咪达唑仑在新生儿机械通气中的临床应用

目的 比较苯巴比妥和咪迭唑仑在新生儿机械通气中的镇静效果.方法 回顾性分析临床上存在人机对抗、抽搐以致呼吸机参数下调困难、血氧饱和度不稳定而需用镇静药物治疗的253例机械通气的新生儿,根据使用镇静药物的不同分为治疗组(咪达唑仑组n=127)和对照组(苯巴比妥组n=126);(1)比较两组用药0.5、6、12、24及48 h机械通气参数(PIP、PEEP、FiO2)和患儿平均血压、心率及血气分析;(2)通过新生儿面部编码系统评价两组患儿用药后0.5、6、12、24、48 h的疼痛行为反应评分;(3)比较两组患儿机械通气时间.结果 (1)咪达唑仑组PIP、PEEP、FiO2在用药后迅速下调,与苯巴比妥组比较差异有统计学意义(P＜0.05);(2)两组用药30 min后,疼痛行为反应评分明显低于用药前(P＜0.05),用药后各时段两组间比较差异均有统计学意义(P＜0.05);(3)两组机械通气时间差异无统计学意义.结论 与苯巴比妥相比,咪达唑仑能降低呼吸机参数(PIP、PEEP、FiO2),改善患儿的人机同步性,提高机械通气的有效性.     

不同剂量舒芬太尼对小儿先天性心脏病术后镇痛镇静效果的影响

目的研究不同剂量舒芬太尼对小儿先天性心脏病(先心病)术后的镇痛镇静效果。方法前瞻性选取2010年11月-2011年7月在本院小儿心脏科行手术治疗的ASD或VSD患儿84例,年龄3～144个月(平均34.2个月);体质量5.0～37.0 kg(平均13.1 kg)。将患儿随机分为3组,分别予0.02μg.kg-1.h-1(Ⅰ组)、0.03μg.kg-1.h-1(Ⅱ组)及0.04μg.kg-1.h-1(Ⅲ组)的舒芬太尼术后持续静脉泵入维持镇静镇痛,比较各组术后拔管时间、恶心呕吐发生率、用药期间临时加用咪达唑仑的发生率、拔管后因呼吸抑制二次插管的发生率,并于术后4 h、8 h、12 h、24 h、48 h记录心率(HR)、收缩压(SBP)、呼吸频率(RR)、中心静脉压(CVP)、血氧饱和度(SPO2)、Wong-Baker镇痛评分、FLACC镇痛评分及Ramsay镇静评分。结果使用舒芬太尼0.02～0.04μg.kg-1.h-1持续镇痛镇静评分结果均满意,组间差异无统计学意义(P>0.05)。术后24 hⅡ组和Ⅲ组RR高于该年龄组正常高限,其余各时间点生命体征均在正常范围。术后拔管时间比较差异无统计学意义(P>0.05)。3组恶心、呕吐发生率分别为6.7%、14.8%、22.2%,差异无统计学意义(P>0.05)。Ⅲ组较Ⅰ组单次加用咪达唑仑的发生率低,差异有统计学意义(P<0.05)。3组均无因呼吸抑制而进行二次插管。结论舒芬太尼可以安全地应用于先心病患儿术后的镇痛镇静,使用0.04μg.kg-1.h-1剂量时对疼痛治疗效果好,并且在此剂量下需要单次加用咪达唑仑对患儿进行镇静的发生率低。     

山东省多中心儿童重症监护室镇静镇痛治疗及管理状况调查

目的了解山东省三级甲等医院儿童重症监护室(PICU)镇静镇痛治疗及管理状况,为镇静镇痛治疗方案的改进提供依据。方法本研究为一项多中心回顾性研究,山东省6家三级甲等医院的PICU参与了本研究。收集2016年1月至2018年12月入住这6家PICU的1340例患儿,调阅病历资料,统计患儿的年龄、性别、入院24 h小儿死亡风险评分Ⅲ、是否接受机械通气、是否接受镇静和(或)镇痛治疗、是否监测镇静和(或)镇痛情况、住院病死率等。依据是否接受镇静治疗和(或)镇痛治疗,将患儿分为单纯镇静组(798例)、镇静+镇痛组(120例)及非镇静镇痛组(422例),比较各组的病种、机械通气比例、低血压发生率、平均住PICU天数及院内病死率。结果1340例患儿的平均年龄为(13.3±6.4)个月,其中男786例(58.7%)。6家PICU均已开展镇静治疗,其中5家PICU进行常规镇静评估;已开展镇痛治疗的PICU有4家,其中仅有2家进行常规疼痛评估。共有918例(68.5%)患儿接受了镇静治疗和(或)镇痛治疗,咪达唑仑是最常用的镇静药物,其次是右美托咪定。526例(57.3%)患儿进行了镇静评估监测,最常用的评估方法是Richmond躁动镇静量表。120例(9.0%)患儿接受了镇静联合镇痛治疗,芬太尼是最常用的镇痛药物,38例(31.7%)患儿接受了常规疼痛评估。3组患儿年龄和性别差异无统计学意义。镇静+镇痛组外科疾病的比例最高,该组机械通气患儿的比例也最高(100.0%,120/120),非镇静镇痛组机械通气患儿的比例最低(11.4%,48/422),两组比较差异有统计学意义(P<0.01)。镇静+镇痛组的平均机械通气时间略短于单纯镇静组,但组间比较差异无统计学意义(P>0.05)。镇静+镇痛组低血压发生率最高,非镇静镇痛组低血压发生率最低[21.7%(26/120)比2.1%(9/422),P<0.01]。院内病死率和平均住PICU天数3组间比较差异无统计学意义。结论苯二氮类药物仍是目前山东省PICU中主要使用的镇静药物,右美托咪定的应用逐渐增加,但镇痛剂应用的比例很低。目前镇痛镇静治疗主要用于外科术后及接受机械通气治疗的患儿,镇痛镇静治疗虽未增加患儿的院内病死率及平均住PICU天数,但增加了低血压的发生率。山东省PICU的镇静镇痛治疗和监测仍欠规范,主要体现在镇痛治疗以及对镇静和疼痛水平的评估未受到重视。     

瑞芬太尼应用于新生儿机械通气疗效差异性的Meta分析

目的 评价瑞芬太尼治疗新生儿机械通气的疗效.方法 通过检索近10年Cochrane Library、Medline、Pubmed、Web of Science、万方数据库、维普中文科技期刊全文数据库、中国学术期刊全文数据库,对纳入研究的方法学进行评价.研究者对纳入文献的质量进行严格评价和资料提取,使用Review manager 5.0软件对符合质量标准的随机对照试验(randomized controlled trial,RCT)行Meta分析.结果 6个RCT共223例患儿纳入研究,其中治疗组(瑞芬太尼)111例,对照组(吗啡)112例,两组患儿均行机械通气等对症支持治疗.Meta分析结果表明,经治疗48 h后治疗组新生儿疼痛评分明显降低、Ramsay镇静评分明显降低、心率明显下降;撤药自撤机时间明显缩短,差异有统计学意义.结论 瑞芬太尼可显著提升新生儿机械通气的疗效.     

异丙酚靶控输注静脉麻醉对唇腭裂患儿血清淀粉酶及三酰甘油的影响

目的 比较小儿异丙酚靶控输注静脉麻醉与咪达唑仑静脉麻醉对唇腭裂患儿血清淀粉酶和三酰甘油的影响.明确异丙酚靶控输注在小儿麻醉中应用的安全性和可行性.方法 选择唇腭裂患儿60例,根据美国麻醉学家学会(ASA)分级分为Ⅰ或Ⅱ级;年龄4个月～3岁;体质量6.5～15.9 kg.随机分为2组,异丙酚静脉靶控输注组(P组,n=30)和咪达唑仑静脉输注组(M组,n=30).麻醉诱导2组均予瑞芬太尼2.0μg/kg及维库溴铵0.1 mg/kg静脉注射,P组同时靶控输注异丙酚,待效应室靶水平达到3.0 mg/L行气管插管;M组同时静脉输注咪达唑仑0.2 mg/kg,待意识消失后行气管插管.麻醉维持2组均用瑞芬太尼0.2μg/(kg·min)及维库溴铵0.01 mg/(kg·min)静脉持续输注,P组同时靶控输注异丙酚(质量浓度3.0 mg/L);M组每隔1 h追加咪达唑仑0.1 mg/kg.术中监测心率、收缩压、舒张压、平均动脉压、诱导时间、苏醒时间及术后不良反应等指标;并在给药前(T1)、停药后4 h(T2)、24 h(T3)分别采集静脉血样本,测定其血清淀粉酶和三酰甘油.结果 与M组比较,P组诱导时间、苏醒时间及拔管时间均明显缩短(Pa<0.05),术中生命体征维持相对平稳,术后无并发症发生;与T1时比较,T2时2组三酰甘油均显著升高(Pa<0.05),以P组升高更为明显(P<0.01),T3时2组三酰甘油恢复至术前水平;2组血清淀粉酶的变化各时间点差异均无统计学意义(Pa>0.05).结论 短时间异丙酚靶控输注引起的血酯增高是短暂的,并不会对儿童血清胰淀粉酶和三酰甘油出现长期的有临床意义的影响.     

镇静镇痛对先天性心脏病婴幼儿术后应激反应的影响

目的探讨小儿先天性心脏病体外循环下心内直视术后镇静镇痛对机体应激反应的影响。方法选择40例择期行先天性心脏病矫治术的患儿,随机分为镇痛组和对照组,各20例。镇痛组应用芬太尼0.5～2.0μg/(kg.h)持续静脉微量泵注入;对照组口服布洛芬5～8mg/(kg.次)。二组均用盐酸咪达唑仑0.01～0.20mg/(kg.h)静脉持续微量泵注入或0.05～0.10mg/(kg.次)间断静脉推注镇静。观察二组术后2、8、24、48h的镇静、镇痛效果,同时检测二组血皮质醇、生长激素、胰岛素和血糖的应激指标水平;观察二组恶心、呕吐、心率及血压下降、呼吸抑制等不良反应情况;评估镇静镇痛对患儿术后应激反应的影响。结果2组在术后2、8、24h行Ramsay、Comfort评分均有显著性差异(Pa<0.05)。镇痛组和对照组术后2、8、24、48h,血皮质醇、生长激素、胰岛素和血糖与术前比较均升高且差异显著(Pa<0.05)。镇痛组术后2、8、24、48h血皮质醇、生长激素、血糖水平均低于对照组。镇痛组8h血皮质醇、血糖,24h血皮质醇、生长激素和血糖,48h血糖水平与对照组相应时点指标比较均有显著性差异(Pa<0.05)。结论婴幼儿心内直视术后存在应激反应,应用芬太尼联合盐酸咪达唑仑持续静脉泵注的术后镇静镇痛可在一定程度上减轻婴幼儿心内直视术后的应激反应,且不良反应较小,有利于患儿顺利度过围术期。     

地佐辛用于儿童术后镇痛有效性和安全性的随机对照试验

背景：新型阿片受体激动 拮抗剂地佐辛用于儿童术后镇痛的研究报道甚少,且没有公认的儿童用药参考剂量。 目的：探讨地佐辛应用于儿童术后镇痛的有效性和安全性,为其用于儿童术后镇痛提供合适的参考剂量。 设计单中心RCT。 方法：纳入在重庆医科大学附属儿童医院行先天性心脏病（CHD）手术后直接转入PICU的患儿,手术时年龄>28 d,术前美国麻醉医师协会（ASA）分级Ⅲ～Ⅳ级。按随机数字表法生成随机分组方案,装入密闭信封保存;由当班的PICU医生负责入组,由管床护士执行干预。随机分为5组,试验组患儿在术后持续静脉泵入低剂量（D1组）、中剂量（D2组）或高剂量（D3组）地佐辛,对照组泵入舒芬太尼（SF组）或吗啡（M组）,观察术后疼痛评分和镇静评分。未对结局指标观察人员和数据分析人员施盲。共同干预措施：入PICU后使用有创呼吸机辅助通气,予对症处理和咪达唑仑镇静。D1、D2、D3组分别予地佐辛20、30、40 μg·kg-1·h-1,SF组予舒芬太尼0.08 μg·kg-1·h-1,M组予吗啡20 μg·kg-1·h-1,均为静脉泵注。疼痛评分包括脸谱疼痛评分法（FPS）和CRIES评分法,镇静评分包括Ramsay评分法和舒适行为量表（Comfort B评分）,均由PICU专科护士完成。 主要结局指标:术后1 h、4 h、8 h、12 h和24 h的镇痛/镇静满意度百分比。 结果:共152例CHD患儿入组,D1、D2、D3、SF和M组分别为30、30、31、31和30例,均完成设计的干预和观察。5组患儿年龄、体重、性别、体外循环时间、危重症评分（PCIS）和术前ASA分级差异均无统计学意义。①FPS评分：D2组术后24 h,D3组术后4 h、24 h镇痛满意度高于M组;CRIES评分：D1、D2组术后1 h、4 h,D3组术后4 h、24 h镇痛满意度高于M组;Ramsay评分： D2、D3组术后1 h、4 h镇静满意度高于M组;Comfort B评分： D1组术后4 h、12 h,D2组术后1 h、4 h,D3组术后1 h、4 h、12 h镇静满意度高于M组;差异均有统计学意义。4种评分D组和SF组的镇痛/镇静满意度差异均无统计学意义。②5组术后各时间点生命体征及相关指标差异均无统计学意义;D1、D2组追加镇静/镇痛药物的比例低于M组和SF组,差异均有统计学意义。M组观察到2例低血压及1例呼吸抑制。 结论:地佐辛应用于儿童CHD术后的镇痛效果优于吗啡,与舒芬太尼效果相当,且不良反应少。     

芬太尼与舒芬太尼对儿童全麻苏醒期躁动的临床研究

目的 探讨芬太尼与舒芬太尼在儿童全身麻醉中对苏醒期躁动的影响.方法 选择2016年1月至2016年6月在中国医科大学附属盛京医院行腹腔镜下腹股沟疝修补术60例患儿,按照数字表法随机分为试验组(舒芬太尼组)及对照组(芬太尼组),每组 30例.麻醉诱导:依托咪酯0.3mg/kg 、琥珀胆碱2mg/kg ,试验组予舒芬太尼0.1μg/kg、 对照组予芬太尼1μg/kg,所有患儿以七氟烷维持麻醉.比较两组患儿拔除喉罩时间(停用麻醉药至拔除喉罩的时间),离开麻醉恢复室(PACU)时间.在PACU对患儿进行儿童苏醒期躁动量表(PAED)评分、Ramsay镇静评分、FLACC疼痛评分.结果 试验组PAED评分低于对照组,差异有统计学意义(P<0.05).两组患儿均无过度镇静(Ramsay镇静评分均<4),试验组镇静评分高于对照组,差异有统计学意义(P<0.05).试验组FLACC评分低于对照组,差异有统计学意义(P<0.05).两组在喉罩拔除时间和离开苏醒时间比较差异无统计学意义(P>0.05).结论 在腹腔镜儿童腹股沟疝修补术中,与等效剂量的芬太尼相比,舒芬太尼具有更好的镇痛效果,能降低术后躁动的发生率.     

瑞芬太尼在重症患儿中的临床应用

镇痛和镇静治疗是重症患儿综合治疗的重要组成部分,随着镇痛镇静理念的发展,新的镇痛、镇静药物也不断推出,瑞芬太尼由于具有半衰期短、不产生蓄积、对患儿重要器官影响较小、可控性较好、镇痛效果较好及起效快等特点,现已较多的应用于重症患儿。本文探讨瑞芬太尼在重症患儿中的应用优势。     

盐酸纳布啡用于小儿尺桡骨骨折闭合复位克氏针内固定术后镇痛的临床观察

目的比较盐酸纳布啡和舒芬太尼对小儿尺桡骨骨折闭合复位克氏针内固定术后的镇痛效果及不良反应,探讨盐酸纳布啡用于术后镇痛的安全性和有效性。方法选取湖南省儿童医院于2017年9月至2018年8月收治的60例尺桡骨骨折需行尺桡骨闭合复位克氏针内固定的患儿为研究对象,依据术后镇痛药物的不同分为盐酸纳布啡组(n=30)和舒芬太尼组(n=30)。比较两组镇痛镇静效果及术后呼吸抑制、恶心呕吐、皮肤瘙痒等不良反应发生率。结果手术前两组患儿的FLACC评分分别为(1.56±0.32)分和(1.54±0.41)分,差异无统计学意义(t=1.12,P=0.41);手术后0.5 h、6 h、12 h、24 h两组患儿FLACC评分差异均无统计学意义(P0.05)。手术后0.5 h、6 h、12 h、24 h两组患儿Ramsay评分差异均无统计学意义(P0.05)。盐酸纳布啡组的术后呼吸抑制、恶心呕吐、皮肤瘙痒等不良反应发生率低于舒芬太尼组,差异均有统计学意义(P0.05)。结论相比于舒芬太尼,盐酸纳布啡更适用于中等疼痛强度手术的术后镇痛。     

脑电双频指数在儿科ICU镇静监测的临床应用价值

目的 探讨脑电双频指数(BIS)在儿科ICU危重患儿镇静深度监测中的应用价值.方法 前瞻性收集我院PICU的42例6个月～13岁的危重患儿,以咪唑安定持续静脉滴注镇静治疗,在应用镇静剂后的10个时间段以Ramsay评分评价镇静深度的同时进行BIS监测,分析BIS与Ramsay评分在儿童危重症镇静评估的相关性及影响因素.结果 42例危重症患儿中共采集420对BIS与Ramsay对照数据,并做Spearman等级相关分析,BIS与Ramsay评分呈明显负相关(r=-0.8879,P<0.01);在6个月～1岁患儿数据分析中,BIS与Ramsay评分无相关性(r=0.842 7,P>0.05);BIS范围在55～80之间为危重症患儿合适的镇静分值.结论 BIS与Ramsay评分在危重症镇静深度评估中具有较好相关性.BIS监测具有操作简单、省时、连续性好等优点,可作为PICU患儿镇静深度判断的客观指标.     

序贯镇痛镇静对预防行机械通气治疗患儿撤机后谵妄及撤药反应的效果研究北大核心CSCD

目的探讨行机械通气治疗患儿在撤机后序贯维持镇痛镇静药物对预防谵妄及撤药反应的效果。方法回顾性将2019年12月至2021年9月广东医科大学附属东莞市儿童医院儿童重症监护室收治的机械通气支持≥5 d的61例患儿分为对照组(30例,撤机后无镇痛镇静药物维持)及观察组(31例,撤机后序贯镇痛镇静药物维持48 h),记录两组患儿撤机后24 h及72 h索菲亚撤药反应观察量表(Sophia Observation Withdrawal Symptoms Scale,SOS)评分、儿童谵妄量表(Paediatric Delirium Scale,PD)评分、Richmond躁动镇静量表(Richmond Agitation-Sedation Scale,RASS)评分及谵妄发生例数、撤药反应发生例数,并进行比较分析。结果两组患儿撤机后24 h及72 h谵妄发生率比较差异无统计学意义(P>0.05);观察组撤机后24 h及72 h撤药反应发生率、SOS评分、PD评分、RASS评分均低于对照组(P<0.01)。结论撤机后序贯镇痛镇静可降低行机械通气治疗重症患儿撤机后72 h内撤药反应发生率,但不能有效降低患儿撤机后谵妄发生率。     

Midazolam sedation in mechanically ventilated newborns: a double blind randomized placebo controlled trial

OBJECTIVE: To determine efficacy of midazolam as a sedative in mechanically ventilated newborns. DESIGN: Double blind randomized placebo controlled trial. SETTING: Neonatal Unit of Tertiary Hospital. OUTCOME: Sedation over 48 h of observation. METHODS: Neonates with birth weight less than 2000 g who were mechanically ventilated within 7 days of life were randomly assigned to midazolam and placebo group. Midazolam and placebo were administered as bolus (0.2 mg/kg) followed by continuous infusion (0.06 mg/kg/h). Both groups received morphine infusion (10 microg/kg/h). Sedation score was noted at 6 hourly intervals for 48 hours. Hemodynamic variables, ventilatory variables, complications and side effects of treatments were also recorded. RESULTS: Thirty-three neonates were enrolled (17 in midazolam, 16 in placebo group). The groups were comparable for birth weights and gestation. The midazolam group had significantly better sedation from 18-24 hours after enrollment compared to placebo group. At 48 h there were no significant differences in proportion of infants with adequate sedation between midazolam and placebo group. The two groups were comparable with respect to heart rate, perfusion, ventilatory indices and blood gas parameters. None of the infants were noted to have hypotension on loading with midazolam or placebo. Seizures were noted in 2 neonates in placebo group 24 hours after enrollment (insignificant statistically). CONCLUSION: Sedation provided by continuous infusion of midazolam and morphine appears to be comparable to morphine alone in newborn babies on mechanical ventilation, with no significant adverse effects. The course of mechanical ventilation is not influenced by use of midazolam.     

Sedative tolerance accompanies tolerance to the analgesic effects of fentanyl in infant rats

Iatrogenic tolerance and physical dependence have been documented in human neonates and infants infused with fentanyl or morphine i.v. to maintain continuous analgesia and sedation during extracorporeal membrane oxygenation (ECMO) and mechanical ventilation for the treatment of life-threatening pulmonary diseases. Using postnatal d 17 infant rats, the hypothesis was tested that sedative tolerance accompanies tolerance to fentanyl analgesia in the tail-flick test. Postnatal d 14 infant rats remained naive or received osmotic minipumps infusing saline (1 microL/h) or fentanyl citrate (60 microg x kg(-1) h(-1)). Seventy-two hours later, fentanyl's antinociceptive potency was reduced 3.1-fold in fentanyl-infused rats. Conscious sedation and deep sedation were examined with the cliff-avoidance and the righting-reflex procedures, respectively. Fentanyl-infused infants were tolerant to both the conscious and deep sedative effects of fentanyl. Another hypothesis tested was that very high receptor intrinsic activity opioids are less likely to produce tolerance, or to be cross-tolerant to other opioids. Dihydroetorphine is 5,000 to 10,000 times more potent than morphine. However, fentanyl-infused infant rats were cross-tolerant to the analgesic and sedative effects of dihydroetorphine. Interestingly, dihydroetorphine's analgesic efficacy was significantly reduced to a maximum analgesic efficacy (Emax) value of 40% maximum possible effect (MPE). Another concern was whether fentanyl tolerance would generalize to another class of sedatives, the benzodiazepines. This was especially relevant considering the widespread use of benzodiazepines like midazolam in ECMO and mechanical ventilation. Midazolam elicited no analgesia in the tail-flick test. Furthermore, fentanyl-tolerant rats were not cross-tolerant to the conscious or deep sedative effects of midazolam.     

咪达唑仑滴鼻用于新生儿磁共振镇静的效果研究——前瞻性单盲随机对照研究

目的 观察并比较咪达唑仑经鼻吸收与苯巴比妥钠肌肉注射对于新生儿头颅磁共振检查时的镇静效果。方法 将2017年9月至2019年3月间行头颅磁共振检查的70例新生儿随机分为观察组和对照组，每组35例。观察组给予咪达唑仑滴鼻（0.3 mg/kg），对照组给予苯巴比妥钠肌肉注射（10 mg/kg）。应用改良Ramsay镇静评分表评估新生儿镇静情况；同时比较两组磁共振完成情况及不良反应发生情况。结果 观察组给药后20 min时镇静评分最高，后逐渐降低，70 min时降至最低；对照组给药后10 min时镇静评分最低，后逐渐增高，40 min、50 min时达最高，再逐渐降低。两组各时间段镇静评分比较，给药后40 min前观察组镇静评分均高于对照组（P < 0.05）；40~70 min两组镇静评分比较差异均无统计学意义（P > 0.05）。观察组磁共振检查成功率（89%）高于对照组（69%，P < 0.05）。两组不良反应比较，差异无统计学意义（P > 0.05）。结论 咪达唑仑滴鼻用于新生儿头颅磁共振检查的镇静效果优于苯巴比妥钠肌肉注射，且快速易行，安全有效。     

咪唑安定联用吗啡在小儿创伤机械通气时镇静镇痛作用的临床评价

目的评价咪唑安定联用吗啡在小儿创伤机械通气中的镇静镇痛作用。方法1999年3月~2005年5月我院PICU收住创伤患儿共58例,其中咪唑安定镇静组(A组)38例,咪唑安定联用吗啡组(B组)32例。镇静水平的监测采用Ramsay镇静指数评分标准,统计A、B组分别达到理想镇静指数的例数并做显著性检验。比较两组用药期间心率、呼吸、血压、经皮氧饱和度和血气分析值。结果B组达到理想镇静水平的例数多于A组,B组血气pH值、氧分压、二氧化碳分压、心率、经皮氧饱和度均较A组改善,差别均有显著性意义。结论咪唑安定联用吗啡在小儿创伤机械通气中的镇静镇痛作用显著,值得推广。     

Age is of influence on midazolam requirements in a paediatric intensive care unit

AIM: To test that age is of influence on midazolam requirements during prolonged mechanical ventilation in critically ill children. METHODS: Retrospective observational study of children (28 days-18 year) admitted between January 1st 2002 and January 1st 2005 who needed controlled mechanical ventilation for 5 days and initial sedation with midazolam were included. Exclusion criteria were psychomotor retardation, therapeutic use of midazolam, ventilator weaning within 5 days, kidney or liver failure. RESULTS: A total of 1186 children were admitted, of which 58 children were included. The children were divided into three age groups: 28 days-1 year (n = 28), 1-4 years (n = 16) and older than 4 years (n = 14). Within 2 days the children age 1-4 years received the maximum midazolam dosage (0.3 mg/kg/h). In addition, the mean total dose of midazolam was higher at all days for this age group. At day 5 none of the children between 1 and 4 years could be sedated with midazolam alone. CONCLUSIONS: Our data showed that children between 1 and 4 years needed higher doses of midazolam as compared to children who were younger and older. Furthermore, we observed that midazolam alone is a poor sedative for all age groups. The influence of and mechanisms for possible age related effects on midazolam requirements remain to be elucidated, as well as the position of midazolam as a first line drug for PICU sedation.     

Sedative, analgesic and muscle relaxant management in Spanish paediatric intensive care units

ObjectiveThe aim of the study was to define the strategies for the use and monitoring of sedative, analgesic, and muscle relaxant medication in Spanish paediatric intensive care units (PICU).Material and methodsA questionnaire with 102 questions was sent by e-mail to all Spanish PICUs.ResultsReplies were received from 36 of the 45 PICUs (80%). A written protocol for sedation and analgesia was used in 64%; this medication was adjusted according to the diagnosis and clinical status of the patient in 30% of the units. Midazolam was the most widely used drug for sedation, followed by ketamine and propofol. Fentanyl was the most widely used drug for analgesia, followed by paracetamol and metamizole. The combination of midazolam and fentanyl in continuous infusion was used most frequently in patients on mechanical ventilation (MV), followed by propofol. Scales to monitor sedation and analgesia were employed in 45% of PICUs, most used the Ramsay scale. The bispectral index (BIS) was used in 50% of PICUs. Muscle relaxants were administered to 26% of patients on MV; the most common indications for MV were head injury and severe respiratory disease. The principal methods for avoiding withdrawal syndrome were a progressive withdrawal of the drugs and morphine chloride.ConclusionsAlthough there is insufficient scientific evidence to determine the ideal drugs for sedation and analgesia in the critically ill child and the methods for monitoring and control, the production of guidelines and written treatment and monitoring protocols could help to improve the management and control of sedation and analgesia.