Introduction: Analgosedation-decision making is subjective, contributing to suboptimal outcomes in over 42% of pediatric critical care cases. Pro re nata (PRN) sedation doses are administered by nurses to address a patient’s immediate analgosedation needs and increase the efficiency of bedside patient care; however, they often lack an objective clinical basis. We hypothesize that continuous monitoring of patient vital signs can be assessed to improve PRN decision making for critical care teams. Methods: Nine mechanically ventilated, continuously sedated, critically ill children were recruited for this pilot study between 2023 and 2025. Patient electronic health record (EHR), continuous waveform vital sign data, and video recordings were obtained. PRN doses were assessed using physiological parameters surrounding PRN administration, incorporating known drug kinetics and patient vitals waveform response patterns compared to baseline (6-hour preceding waveform mean). Results: We analyzed 358 total PRN administrations of sedation medications (dexmedetomidine, hydromorphone, morphine, fentanyl, and diazepam) and quantified physiological changes from baseline levels in the 30 minutes following the PRN to account for variations in drug onset time. Contrary to expected sedation effects, heart rate increased by 0.77 ± 11.53 bpm following PRN administration (p < 0.3022, Wilcoxon p-value). Respiratory rate showed -0.79 ± 5.31 breaths/min increase in variability post-medication (p < 0.0004, Wilcoxon p-value). Our findings of increased physiological waveform signal following PRN administration were further validated by movement descriptions annotated in patient video recordings by the clinical team. Conclusions: Current PRN administration demonstrates poor correlation with physiological waveform data, often resulting in paradoxical increases in agitation markers. Continuous monitoring can provide objective PRN effectiveness data to clinical teams during daily rounds, enabling evidence-based titration of continuous analgosedation infusions. Data-driven PRN assessment tools and heuristics are needed to ensure informed analgosedation decision-making in pediatric critical care.
Hoffmann et al. (Sun,) studied this question.