Tolerance, withdrawal, and physical dependency after long-term sedation and analgesia of children in the pediatric intensive care unit

Objective: To describe the consequences of the prolonged administration of sedative and analgesic agents to the pediatric intensive care unit (PICU) p atient. The problems to be investigated include tolerance, physical depende ncy, and withdrawal. Data Sources: A MEDLINE search was performed of literature published in the English language. Cross-reference searches were performed using the follow ing terms: sedation, analgesia with PICU, children, physical dependency, wi thdrawal; tolerance with sedative, analgesics, benzodiazepines, opioids, in halational anesthetic agents, nitrous oxide, ketamine, barbiturates, propof ol, pentobarbital, phenobarbital. Study Selection: Studies dealing with the problems of tolerance, physical d ependency, and withdrawal in children in the PICU population were selected. Data Extraction: All of the above-mentioned studies were reviewed in the cu rrent manuscript. Data Synthesis: A case by case review is presented, outlining the reported problems of tolerance, physical dependency, and withdrawal after the use of sedative/analgesic agents in the PICU population. This is followed up by a review of the literature discussing current treatment options for these pr oblems. Conclusions: Tolerance, physical dependency, and withdrawal can occur after the prolonged administration of any agent used for sedation and analgesia in the PICU population. Important components in the care of such patients i nclude careful observation to identify the occurrence of withdrawal signs a nd symptoms. Treatment options after prolonged administration of sedative/a nalgesic agents include slowly tapering the intravenous administration of t hese agents or, depending on the drug, switching to subcutaneous or oral ad ministration.