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The Pharmaceutical Journal Vol 265 No 7114 September 16, 2000
Pharmacy Practice Research
Papers presented at the British Pharmaceutical Conference, Birmingham, September 10 to 13, 2000 pR18

Development of a sedation score to assess critically ill children

By Karen Whitfield, J. Marriott, K. A. Wilson and C. Ralston*

Introduction Sedation is an essential part of the treatment of children in intensive care. Achievement of optimal sedation is difficult in children because disease state, age, severity of illness, mechanical ventilation and drug interactions all alter drug effects and may result in poor management.1 A reliable method of sedation assessment is necessary in order to research the handling of sedatives in children. A number of sedation assessment methods has been reported but few have been comprehensively validated in critically ill children.2
This study investigated the reproducibility and sensitivity of the sedation assessment scale used at the Birmingham paediatric intensive care unit (PICU) which comprises visual assessment of five graded levels of sedation, where level 1 represents an agitated state and level 5 heavy sedation.

Method The sedation level of ventilated children aged between 0 and 16 years (2.28±0.64 years, n=46) was visually assessed by two independent members of the nursing staff. The duplicate sedation assessments were conducted concurrently and assessors were blind to each other's score. The intensive care experience (years) of the nurse making the assessment was recorded. Patients receiving neuromuscular blockade were excluded. The data were collected over a three-month period between November, 1999, and February, 2000, and scores are presented as arithmetic mean ± standard error of mean.

Focal points

  • Overall theme: Sedation assessment in paediatric intensive care
  • Rationale: Development of a reliable and accurate method of assessment for the safe and effective administration of sedative agents
  • Study design: Prospective, blinded, duplicate, visual, near-patient assessment of a sedation scoring system
  • Outcomes: A reliable sedation assessment method, providing agreement between assessors, independent of intensive care experience, age of child and disease state
  • Future work: Study forms part of a larger investigation into different types of sedation assessment methods and the correlation of sedative drug levels in critically ill children

Results A total of 46 patients was investigated and 100 duplicate sedation score assessments were made. Duplicate scores were identical in 61 per cent of the assessments, whereas sedation scores differed by one level in 35 per cent of cases and by two levels in the remaining 4 per cent.
The sedation scores were also assessed in a longitudinal analysis. During the first 24 hours, the average sedation score was 3.86±0.20 (n=28), whereas after five days the average score had reduced to 2.61±0.15 (n=74).
No significant difference was detected between assessments made by experienced members of nursing staff and those with little PICU experience. Similarly, assessments were unrelated to age or disease state.

Discussion The scoring method used in the present study appears to enable reproducible estimations of sedation, since duplicate scores agreed in 61 per cent of cases. The assessment method is also sensitive to changes in the depth of sedation within an individual, as shown by the reduction in average sedation score with time, reflecting the medical management of sedation as conditions improve. This is an important consideration in paediatric patients where change occurs rapidly.
The results from the present study also indicate that estimations of sedation are independent of the assessor's PICU experience, which is essential for wide application.
This research forms part of a larger study investigating the correlation of sedative plasma levels with depth of sedation in critically ill children.

Pharmacy practice group, Aston pharmacy school, Aston university, Birmingham B4 7ET; *Paediatric intensive care unit, Birmingham Children's hospital, Birmingham B4 6NH

References

1. Murray K. The need for assessment of sedation in the critically ill. Nurs Crit Care 1997;2:297-302.
2. Creasey J. Sedation scoring. Assessment tools. Nurs Crit Care 1996;1: 171-7.