We rarely use neuromuscular blockers like Nimbex, although a few years ago we had a fellow who was doing a combined anaesthesia/critical care fellowship who loved it. (He's also the one who bequeathed us the epi "spritzer" we're using all the time now on kids who are pre-arrest... don't get me going!) We tend to use Zemuron if we're going to paralyse and then it's usually only for bedside procedures like intubation, line placement, perc drainage, chest tubes and that sort of thing. I can't even remember the last time I paralysed a kid for any other reason.
I agree with your sentiment RNx54p... lazy nurses often have stoned patients. I hate it when the first thing they try when a kid is upset is a drug. The other night I spent a solid half hour trying to settle a baby that I know well for the nurse who was assigned to him (I was charge). It was only after the 5 S's failed and the dad was getting quite antsy that the baby got some Ativan. (Followed by a fluid bolus, because he'd gotten captopril in the previous hour.) Turns out he was in withdrawal and needed a slight increase in his baseline sedation to fix him up.
We don't actually have a formula or a protocol. We kind of make it up as we go along. Morphine 20-50 mcg/kg/hr and Versed 1-4 mcg/kg/min infusions are our usual tools, depending on the kid's previous exposure. The morphine may be increased to as much as 100 mcg/kg/hr in kids on CRRT or ECMO where the circuit could be adsorbing. There will also be morphine and Ativan boluses ordered prn. 0.1 mg/kg q2h for each of them in intubated kids, half that for non-intubated, and once we can use their gut, we'll have a chloral hydrate prn, 10-20 mg/kg q3h. If we're still struggling with sedation and analgesia in a hemodynamically stable patient, clonidine is added next, 1 mcg/kg q6h. (Another
gift from our former fellow, but it actually works.) Only if all of that fails do we consider ketamine or Precedex. Having said that, we've had several kids on Precedex infusions for weeks at a time, after which we wean by 10% q12h to off to minimize risk of withdrawal effects. Our long-term kids all develop some degree of withdrawal and will be converted to enteral morphine and Ativan with a weaning schedule on the Kardex.
Our unit does a poor job of assessing pain (we use the FLACC scale with mostly infants and toddlers, for whom it is much less specific for pain than it might be for other causes of distress) and the scores aren't reported or used other than as a box to tick on our assessment charting. Neither are the sedation scores that are recorded with our q4h assessments. We don't assess for delirium. We use a neonatal abstinence scale for scoring withdrawal, which isn't really the right tool for most of our patients. Almost all of them will score high because of loose stools (lots and lots of very elemental formula used on our unit!) and work of breathing (lots of sick chests from pulmonary hypertension,
chylothorax, RV dysfunction and so on) and sleeping less than 3 hours since the last feed - they're all on continuous feeds and many of them are old enough that they wouldn't be sleeping for 3 hours at a stretch anyway. There is NO education to staff on how to use the scale, and scoring is very inconsistent. We bedside staff have absolutely no influence on any of the things we're expected to do, and aren't properly educated on how to do most of it. Very frustrating.