Sedation in mechanically ventilated children: we are advancing.

Mechanic ventilation (MV) is an essential part of the support given to patients with respiratory failure, central nervous system injuries or undergoing postoperative care of adults, children or newborns. This support, in conjunction with frequent invasive monitoring, may cause anxiety, agitation and pain.(1) Children admitted to intensive care units (ICUs) have fear and anxiety both from the absence of their relatives and from the stressful environment, in which they constantly undergo painful procedures.(2) In particular, younger children have physiological responses to small stimuli, and they cannot appropriately verbalize their pain intensity or the location of their pain. Differentiating between sedation and analgesia is thus very difficult in young children.(3) However, there is a consensus that sedation and analgesia are essential for the comfort and safety of MV patients. Indeed, sedation and analgesia are proven to reduce MV-associated discomfort, which in turn reduces the use of oxygen, modulates the response to stress intensity, reduces the risk of injury associated with agitation and the displacement of invasive devices, and therefore promotes a patient’s safety and facilitates bedside care.(4-7) Ventilation support has shown a marked evolution; currently, mechanical ventilation support is frequently provided as a complement to, rather than a full replacement of, spontaneous respiration. Despite all of the technical advances in MV, procrastination on the part of caregivers to begin gradual weaning from mechanical ventilation may cause unnecessary discomfort to the patient and may increase tracheal intubation and MV risks. Because the weaning period accounts for up to 40% of a patient’s total time on ventilation support(8) and because there are numerous ventilation modes and strategies for different diseases, ventilation weaning protocols have been developed, accordingly. While these protocols are employed with all ventilated patients, respiratory support weaning methods have never been accurately studied using children,(9) and these methods have mostly been extrapolated from trials in adults and premature children. Thus, these methods may be inappropriate for use with children. The understanding that deep or prolonged sedation and analgesia may potentially increase morbidity and mortality led to the creation of a new model emphasizing the patient’s comfort while keeping them interactive, oriented and able to follow instructions.(10) This new model is based Marcelo Cunio Machado Fonseca1, Werther Brunow de Carvalho2