Sedation Management in Pediatric Patients

描述(申请人提供)：这个为期两年的项目的目的是试行一种干预措施，以改变儿科重症监护病房(PICU)中因急性呼吸衰竭而接受机械通气支持的儿科患者的镇静管理。虽然确保患者舒适是儿科危重护理不可或缺的一部分，但在这类患者中，止痛剂和镇静剂的使用可能与医源性损伤有关；具体地说，舒适性药物可能会抑制自发通气量，延长机械通气的撤机时间。此外，药物耐受性会随着时间的推移而发展，当患者不再需要镇静剂时，可能会引发医源性戒断综合征。或者，次优的舒适度管理会导致呼吸机不同步和非计划的气管内拔管。我们团队已经开发并验证了一种护士实施的镇静算法来指导舒适性药物的滴定，这可能会优化患者的舒适性并减少用药不足的风险，但该算法需要进一步评估。我们将在两家不同医院的两个匹配的儿科重症监护病房进行随机对照临床试验，对镇静算法进行试点测试。一家医院将被随机分配到他们通常的镇静管理标准实践中，而另一家医院将接受(A)多学科团队教育和建立共识，(B)多学科团队识别患者的病情轨迹和每日镇静目标处方，(C)护士实施的镇静算法来指导舒适性药物的滴定，以及(D)团队对临床表现的反馈。 我们假设，与接受常规护理的患者相比，接受镇静治疗的儿科患者将经历更少的机械通气天数。次要结果包括急性肺损伤恢复时间、脱离机械通气的时间、不良事件的发生、舒适药物的总暴露时间、医源性阿片类药物和苯二氮卓类药物戒断症状的发生、PICU住院时间、成功实施干预的障碍和PICU费用。 这项研究的总体目标是开发一种可以在任何PICU实施的干预措施，为插管和机械通气的婴儿和儿童提供舒适，而不会对他们造成伤害。这项先导性研究的结果将被用于设计未来的多中心随机对照临床试验。

DESCRIPTION (provided by applicant): The purpose of this two-year project is to pilot test an intervention to change sedation management in pediatric patients supported on mechanical ventilation for acute respiratory failure in the pediatric intensive care unit (PICU). While ensuring patient comfort is an integral part of pediatric critical care, analgesic and sedative use in this patient population can be associated with iatrogenic injury; specifically, comfort medications may depress spontaneous ventilation and prolong the duration of weaning from mechanical ventilation. Additionally, drug tolerance develops over time and may precipitate iatrogenic abstinence syndrome when the patient no longer requires sedation. Alternatively, suboptimal comfort management contributes to ventilator dysynchrony and unplanned endotracheal extubation. Our group has developed and validated a nurse-implemented sedation algorithm to guide titration of comfort medications that may optimize patient comfort and reduce the risk of under-medication, but this algorithm needs to be evaluated further. We will pilot test the sedation algorithm in a randomized controlled clinical trial of two matched pediatric intensive care units in two different hospitals. One hospital will be randomized to their usual standard practices for managing sedation, while the other will receive (a) multidisciplinary team education and consensus building, (b) multidisciplinary team identification of the patient's trajectory of illness and daily prescription of a sedation goal, (c) a nurse-implemented sedation algorithm to guide titration of comfort medications, and (d) team feedback on clinical performance. We hypothesize that pediatric patients managed per sedation protocol will experience fewer days of mechanical ventilation than patients receiving usual care. Secondary outcomes include time to recovery from acute lung injury, duration of weaning from mechanical ventilation, occurrence of adverse events, total exposure to comfort medications, occurrence of iatrogenic opioid and benzodiazepine withdrawal symptoms, PICU length of stay, barriers to successful implementation of the intervention and PICU costs. The overall objective of this study is to develop an intervention that can be implemented in any PICU that will provide comfort to intubated and mechanically ventilated infants and children that will not cause them harm. Results of this pilot study will be used to design a future multi-center randomized controlled clinical trial.