Sedation Management in Pediatric Patients supported on *

描述（由申请人提供）：这个为期两年的项目的目的是试点测试一种干预措施，以改变儿科重症监护病房（PICU）急性呼吸衰竭的机械通气儿童患者的镇静管理。虽然确保患者舒适是儿科重症护理的一个组成部分，但在这一患者群体中使用止痛药和镇静剂可能与医源性损伤有关；具体来说，舒适药物可能会抑制自发通气，延长机械通气的脱机时间。此外，药物耐受性随着时间的推移而发展，当患者不再需要镇静时，可能会导致医源性戒断综合征。另外，次优的舒适管理会导致呼吸机不同步和计划外的气管内拔管。我们小组已经开发并验证了一种由护士实施的镇静算法，以指导舒适药物的滴定，可以优化患者的舒适度并降低药物不足的风险，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室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)多学科团队教育和共识建立，(b)多学科团队确定患者的疾病轨迹和镇静目标的日常处方，(c)护士实施的镇静算法来指导安慰药物的滴度，以及(d)团队对临床表现的反馈。

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.