Sedation challenges in the pediatric ICU: is dexmedetomidine the solution?
[editorial]
R Blaine Easley
2009
Indian Pediatrics
E D I T O R I A L T he pediatric intensive care unit (PICU) poses unique pain and sedation management challenges. Treatment of pain and anxiety in the PICU has historically been accomplished with opioids and benzodiazepines. More recently, drug therapy has been complemented with sedation scales and nonpharmacologic treatment measures, such as parental presence at the bedside and psychologic interventions (i.e. distraction, redirection, etc.), to help create more effective sedation practices and
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... less-threatening PICU environments(1). Even with these measures, critically ill children often need prolonged sedation to facilitate respiratory management, treatment of multi-organ system dysfunction and/or performance of invasive procedures. The consequence is escalating dosages, physiologic tolerance and subsequent development of withdrawal when these agents are discontinued(2). These sedation challenges drive many PICU clinicians to seek alternative pharmacologic agents (even volatile anesthesia) to provide comfort to critically ill children(1). Dexmedetomidine (DEX) is a highly selective α 2 -adrenergic agonist with sedative, anxiolytic, and analgesic properties. DEX provides effective sedation without the respiratory depression often seen with other agents and exhibits a synergistic sedative and analgesic effect when given in conjunction with benzodiazepines and opioid analgesics(3). The most common adverse effects associated with DEX include hypotension, bradycardia, and even hypertension, which are usually related to rate of administration and dosage. DEX is currently approved for use in critically ill, mechanically ventilated and intubated adults as a continuous infusion for <24 hours. To date, the drug is not approved for use in children or for prolonged infusion. Studies evaluating the pharmacology and pharmacodyamics of DEX in pediatric patients are limited in scope and number, and yet there is a growing international experience with the use of DEX for children undergoing procedural and ICUbased sedation for acute and prolonged periods of time(4,5). The study by Reiter, et al.(6), in this issue of Indian Pediatrics, describes their experience with the usage of DEX for prolonged sedation in critically ill children. By retrospectively reviewing the charts of children receiving DEX, they characterized indications, patient demographics, and observed adverse events. DEX was initiated in 41% of children (n=12/29) to facilitate extubation and resulted in a duration of DEX treatment ≥32 hours (n=29). Only 33% (n=10) received a loading dose of DEX prior to initiating a continuous infusion. Though there were no adverse events reported in their study population, there was a transient and statistically significant reduction in heart rate (±13 beats per min) within the first 24 hours of therapy, independent of a DEX loading dose, and no interventions were required. An important finding of this study was the clinician's expectation that DEX would help facilitate extubation, but instead DEX treatment was associated with an increase in the extubation failure rate from 6% to 30%. The authors correctly discuss the potential confounding issues that may have contributed to this finding including
pmid:19812420
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