Cycling of Sedative Infusions in Critically Ill Pediatric Patients

Continuous sedative infusions have been associated with longer duration of mechanical
ventilation, longer stay in the intensive care unit (PICU) and total hospital stay. Also,
extended duration of continuous sedative infusions limits the ability to assess for adequate
neurologic function.

There is, however, no published data on the use of daily interruption of continuous sedative
infusions in pediatric patients, nor are there any recommendations from the leading pediatric
critical care groups regarding this issue. Infants and children exposed to noxious stimuli
(endotracheal tube, endotracheal suctioning, mechanical ventilation, indwelling catheters) in
addition to an unknown environment are less likely to cooperate during normal daily
interventions in the PICU. Continuous infusions of benzodiazepines and opioids in addition to
as needed (PRN) bolus doses have been the standard of care in our institution for
mechanically ventilated patients.

The study seeks to determine if reducing the total dose of sedatives, by holding them in a
cyclical manner, will be a safe and effective intervention that will not increase adverse
patient outcomes. This will be achieved by limiting the patient tolerance to the sedatives,
decreasing the body total deposit of sedatives and subsequently decreases awakening time when
patient is ready for extubation.

Inclusion Criteria:

- Less than or equal to 18 years of age

- Intubated and mechanically ventilated

- Expected to require continuous infusions of sedatives for at least 48 hours

- Parent or legal guardian available for informed consent

- Males and females of any race are eligible

Exclusion Criteria:

- Less than 72 hours after surgery

- Cyanotic heart disease with unrepaired or palliated right to left intracardiac shunt

- Critical airway (according to PICU Attending)

- Ventilator dependent (including noninvasive) on PICU admission

- Greater than 48 hours of continuous sedation infusion(s)

- Neuromuscular respiratory failure

- Managed by patient controlled analgesia (PCA) or epidural catheter

- Known allergy to any of the study medications (fentanyl or midazolam)

- Family/Medical team have decided not to provide full support (patient treatment
considered futile)

- Patient requires ECMO

- Head trauma requiring intracranial pressure monitoring

- Pregnancy

- Following resuscitation from cardiorespiratory arrest whose initial pH is < 6.9

- ICU Attending judgment that patient should be excluded for safety reasons