Comfortably Calm: Soothing Sedation of Critically Ill Children without Withdrawal Symptoms

Critically ill children admitted to an intensive care unit (ICU) are bound to experience some degree of discomfort, distress and pain, more than in other settings in a children’s hospital. Inserting intravenous lines, catheters and tubes is a major source of these adverse effects. In order to achieve that children will experience ICU stay less consciously they will regularly receive sedatives, such as midazolam, and analgesics, such as morphine, fentanyl). One of the nurse’s responsibilities is observing the degree of discomfort and the effect of the sedatives and analgesics used. Adequate sedation is very important. Scoring tools may help to objectivize evaluation. This thesis explores how to best determine depth of sedation in children in an ICU. We concluded that on the basis of the behavioral items, which form the COMFORT behavior scale, nurses are capable of assessing level of sedation in critically ill children in a reliable and valid manner. As a next step we defined new cutoff points for the COMFORT behavior scale. Score ranges 6 to 10 and 23 to 30 are associated with a high degree of certainty that a child is ‘oversedated’ or ‘undersedated’, respectively. The intervening score range 11 to 22 forms a grey area that requires the nurse’s clinical expertise expressed in the Nurse’s Interpretation of Sedation Score (NISS). Long-term administration of sedatives and analgesics in critically ill children may lead to various complications. For example, too rapid tapering or abrupt discontinuation of this medication may result in withdrawal symptoms. We therefore studied frequencies of occurrence of withdrawal symptoms in critically ill children. On the basis of the findings we then constructed a tool, the Sophia Observation withdrawal Symptoms-scale (SOS), with which nurses can assess withdrawal symptoms.