PEDIATRIC NURSING/September-October 2006/Vol. 32/No. 5 435 I n the Pediatric Intensive Care Unit (PICU), sedation and analgesia are administered to provide comfort and pain relief, decrease anxiety, and prevent accidental removal of life- saving devices. Many patients are managed without the use of neuro- muscular blockade. When a patient is pharmacologically paralyzed with a neuromuscular blockade agent, phys- ical assessment of comfort often becomes impossible and the nurse must rely on physiologic variables (Berkenbosch, Fichter, & Tobias, 2002). Through the use of medical and nursing assessments, patient observation, parental input, and phys- iologic parameters, a valid and reli- able tool can be developed to assess comfort and pain in the sedated neu- romuscular blocked pediatric patient. Research Problem Pain and agitation assessments often have been inadequate in chil- dren because of the child’s develop- mental level or inability to communi- cate because of sedation or intuba- tion. The major limitations of obser- vational scales are that they cannot be used in children with neurologic deficits or for patients receiving neu- romuscular blocking agents (Brinker, 2004). The advantage to having an appropriate sedation scale is that it promotes synchrony with the ventila- tor and helps relieve anxiety and dis- comfort associated with the intensive care environment (Brinker, 2004). Neuromuscular blocking agents (NBAs) are used to improve oxy- genation and facilitate mechanical ventilation. These agents do not have sedative or analgesic properties and are not intended to be used without concomitant use of opioids and seda- tion (Martin, Bratton, & O’Rourke, 1999). Previous studies confirm that protocols using valid and reliable scoring systems can enhance the use of sedation and analgesia, thereby improving patient outcomes and cost effectiveness (Brook et al., 1999; Kress, Pohman, O’Connor, & Hall, 2000; Mascia, Koch, & Medicis, 2000). Literature Review Currently, two methods exist for assessing the level of neuromuscular blockade and titration of drugs: (a) the peripheral nerve assessment (with the train-of-four stimulation) and (b) the periodic discontinuation of neuromuscular therapy (drug holi- day) (Martin et al., 1999). Train-of- four involves the application of an electrical impulse that is sensed at the neuromuscular junction and translated into muscular movement when the neuromuscular junction is intact. Muscular movement is mea- sured while paralytic agents are administered; movement is used to assess the depth of blockade (Strange, Vaughan, Franklin, & Johnson, 1997). Although there is insufficient evidence to support the periodic discontinuation of neuro- muscular blockade therapy (often called a ‘drug holiday’), critical care experts often recommend this prac- tice to allow for clinical assessment of the adequacy of sedation/analge- sia and to evaluate the need for con- tinued paralysis (Shapiro, Warren, Egol, Greenbaum, Jacobi, et al., 1995). Multiple scales have been developed to assess sedation and analgesia in the critical care patient; however there are no known pub- lished scales for the pharmacologi- cally paralyzed pediatric critical care patient. Adult sedation studies. Several sedation studies conducted with adults have been cited in the litera- ture. The Ramsay scale, developed in 1974, has been used as a reference for sedation and is still in use today (Ramsay, Savage, Simpson, & Goodwin, 1974; Watson & Kane-Gill, 2004). The Motor Activity Assess- ment Scale was found to be a valid measure of sedation for mechanical- ly ventilated surgical patients (Devlin et al., 1999). Numerous researchers have compared a variety of sedation scales. Hogg and colleagues (2001) found the Motor Activity Assessment Scale more reliable than the Luer scale (Luer, 1995). Data collectors included registered nurses, a phar- macist, and physicians. They simul- taneously and independently fol- lowed a standardized procedure to rate each patient using the two scales (see Table 1). Ivy Razmus, MSN, RN, is Clinical Manager, Saint Francis Health System, Tulsa, OK. David Wilson, MSN, RNC, is Faculty, Langston University School of Nursing, Tulsa, OK. The CE Posttest can be found on pages 452-454. Continuing Education Series Current Trends in the Development of Sedation/ Analgesia Scales For the Pediatric Critical Care Patient Ivy Razmus David Wilson Evaluation of pain and sedation in the PICU patient population is challenging. This article provides an overview of sedation and anal- gesia assessment tools developed for the critical pediatric patient who is mechanically ventilated and pharmacologically paralyzed. Studies reviewed include adult critical care, pediatric, and neonatal patients. No single tool has emerged that can adequately address pain management in the mechanically ventilated pharmacologically paralyzed pediatric patient. Nurses, as an integral part of the health care of critical pediatric patients, should endeavor to develop evi- dence-based methods for the evaluation of simple yet accurate scales to monitor sedation and pain in the pharmacologically para- lyzed pediatric patient.