Pharmacological and Non-Pharmacological Strategies for Sedation and Analgesia in Critically Ill Children: A Systematic Review and Narrative Synthesis

Abstrak

Background: The management of pain and agitation in the Pediatric Intensive Care Unit (PICU) is critical for patient comfort and preventing adverse outcomes. A wide array of sedation and analgesia strategies exists, but a synthesized appraisal of contemporary evidence is needed to guide clinical practice. This systematic review evaluates the efficacy and safety of various pharmacological and non-pharmacological interventions for sedation and analgesia in critically ill children. Methods: A systematic search was conducted in PubMed, Embase, Cochrane CENTRAL, and CINAHL for studies published between January 2020 and December 2024. Following the PRISMA 2020 guidelines, two independent reviewers screened studies, extracted data, and assessed the risk of bias using the Cochrane RoB 2 tool for Randomized Controlled Trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for observational studies. Results: From 4,366 identified records, five studies (two RCTs, three observational) involving 875 patients met the inclusion criteria. Study 1, an RCT (n=120), found that adjunctive ketamine significantly reduced mechanical ventilation duration by a mean of 2.1 days (95% CI: 1.2-3.0, p=0.001) compared to standard care. Study 3, a prospective cohort study (n=350), linked continuous sedation to longer PICU stays (median 9 vs. 6 days, p<0.001) and a higher incidence of iatrogenic withdrawal syndrome (45% vs. 18%, p<0.001) compared to intermittent sedation. Study 4, an RCT on music therapy (n=85), demonstrated a significant reduction in postoperative pain scores. Observational studies supported the opioid-sparing effects of multimodal analgesia (Study 5) and noted differences in recovery profiles between midazolam and propofol (Study 2). Conclusion: This review highlights the benefits of a multimodal, goal-directed approach to pediatric sedation and analgesia. Adjunctive ketamine and non-pharmacological interventions show promise in reducing opioid reliance and improving clinical outcomes. Protocols favoring intermittent sedation may reduce length of stay and withdrawal incidence. These findings support a paradigm shift away from deep, continuous sedation towards more nuanced, patient-centered strategies.