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 language | English (US) |
|---|---|
| Pages (from-to) | 204-211.e1 |
| Journal | journal of pediatrics |
| Volume | 206 |
| DOIs | |
| State | Published - Mar 2019 |
Funding
David Wypij, (Principal Investigator–Data Coordinating Center (Boston, MA); Department of Biostatistics, Harvard T.H. Chan School of Public Health; Department of Pediatrics, Harvard Medical School; Department of Cardiology, Boston Children's Hospital, Boston, MA); Geoffrey L. Allen (Children's Mercy Hospital, Kansas City, MO); Derek C. Angus (Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Pittsburgh, PA); Judy A. Ascenzi (The Johns Hopkins Hospital, Baltimore, MD); Scot T. Bateman (University of Massachusetts Memorial Children's Medical Center, Worcester, MA); Santiago Borasino (Children's Hospital of Alabama, Birmingham, AL); Cindy Darnell Bowens (Children's Medical Center of Dallas, Dallas, TX); G. Kris Bysani (Medical City Children's Hospital, Dallas, TX); Ira M. Cheifetz (Duke Children's Hospital, Durham, NC); Allison S. Cowl (Connecticut Children's Medical Center, Hartford, CT); Brenda L. Dodson (Department of Pharmacy, Boston Children's Hospital, Boston, MA); E. Vincent S. Faustino (Yale-New Haven Children's Hospital, New Haven, CT); Lori D. Fineman (University of California San Francisco Benioff Children's Hospital at San Francisco, San Francisco, CA); Heidi R. Flori (University of California at San Francisco Benioff Children's Hospital at Oakland, Oakland, CA); Linda S. Franck (University of California at San Francisco School of Nursing, San Francisco, CA); Rainer G. Gedeit (Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI); Mary Jo C. Grant (Primary Children's Hospital, Salt Lake City, UT); Andrea L. Harabin (National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD); Catherine Haskins-Kiefer (Florida Hospital for Children, Orlando, FL); James H. Hertzog (Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE); Larissa Hutchins (The Children's Hospital of Philadelphia, Philadelphia, PA); Aileen L. Kirby (Oregon Health & Science University Doernbecher Children's Hospital, Portland, OR); Ruth M. Lebet (School of Nursing, University of Pennsylvania, Philadelphia, PA); Michael A. Matthay (University of California at San Francisco School of Medicine, San Francisco, CA); Gwenn E. McLaughlin (Holtz Children's Hospital, Jackson Health System, Miami, FL); JoAnne E. Natale (University of California Davis Children's Hospital, Sacramento, CA); Phineas P. Oren (St. Louis Children's Hospital, St. Louis, MO); Nagendra Polavarapu (Advocate Children's Hospital-Oak Lawn, Oak Lawn, IL); James B. Schneider (Cohen Children's Medical Center of New York, Hyde Park, NY); Adam J. Schwarz (Children's Hospital of Orange County, Orange, CA); Thomas P. Shanley (C. S. Mott Children's Hospital at the University of Michigan, Ann Arbor, MI); Shari Simone (University of Maryland Medical Center, Baltimore, MD); Lewis P. Singer (The Children's Hospital at Montefiore, Bronx, NY); Lauren R. Sorce (Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL); Edward J. Truemper (Children's Hospital and Medical Center, Omaha, NE); Michele A. Vander Heyden (Children's Hospital at Dartmouth, Dartmouth, NH); R. Scott Watson (Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA); Claire R. Wells (University of Arizona Medical Center, Tucson, AZ). All phases of data collection in the RESTORE study were supported by NIH grant HL086622/HL086649 (PIs: M.C. and Dr David Wypij). This secondary analysis was supported by a grant from The Children's Hospital of Philadelphia Center for Nursing Research and Evidence-Based Practice (PI: K.B.). The authors declare no conflicts of interest.
Keywords
- analgesia
- cognitive impairment
- critical care
- neurodevelopmental disability
- pediatric
- sedation
ASJC Scopus subject areas
- Pediatrics, Perinatology, and Child Health