National survey on the use of sedatives and neuromuscular blocking agents in the pediatric intensive care unit

Objectives To describe the sedative and neuromuscular blocking agents (NMBA) that are currently used in pediatric intensive care units across the country and to assess the use of written protocols for their use, criteria used for selecting these agents, monitoring practices, and clinicians responsible for making therapeutic decisions in the pediatric intensive care units. Design A questionnaire was mailed to pediatric attending physician members of the Society of Critical Care Medicine practicing in the United States in January 1997. A cover letter was also enclosed that explained the purpose of the survey and asked the respondent to forward the questionnaire to a colleague if unable to complete. Results A total of 176 questionnaires were returned, which represented 145 pediatric institutions across the country, for a response rate of 51%. The agents reported to be used most often for sedation were the opioids and benzodiazepines, which were used for >72 hrs. The NMBA used were vecuronium and pancuronium, which were used for >48 hrs. Newer agents such as propofol and cisatracurium were being used by some clinicians as well. Respondents primarily use the intravenous route of administration as either intermittent bolus or continuous infusion. Frequently cited indications for sedatives were anxiety, fear, and amnesia and facilitation of intubation and maintenance of mechanical ventilation for NMBA. Only 13.4% indicated using written protocols for sedatives and 26.1% for NMBA. Decisions regarding the choice of agent were usually based on clinician preference and experience and the duration of action of the agent. Respondents most often reported using clinical assessment (57%) or the Glasgow Coma Scale (47.3%) to monitor the depth or adequacy of sedation. Over 80% of those surveyed use a peripheral nerve stimulator to monitor NMBA activity. Conclusion Clinicians continue to use the opioids and benzodiazepines most often for sedation in the pediatric intensive care units, but newer agents are being used more often and warrant further investigation. The use of written protocols is very low, possibly because of the lack of guidelines in the literature on pediatric intensive care unit sedation and neuromuscular blockade. Development and implementation of protocols for the selection, use, and monitoring of sedatives and NMBA through a multidisciplinary team approach may be a beneficial way to provide safe and cost-effective therapy to critically ill pediatric patients.