessment by 71% of the respondents in their study.[18]
A variety of environmental strategies can improve sleep patterns and decrease delirium. These include maintaining a daily routine that regulates sleep and waking times, decreasing disturbances due to light and noise during sleeping, involving the parents, and reducing the use of restraints.[33] In this study, less than half of the participating PICUs consisted of only single-patient rooms, and most patient beds were not exposed to natural sunlight. Light and noise reduction were not commonly practised, and only one-fifth of the respondents used protocols to decrease light-related disturbances and maintain day- and night-specific routines. Nonpharmacological methods of comfort were widely used, including listening to the Holy Quran, watching TV or videos, and being held by a caregiver.
This study has some limitations. Although the response rate was reasonable, the sample size was small. Moreover, some surveys were returned incomplete, decreasing the number of respondents to some questions. This may have reduced statistical power. There was a selection bias because the survey was distributed mainly to pediatric intensivists registered at the Saudi Critical Care Society and participating in professional groups. It was challenging to invite pediatric intensivists who were not involved in such activities. In addition, more than half of the respondents were from the central region. Thus, our sample might not adequately represent the overall population of paediatric critical care physicians in Saudi Arabia, and the generalization of these results may be inappropriate.
Conclusions
This study shows heterogeneity in sedation practices and the lack of sufficient assessment for delirium in PICUs in Saudi Arabia. Therefore, further improvement in current practices, particularly environmental changes to improve sleep patterns, is required. Future nationwide studies and quality improvement projects targeting sedation can enhance patient care and safety in Saudi PICUs.
Acknowledgments
We thank the participating investigators, Dr Shehzad A, Dr Salem M, Dr Aburjeila H, and Dr Alsawadi H, for contributing to developing and modifying the survey questions. This study did not receive any external funding.
Authorship contribution
M.B., M.A., A.Z., and R.B. designed the study and prepared the questionnaire; M.B. and R. B. collected the data. T.N. performed the statistical analysis. S.O. wrote the manuscript draft; M.H. finalised it. A.Z., M.B., and M.A. supervised the entire study. All authors read and approved the final manuscript.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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