SEDATING THE INTUBATED PATIENT

SEDATING THE INTUBATED PATIENT

THEORY
Once an infant or child has respiratory failure requiring intubation, the use of mechanical ventilation is facilitated by
sedation and analgesia in order to maintain the childs comfort and safety.
INTRODUCTION
Medications are only part of providing sedation and analgesia for the intubated child.
Whenever possible, one should use environmental techniques. Examples include keeping the lights low, using distraction
techniques, decreasing the sound in the room, and swaddling the patient.
Also consider correcting reversible causes of discomfort such as hypercarbia, skin breakdown and urinary retention.
Consider the patients pre-existing conditions. A healthy and neurologically normal child who is intubated and ventilated
will require a dierent medication regimen than a child who has signicant, preexisting neurologic problems.
Any patient who is intubated, ventilated, and receiving chemical paralysis, should be treated with sedatives and
analgesics with the assumption that they are uncomfortable. The assessment of this patient may be challenging.
GENERAL APPROACH TO SEDATION AND ANALGESIA
1. Anticipate the trajectory of illness: is this child going to be intubated and ventilated for hours, days, or weeks?
2. Dene the comfort goals: how sedated and comfortable does the child need to be to safely care for him or her?
3. Choose medications based on whats available in the facility and based on the childs underlying condition
4. Continuously adjust the sedation regimen to maintain the sedation comfort goal that have been set, or reassess
the comfort goal as the childs condition changes.
5. Determine if the patient will have a short term trajectory of illness or a long term trajectory of illness.
A short term illness may be a post-operative or post procedural situation, and the need for intubation and
mechanical ventilation can be predicted to be a short time.
A long term illness has an unclear or long time trajectory, and can be divided into two phases: acute phase and
recovery or maintenance phase.
COMFORT GOAL
When dening the comfort goals for a patient, consider using a standardized score, such as the State Behavioral Score
which describes children at dierent levels of sedation (comatose, awake and comfortable, awake and uncomfortable).
Reassess the levels of sedation and analgesia frequently.
MEDICATIONS
A common choice for sedation and analgesia for an intubated and ventilated patient is a combination of narcotics and
benzodiazepines. Morphine may be used for analgesia, and midazolam for anxiolysis and amnesia, but the choice should
be based on what is available and the common practice in the intensive care unit.
Chemical Paralysis
The need for chemical paralysis depends on the patients condition.
It is more challenging to assess the comfort levels of a patient who is chemically paralyzed
Patients who are chemically paralyzed display discomfort through autonomic changes in their vital signs, including
tachycardia and hypertension. Assume that a change in the patients vital signs due to mild stimulation indicates pain .
Pupillary reaction has been used to determine the patients level of sedation. However, it may not be as reliable as vital
sign changes, so it is important to use all of the information available when deciding whether a paralyzed patient needs
more sedation or analgesia.
Titration
Once a medication is started, the major goal is to adjust the medications to achieve the target level of comfort
For short term intubation patients use intermittent doses of medication may be used, such as a a bolus dose of a
narcotic, alternating with a bolus dose of a benzodiazepine.

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SEDATING THE INTUBATED PATIENT

Consider the patient condition when titrating medications. A post operative patient will likely be in pain, making a
narcotic a good choice. An asthmatic patient will likely be anxious, making a benzodiazepine a good option.
LONG TERM PATIENTS
For patients who will be intubated for longer than two days, consider initiation of continuous infusions of narcotics and
benzodiazepine to avoid swings in levels of comfort.
Provide extra boluses of medication as needed to quickly get the patient to a better level of sedation, pre-medicate
before noxious stimulation, or bolus while awaiting the new infusion rate to take eect.
Try to avoid adding other agents unless the narcotics and benzodiazepine have been maximized, or if toxic side eects
limit the ability to increase them further, and if other agents must be added, add them one at a time.
EXTUBATION CONCERNS
During extubation, a child needs to go from sedated and calm to a more awake state, so that when the endotracheal
tube (ETT) is removed, they can protect their airway and breathe comfortably.
Adjust the sedation goals and allow the patient to be more awake. An improving child may need less sedation.
Titrate medications to the minimum eective dose necessary for comfort.
Short Term Patients (patients intubated and sedated for less than 5-7 days): Consider stopping sedatives all at once, and
remove the ETT when the child is adequately awake.
Long Term Patients (patients intubated and sedated for more than 5-7 days): Wean sedatives to avoid acute withdrawal,
and when patients is awake enough, remove the ETT while leaving on some medication.
WITHDRAWAL
Most children who have been on benzodiazepines and/or narcotics for a signicant amount of time will exhibit signs of
withdrawal as they are weaned from the medications.
Some patients who have been on medications for 3-4 days will demonstrate withdrawal when the medications are
abruptly stopped, while others who have been on medications for 10 days will not show any signs of withdrawal.
The goal of withdrawal management is to make the patient comfortable, not totally eliminate withdrawal
Withdrawal Management Strategies
A standardized assessment tool, such as the Withdrawal Assessment Tool (WAT), can be helpful to identify withdrawal
and to describe the childs signs and symptoms, including level of discomfort, agitation and sweatiness.
The care team must agree on the level of withdrawal symptoms to be tolerated when weaning from medications. If
symptoms become excessive, rescue doses of medication can be provided, and/or weaning rates can be slowed.
SUMMARY
The child intubated for respiratory failure will need respiratory treatment for the underlying condition, but it is important
to provide comfort and safety while he or she is on the mechanical ventilator.
Comfort goals need to be established and should be assessed based on a standardized scoring tool.
For a child intubated for a short time, intermittent doses of medications, (narcotic and benzodiazepine) can be used.
For a child intubated for a long time, continuous infusions of medications can be used to keep a constant level of
sedation, with extra bolus doses when needed for procedures or when the child appears uncomfortable.
Withdrawal to medications is possible, especially in children who have been on medications for longer periods of time,
and excessive withdrawal symptoms must be recognized and treated appropriately.

This document is meant to be used as an educational resource for physicians and other healthcare professionals. It is in no way a substitute for the independent
decision making and judgment by a qualified health care professional. Users of this guideline assume full responsibility for utilizing the information contained
in this guideline. OPENPediatrics and its affiliations are not responsible or liable for any claim, loss, or damage resulting from the use of this information.
OPENPediatrics attempts to keep the information as accurate and up to date as possible. However, as recommendations for care and treatment change,
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