Isoflurane for difficult sedation in critically ill children: a retrospective analysis in a mixed pediatric intensive care population

Introduction When standard intravenous regimens fail, children in the pediatric intensive care unit often face escalating sedative polypharmacy with potential harm; we therefore evaluated inhaled isoflurane as a rescue sedation strategy in mechanically ventilated children with failure of a conventional sedation regimen. Methods In this single-center retrospective observational study (2017–2020) in a 10-bed tertiary mixed pediatric intensive care unit (medical, neurologic, cardiac and traumatic conditions), isoflurane was delivered via an anesthetic conserving device while concomitant intravenous sedatives were down-titrated to sedation targets assessed by the COMFORT-B score, and cardiovascular support was quantified using the vasoactive-inotropic score. Results Twenty-one children were analyzed (median age 3.0 years; median Pediatric Index of Mortality 3 score 15.9%); isoflurane was initiated after a median of 3 days of prior sedation and continued for a median of 8 days; the median number of sedative agents decreased from 4 to 3 ( p < 0.001), doses of clonidine, sufentanil, and propofol were significantly reduced, and rescue medication use for breakthrough agitation declined from 100% to 42.9% ( p < 0.001), while vasoactive-inotropic score increased from 6.22 to 9.70 ( p = 0.008); five patients died, and among survivors delirium (87.5%) and withdrawal (44%) were frequent, with most extubated within 24 h after isoflurane cessation. Discussion Isoflurane can meaningfully reduce sedative burden and agitation-related rescue interventions in difficult-to-sedate children, but the observed increase in vasoactive support and frequent delirium/withdrawal after prolonged use underscore the need for vigilant hemodynamic monitoring and structured down-titration—key considerations for centers contemplating volatile-based rescue sedation.