What sedation scales can be used in pediatric patients?

Sedation Assessment Scales for Pediatric Patients

The COMFORT Behaviour Scale is the primary recommended sedation assessment tool for critically ill pediatric patients aged 0-16 years (Grade A recommendation), with the State Behavioural Scale as an alternative for children aged 6 weeks to 6 years (Grade B recommendation). 1

Primary Recommended Scales

COMFORT Behaviour Scale (Grade A)

• Age range: 0-16 years 1
• Variables assessed: Alertness, calmness/agitation, respiratory response or crying, physical movement, muscle tone, and facial tension 1
• Score range: 6-30 points 1
  • <11 indicates oversedation
  • 11-22 indicates adequate sedation

  • 22 indicates undersedation

• Validation: Established face, construct, concurrent validity, and responsiveness; feasibility and utility proven at bedside 1
• Key advantage: Does not include physiologic parameters (heart rate, blood pressure), making it more practical for bedside use compared to the original COMFORT scale 1

State Behavioural Scale (Grade B)

• Age range: 6 weeks to 6 years 1
• Variables assessed: Respiratory drive, coughing, best response to stimuli, attentiveness to care provider, tolerance to care, consolability, and movement after consoled 1
• Score range: 6-point scale from -3 to +2, with 0 = awake and calm 1
• Validation: Face and construct validity established; feasibility and utility proven at bedside 1

Alternative Validated Scales

COMFORT Scale (Original Version, Grade A)

• Age range: 0-16 years 1
• Variables assessed: Includes physiologic parameters (heart rate, mean arterial pressure) plus behavioral indicators (alertness, calmness, respiratory response, movement, muscle tone, facial expression) 1
• Score range: 8-40 points 1
  • <17 indicates oversedation
  • 17-26 indicates optimal sedation

  • 26 indicates undersedation

• Limitation: Less practical than COMFORT Behaviour Scale due to inclusion of vital signs 1

Richmond Agitation-Sedation Scale (RASS)

• Age range: Validated in critically ill children aged 2 months to 21 years 2
• Key advantage: Single tool assessing both agitation and sedation; highly correlated with visual analog scale (Spearman 0.810) and University of Michigan Sedation Scale (weighted kappa 0.902) 2
• Inter-rater reliability: Excellent (weighted kappa 0.825) 2
• Clinical utility: Accurate for both mechanically ventilated and spontaneously breathing patients 2

Ramsay Scale

• Age range: Validated for children ≥6 months undergoing invasive procedures under deep sedation 3
• Validation: High correlation with University of Michigan Sedation Scale (ρ = 0.621); excellent interobserver reliability (ICC = 0.94) 3
• Limitation: Not formally recommended by major pediatric intensive care guidelines, though widely used in practice 3

University of Michigan Sedation Scale (UMSS)

• Age range: 4 months to 5 years (validated range) 4
• Score range: 5-point scale from 1 (wide awake) to 5 (unarousable with deep stimulation) 4
• Validation: Demonstrated construct and criterion validity; good interobserver agreement for lighter sedation levels (scores 0-1) but less agreement for deeper sedation (scores 2-3) 4
• Clinical utility: Simple observational tool facilitating rapid assessment 4

Assessment Frequency and Documentation

• Routine assessment: Every 4-8 hours alongside vital signs 1
• During sedative infusions: Every 1-2 hours 1
• Clinical condition-dependent: More frequent assessment when symptoms are uncontrolled or during ventilator weaning 1
• Documentation: Accurate recording of sedation scores is mandatory 1

Critical Implementation Points

Common Pitfalls to Avoid

• Oversedation consequences: Prolonged mechanical ventilation, increased healthcare costs 1
• Undersedation consequences: Increased distress, self-extubation, accidental displacement of catheters and tubes 1
• Assessment challenges: Children under 4 years cannot understand their situation and often require greater sedative amounts to maintain lines and tubes 1

Before Assessing Sedation

• Rule out other causes of distress: Verify ventilator settings are appropriate before attributing agitation to inadequate sedation 1
• Environmental factors: Address noise, need for repositioning, or diaper care before escalating sedation 1

Quality Assurance

• Regular audits: Conduct sedation assessment audits every 12 months to evaluate quality of care and patient outcomes (Grade C recommendation) 1

Objective Monitoring Adjuncts

Bispectral Index (BIS) Monitoring

• Limitation in pediatrics: Moderate correlation with clinical scales (Spearman r = -0.499); poor correlation with chloral hydrate sedation (r = -0.213) 5
• Accuracy issue: BIS underestimates clinical sedation depth in children; matched clinical assessment only 36% of the time 5
• Deep sedation detection: BIS ≤80 most sensitive for identifying deep sedation, but ongoing limitations exist in distinguishing moderate from deep sedation 6
• ICU application: Should be used as adjunct to clinical assessment in paralyzed patients receiving neuromuscular blockade 7