Novel Sedation Strategies in the Pediatric Cardiac ICU with Volatile Anesthetics

Background: Sedation in children may be a tricky business and challenging. Especially long-term intravenous sedation may create a lot of problems including increasing doses required, substance dependence, delirium, agitation, and other side effects. Isoflurane, a volatile anesthetic used mainly during surgery, can easily be used in an intensive care unit even for small children. We investigated this promising new strategy also in children with congenital heart defects and cardiomyopathy.

Methods: We used standard respirators with humidifiers and a configuration for the administration of isoflurane. Patients were ventilated with a minimum absolute tidal volume of 30 mL. The lowest patient weight was 4.6 kg. So far we used Isoflurane in 6 patients after heart surgery and an expected long term stay with ventilation after surgery. Median age was 28 month (5–55 M); patients diagnosis were hypoplastic left heart syndrome (HLHS), chronic myocarditis, tachycardic myopathy and dilated cardiomyopathy with LVAD and pulmonary vein stenosis. One child was ventilated via tracheostoma. To assess the depth of sedation, we used N-PASS, Comfort-B and RASS-Score depending on the age of the patient. We also used an anesthesia gas monitor. Because of the low analgetic effect of isoflurane additional low dose sufentanil (5–10 µg/kg/h) was needed.

Results: In no case we did have to switch to conventional intravenous anesthesia. The mean ventilation time was 10 days (3–23 days). Inhaled sedation allows real-time monitoring of the agent using an anesthetic gas monitor. The isoflurane dose administered was 12–18 mL/h. There was very few effect on blood pressure which were treated with low dose noradrenaline. Advantages of sedation with isoflurane are a reduction in ICU length of stay compared with a standard cohort of patients treated with intravenous sedatives e.g., propofol, faster, predictable awakening of patients and a very good neurological accessibility of patients. The application of opioids was significantly reduced.

Conclusion: So far, we have used sedation with isoflurane in 6 patients after heart surgery and with severe heart failure including DCM. We never observed any reduction in cardiac function or severe hypotension compared with conventional intravenous sedation strategies. In our opinion volatile sedation is not only a save in pediatric cardiac patients including DCM, but also has less adverse effects. More studies with pediatric cardiology patients are required.

Publication History

Article published online:
13 February 2024