Sedation Management for Critically Ill Children with Pre-Existing Cognitive Impairment

Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Study Investigators

Research output: Contribution to journalArticle

Abstract

Objective: To compare current analgesia and sedation management practices between critically ill children with pre-existing cognitive impairment and critically ill neurotypical children, including possible indicators of therapeutic efficacy. Study design: This study used secondary analysis of prospective data from the RESTORE clinical trial, with 2449 children admitted to the pediatric intensive care unit and receiving mechanical ventilation for acute respiratory failure. Subjects with a baseline Pediatric Cerebral Performance Category ≥3 were defined as subjects with cognitive impairment, and differences between groups were explored using regression methods accounting for pediatric intensive care unit as a cluster variable. Results: This study identified 412 subjects (17%) with cognitive impairment. Compared with neurotypical subjects, subjects with cognitive impairment were older (median, years, 6.2 vs 1.4; P <.001) with more severe pediatric acute respiratory distress syndrome (40% vs 33%; P =.009). They received significantly lower cumulative doses of opioids (median, mg/kg, 14.2 vs 16.2; P <.001) and benzodiazepines (10.6 vs 14.4; P <.001). Three nonverbal subjects with cognitive impairment received no analgesia or sedation. Subjects with cognitive impairment were assessed as having more study days awake and calm and fewer study days with an episode of pain. They were less likely to be assessed as having inadequate pain/sedation management or unplanned endotracheal/invasive tube removal. Subjects with cognitive impairment had more documented iatrogenic withdrawal symptoms than neurotypical subjects. Conclusions: Subjects with cognitive impairment in this study received less medication, but it is unclear whether they have authentically lower analgesic and/or sedative requirements or are vulnerable to inadequate assessment of discomfort because of the lack of validated assessment tools. We recommend the development of pain and sedation assessment tools specific to this patient population.

Original languageEnglish (US)
Pages (from-to)204-211.e1
JournalJournal of Pediatrics
Volume206
DOIs
StatePublished - Mar 1 2019
Externally publishedYes

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Critical Illness
Pediatric Intensive Care Units
Analgesia
Pediatrics
Substance Withdrawal Syndrome
Cognitive Dysfunction
Practice Management
Adult Respiratory Distress Syndrome
Pain Measurement
Pain Management
Hypnotics and Sedatives
Benzodiazepines
Artificial Respiration
Respiratory Insufficiency
Opioid Analgesics
Analgesics
Clinical Trials
Pain
Population

Keywords

  • analgesia
  • cognitive impairment
  • critical care
  • neurodevelopmental disability
  • pediatric
  • sedation

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health

Cite this

Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Study Investigators (2019). Sedation Management for Critically Ill Children with Pre-Existing Cognitive Impairment. Journal of Pediatrics, 206, 204-211.e1. https://doi.org/10.1016/j.jpeds.2018.10.042
Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Study Investigators. / Sedation Management for Critically Ill Children with Pre-Existing Cognitive Impairment. In: Journal of Pediatrics. 2019 ; Vol. 206. pp. 204-211.e1.
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abstract = "Objective: To compare current analgesia and sedation management practices between critically ill children with pre-existing cognitive impairment and critically ill neurotypical children, including possible indicators of therapeutic efficacy. Study design: This study used secondary analysis of prospective data from the RESTORE clinical trial, with 2449 children admitted to the pediatric intensive care unit and receiving mechanical ventilation for acute respiratory failure. Subjects with a baseline Pediatric Cerebral Performance Category ≥3 were defined as subjects with cognitive impairment, and differences between groups were explored using regression methods accounting for pediatric intensive care unit as a cluster variable. Results: This study identified 412 subjects (17{\%}) with cognitive impairment. Compared with neurotypical subjects, subjects with cognitive impairment were older (median, years, 6.2 vs 1.4; P <.001) with more severe pediatric acute respiratory distress syndrome (40{\%} vs 33{\%}; P =.009). They received significantly lower cumulative doses of opioids (median, mg/kg, 14.2 vs 16.2; P <.001) and benzodiazepines (10.6 vs 14.4; P <.001). Three nonverbal subjects with cognitive impairment received no analgesia or sedation. Subjects with cognitive impairment were assessed as having more study days awake and calm and fewer study days with an episode of pain. They were less likely to be assessed as having inadequate pain/sedation management or unplanned endotracheal/invasive tube removal. Subjects with cognitive impairment had more documented iatrogenic withdrawal symptoms than neurotypical subjects. Conclusions: Subjects with cognitive impairment in this study received less medication, but it is unclear whether they have authentically lower analgesic and/or sedative requirements or are vulnerable to inadequate assessment of discomfort because of the lack of validated assessment tools. We recommend the development of pain and sedation assessment tools specific to this patient population.",
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author = "{Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Study Investigators} and Best, {Kaitlin M.} and Asaro, {Lisa A.} and Curley, {Martha A.Q.} and David Wypij and Allen, {Geoffrey L.} and Angus, {Derek C.} and Ascenzi, {Judy A.} and Bateman, {Scot T.} and Santiago Borasino and Bowens, {Cindy Darnell} and Bysani, {G. Kris} and Cheifetz, {Ira M.} and Cowl, {Allison S.} and Dodson, {Brenda L.} and Faustino, {E. Vincent S.} and Fineman, {Lori D.} and Flori, {Heidi R.} and Franck, {Linda S.} and Gedeit, {Rainer G.} and Grant, {Mary Jo C.} and Harabin, {Andrea L.} and Catherine Haskins-Kiefer and Hertzog, {James H.} and Larissa Hutchins and Kirby, {Aileen L.} and Lebet, {Ruth M.} and Matthay, {Michael A.} and McLaughlin, {Gwenn E.} and Natale, {Jo Anne E.} and Oren, {Phineas P.} and Nagendra Polavarapu and Schneider, {James B.} and Schwarz, {Adam J.} and Shanley, {Thomas Patrick} and Shari Simone and Singer, {Lewis P.} and Sorce, {Lauren R.} and Truemper, {Edward J.} and {Vander Heyden}, {Michele A.} and Watson, {R. Scott} and Wells, {Claire R.}",
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Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Study Investigators 2019, 'Sedation Management for Critically Ill Children with Pre-Existing Cognitive Impairment', Journal of Pediatrics, vol. 206, pp. 204-211.e1. https://doi.org/10.1016/j.jpeds.2018.10.042

Sedation Management for Critically Ill Children with Pre-Existing Cognitive Impairment. / Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Study Investigators.

In: Journal of Pediatrics, Vol. 206, 01.03.2019, p. 204-211.e1.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Sedation Management for Critically Ill Children with Pre-Existing Cognitive Impairment

AU - Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Study Investigators

AU - Best, Kaitlin M.

AU - Asaro, Lisa A.

AU - Curley, Martha A.Q.

AU - Wypij, David

AU - Allen, Geoffrey L.

AU - Angus, Derek C.

AU - Ascenzi, Judy A.

AU - Bateman, Scot T.

AU - Borasino, Santiago

AU - Bowens, Cindy Darnell

AU - Bysani, G. Kris

AU - Cheifetz, Ira M.

AU - Cowl, Allison S.

AU - Dodson, Brenda L.

AU - Faustino, E. Vincent S.

AU - Fineman, Lori D.

AU - Flori, Heidi R.

AU - Franck, Linda S.

AU - Gedeit, Rainer G.

AU - Grant, Mary Jo C.

AU - Harabin, Andrea L.

AU - Haskins-Kiefer, Catherine

AU - Hertzog, James H.

AU - Hutchins, Larissa

AU - Kirby, Aileen L.

AU - Lebet, Ruth M.

AU - Matthay, Michael A.

AU - McLaughlin, Gwenn E.

AU - Natale, Jo Anne E.

AU - Oren, Phineas P.

AU - Polavarapu, Nagendra

AU - Schneider, James B.

AU - Schwarz, Adam J.

AU - Shanley, Thomas Patrick

AU - Simone, Shari

AU - Singer, Lewis P.

AU - Sorce, Lauren R.

AU - Truemper, Edward J.

AU - Vander Heyden, Michele A.

AU - Watson, R. Scott

AU - Wells, Claire R.

PY - 2019/3/1

Y1 - 2019/3/1

N2 - Objective: To compare current analgesia and sedation management practices between critically ill children with pre-existing cognitive impairment and critically ill neurotypical children, including possible indicators of therapeutic efficacy. Study design: This study used secondary analysis of prospective data from the RESTORE clinical trial, with 2449 children admitted to the pediatric intensive care unit and receiving mechanical ventilation for acute respiratory failure. Subjects with a baseline Pediatric Cerebral Performance Category ≥3 were defined as subjects with cognitive impairment, and differences between groups were explored using regression methods accounting for pediatric intensive care unit as a cluster variable. Results: This study identified 412 subjects (17%) with cognitive impairment. Compared with neurotypical subjects, subjects with cognitive impairment were older (median, years, 6.2 vs 1.4; P <.001) with more severe pediatric acute respiratory distress syndrome (40% vs 33%; P =.009). They received significantly lower cumulative doses of opioids (median, mg/kg, 14.2 vs 16.2; P <.001) and benzodiazepines (10.6 vs 14.4; P <.001). Three nonverbal subjects with cognitive impairment received no analgesia or sedation. Subjects with cognitive impairment were assessed as having more study days awake and calm and fewer study days with an episode of pain. They were less likely to be assessed as having inadequate pain/sedation management or unplanned endotracheal/invasive tube removal. Subjects with cognitive impairment had more documented iatrogenic withdrawal symptoms than neurotypical subjects. Conclusions: Subjects with cognitive impairment in this study received less medication, but it is unclear whether they have authentically lower analgesic and/or sedative requirements or are vulnerable to inadequate assessment of discomfort because of the lack of validated assessment tools. We recommend the development of pain and sedation assessment tools specific to this patient population.

AB - Objective: To compare current analgesia and sedation management practices between critically ill children with pre-existing cognitive impairment and critically ill neurotypical children, including possible indicators of therapeutic efficacy. Study design: This study used secondary analysis of prospective data from the RESTORE clinical trial, with 2449 children admitted to the pediatric intensive care unit and receiving mechanical ventilation for acute respiratory failure. Subjects with a baseline Pediatric Cerebral Performance Category ≥3 were defined as subjects with cognitive impairment, and differences between groups were explored using regression methods accounting for pediatric intensive care unit as a cluster variable. Results: This study identified 412 subjects (17%) with cognitive impairment. Compared with neurotypical subjects, subjects with cognitive impairment were older (median, years, 6.2 vs 1.4; P <.001) with more severe pediatric acute respiratory distress syndrome (40% vs 33%; P =.009). They received significantly lower cumulative doses of opioids (median, mg/kg, 14.2 vs 16.2; P <.001) and benzodiazepines (10.6 vs 14.4; P <.001). Three nonverbal subjects with cognitive impairment received no analgesia or sedation. Subjects with cognitive impairment were assessed as having more study days awake and calm and fewer study days with an episode of pain. They were less likely to be assessed as having inadequate pain/sedation management or unplanned endotracheal/invasive tube removal. Subjects with cognitive impairment had more documented iatrogenic withdrawal symptoms than neurotypical subjects. Conclusions: Subjects with cognitive impairment in this study received less medication, but it is unclear whether they have authentically lower analgesic and/or sedative requirements or are vulnerable to inadequate assessment of discomfort because of the lack of validated assessment tools. We recommend the development of pain and sedation assessment tools specific to this patient population.

KW - analgesia

KW - cognitive impairment

KW - critical care

KW - neurodevelopmental disability

KW - pediatric

KW - sedation

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Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Study Investigators. Sedation Management for Critically Ill Children with Pre-Existing Cognitive Impairment. Journal of Pediatrics. 2019 Mar 1;206:204-211.e1. https://doi.org/10.1016/j.jpeds.2018.10.042