Opinion
Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association.
EDITORIAL
Protocolized Sedation in Critically Ill Children Sangeeta Mehta, MD, FRCPC
Light sedation1 or no sedation2 has become the therapeutic goal in critically ill adults. Large randomized trials3-5 and systematic reviews6,7 have demonstrated that this goal is feasible, safe, and beneficial. The benefits include shorter durations of mechanical venRelated article page 379 tilation and stay in the intensive care unit (ICU).2-4 However, prospective data supporting the benefits of minimizing sedation in children are lacking, with only 1 randomized trial of 102 children showing shorter durations of mechanical ventilation and ICU stay with daily interruption of midazolam infusions compared with no interruption.8 In this issue of JAMA, Curley and colleagues add an important trial to the sparse pediatric data: the first clinical trial evaluating the use of a nurse-directed sedation protocol in children.9 The authors conducted a cluster randomized trial in 31 pediatric intensive care units (PICUs) in the United States, enrolling children aged 2 weeks to 17 years who were receiving mechanical ventilation for acute respiratory failure. In this rigorously conducted, comprehensive trial, intervention PICUs (17 sites; n = 1225 patients) managed sedation using a protocol that included targeted sedation, arousal assessments, extubation readiness testing, and sedation titration every 8 hours; control PICUs (14 sites; n = 1224 patients) managed sedation per usual care without a protocol. The primary outcome, duration of mechanical ventilation, was not significantly different between the intervention and control groups (median, 6.5 days in both groups). In exploratory analyses of secondary outcomes, intervention patients, compared with controls, had fewer days of opioids (median, 9 vs 10; P = .01), were exposed to 2 vs 3 sedative classes (P < .001), and were less likely to develop pressure ulcers (
Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association.
EDITORIAL
Protocolized Sedation in Critically Ill Children Sangeeta Mehta, MD, FRCPC
Light sedation1 or no sedation2 has become the therapeutic goal in critically ill adults. Large randomized trials3-5 and systematic reviews6,7 have demonstrated that this goal is feasible, safe, and beneficial. The benefits include shorter durations of mechanical venRelated article page 379 tilation and stay in the intensive care unit (ICU).2-4 However, prospective data supporting the benefits of minimizing sedation in children are lacking, with only 1 randomized trial of 102 children showing shorter durations of mechanical ventilation and ICU stay with daily interruption of midazolam infusions compared with no interruption.8 In this issue of JAMA, Curley and colleagues add an important trial to the sparse pediatric data: the first clinical trial evaluating the use of a nurse-directed sedation protocol in children.9 The authors conducted a cluster randomized trial in 31 pediatric intensive care units (PICUs) in the United States, enrolling children aged 2 weeks to 17 years who were receiving mechanical ventilation for acute respiratory failure. In this rigorously conducted, comprehensive trial, intervention PICUs (17 sites; n = 1225 patients) managed sedation using a protocol that included targeted sedation, arousal assessments, extubation readiness testing, and sedation titration every 8 hours; control PICUs (14 sites; n = 1224 patients) managed sedation per usual care without a protocol. The primary outcome, duration of mechanical ventilation, was not significantly different between the intervention and control groups (median, 6.5 days in both groups). In exploratory analyses of secondary outcomes, intervention patients, compared with controls, had fewer days of opioids (median, 9 vs 10; P = .01), were exposed to 2 vs 3 sedative classes (P < .001), and were less likely to develop pressure ulcers (
