Sedation, sleep, delirium, and rehabilitation

Advances in cardiac surgery over the last three decades have translated to a shift in the epidemiology of congenital heart disease mortality from childhood to adulthood. As a result, patient and family-centered care with therapies designed to improve neurodevelopmental, functional, and quality-of-life outcomes in children with heart disease are crucial. There is no question that sedation, analgesia, and mechanical ventilation will always be central aspects of care for children with critical heart disease. However, minimizing the risks associated with these therapies while optimizing patient safety and both short- and long-term outcomes is a practical and achievable goal for all providers caring for these children. There is a strong interplay between sedation, sleep, delirium, and rehabilitation-a child who is heavily sedated and restrained is at high risk for sleep disturbance and delirium and is unable to participate in rehabilitation therapies. Conversely, a child who is awake during the day and engages in rehabilitation in the acute phase of his or her recovery will be more likely to maintain a normal circadian rhythm and less likely to transition to delirium due to decreased administration of sedative medications. When immobilization with sedation is medically necessary (generally only for the most severely ill children), goal-directed and titrated-sedation approaches are needed to optimize outcomes. In the following sections we provide an overview of sedation, analgesia, delirium, sleep, and rehabilitation as they relate to the pediatric cardiac patient.