Jornal de Pediatria (Aug 2003)
A sedação e analgesia de crianças submetidas à ventilação mecânica estariam sendo superestimadas? Sedation and analgesia in children submitted to mechanical ventilation could be overestimated?
Abstract
OBJETIVO: descrever o perfil de uso de analgésicos e sedativos em crianças submetidas à ventilação mecânica, internadas em uma UTI pediátrica de referência, em um período de 12 meses, avaliando o tempo de uso dessas drogas, as doses diárias utilizadas e a incidência de síndrome de abstinência. MÉTODOS: estudo de coorte prospectivo (abril de 2001 a março de 2002), envolvendo crianças em ventilação mecânica (via tubo traqueal) por um período superior a 12 horas, com idade entre 30 dias e 15 anos, que tivessem sucesso no processo de extubação (excluídos os óbitos ou aqueles que necessitassem reintubação). Uma equipe não envolvida com a assistência coletava os dados diariamente, até o 28º dia de ventilação mecânica (tempo máximo de seguimento para aqueles que eventualmente permanecessem um tempo superior a 28 dias em ventilação artificial), sendo o principal desfecho a dose, infundida às 12h da manhã, de morfina, fentanil, quetamina e midazolam (assumindo esta como a dose média naquele dia para cada uma destas drogas). O diagnóstico de síndrome de abstinência foi definido através de pesquisa no prontuário (registro do diagnóstico ou tomada de medidas terapêuticas neste sentido) e por entrevista com o médico assistente de cada paciente, realizada nos dias subseqüentes à extubação. A pesquisa foi aprovada pelo Comitê de Ética e Pesquisa do HSL-PUCRS. RESULTADOS: dos 127 pacientes elegíveis para este estudo, obtivemos dados de 124 pacientes (16,0+29,5 meses, 58% meninos; 92 definidos como clínicos e 32 como cirúrgicos). Cada criança utilizou uma média de 1,7 sedativos-analgésicos em infusão por dia (sem diferença entre pacientes clínicos e cirúrgicos). Os opióides (morfina e fentanil) foram as drogas mais utilizadas em ambos grupos (fentanil o preferido entre os clínicos, e a morfina entre os cirúrgicos, pOBJECTIVE: to describe the pattern of analgesic and sedative infusions in children submitted to mechanical ventilation in a regional pediatric intensive care unit during a 12-month period. To compare the use of these drugs among clinical and surgical patients, as well evaluate the influence of the length of use on the average daily doses and on the incidence of abstinence syndrome. METHODS: this cohort study was performed from April 2001 to March 2002, involving children (1 month old to 15 years old) submitted to the mechanical ventilation with a tracheal tube for a period longer than 12 hours and who were successfully extubated (dead patients and those who required reintubation were excluded from the study). A team of professionals not involved with the patient's assistance performed a daily collection of all data up to the 28th day under mechanical ventilation (maximum length of follow up for those who remain longer under mechanical ventilation). The main outcome was the infusion doses of morphine, fentanyl, ketamine and midazolam administered at 12 AM (considering this dose as the average dose for that day). The diagnosis of abstinence syndrome was based on the chart revision (recorded diagnosis or based on the specific antagonist treatment used) and in an interview with the assistant physician on the following days after the extubation. This study was approved by the Ethics and Scientific Committee of the HSL-PUCRS. RESULTS: 127 children were eligible for this study, but only 124 patients were analyzed (16.0+29-5 months old; 58% male; 92 defined as clinical patients and 32 as surgical patients). An average of 1.7 sedative-analgesic infusion per patient a day was used in the whole group (without difference between clinical and surgical groups). Morphine and fentanyl were the most common drugs infused in both groups (fentanyl was preferred for the clinical group and morphine for the surgical group). The mean length of infusion was different (p<0.01) between clinical and surgical patients (6.8 and 3.9 days, respectively). After the 7th day, there was a significant increase in the fentanyl and midazolam doses (p<0.01), as well as a higher incidence of abstinence syndrome in the clinical group (p<0.01). CONCLUSIONS: this study evaluated the daily practice in a regional PICU, and it demonstrated that analgesic and sedative infusions in children submitted to mechanical ventilation are used according to an uncontrolled pattern (average 1.7 drugs/patient/day) and those classified as clinical patients used these drugs for longer periods, what could explain the higher prevalence of abstinence syndrome in this group.
Keywords
