Effective management of pain and agitation is a fundamental component of pediatric intensive care. In critically ill children, the primary goals of analgesia and sedation are to relieve pain, reduce anxiety, and facilitate tolerance of invasive interventions, including mechanical ventilation, at an optimal level of sedation. However, these tasks remain challenging for pediatric intensive care unit (PICU) healthcare providers [1,2]. Therefore, numerous studies, including nationwide surveys, have been conducted to assess current practices and serve as a foundation for the development of evidence-based guidelines aimed at improving clinical implementation [1,3-11].

In recent years, sedation practices have undergone a significant paradigm shift, with increasing emphasis on the concept of “analgosedation.” This approach prioritizes optimal pain control before the administration of sedatives, aiming to minimize sedative-related complications while maintaining patient comfort. The shift reflects growing recognition of the long-term consequences of sedation in pediatric patients and is supported by recent international guidelines. Notably, in 2022, two major consensus-based guidelines on pediatric analgesia and sedation were published, followed by a 2023 summary to assist clinical interpretation and implementation [12-14].

However, in Korea, there are currently no consensus-based guidelines for pediatric analgosedation, and, more importantly, the actual clinical practices remain largely undocumented. Therefore, this study aims to investigate current approaches to analgesia and sedation management in Korean PICUs. The findings are intended to provide a foundational step toward the development of national guidelines and promote standardized, evidence-based care for critically ill children in Korea.

This study was approved by the Institutional Review Board of Seoul St. Mary’s Hospital (No. 2025-1671-0001). Patient consent was not applicable.

This nationwide survey is the first to investigate current practices of analgesia and sedation management in PICUs across Korea. Although notable inter-unit variability was observed, overall patterns of practice suggest general alignment with international guidelines. Most Korean PICUs reported adopting the "analgosedation" approach, a paradigm shift emphasized in recent international recommendations, in which opioid-based analgesia is initiated prior to the use of sedative agents [12]. In our survey, 11 units identified opioids as their first-line treatment, reflecting this trend. Notably, sufentanil emerged as the most commonly selected first-line opioid among Korean PICUs, differing from a 2022 European survey that ranked fentanyl, morphine, and sufentanil in that order of opioid preference [10]. Regarding sedatives, dexmedetomidine, a selective alpha-2 agonist used for light sedation, was frequently used in Korean PICUs, whereas midazolam remained the predominant choice (66%) in the 2022 European data. Acetaminophen, used for opioid-sparing purposes, and NMBAs, when clinically indicated, were also actively employed. Despite this, there was significant inter-unit variability in drug combinations, dosing strategies, and escalation protocols.

Due to the small sample size (18 units) and structural heterogeneity among the participating PICUs, no clear correlation was identified between unit characteristics and specific analgosedation practices. A substantial number of units reported never using inhaled agents or clonidine, which may reflect limited drug availability in Korea. Propofol, although conditionally recommended in international guidelines for short-term sedation at doses less than 4 mg/kg/hr for up to 48 hours, was not widely used and was never used in seven Korean PICUs, possibly due to safety concerns or institutional policies.

Protocolized sedation and analgesia, which has been shown to improve patient outcomes and is recommended in recent guidelines, was implemented in only half of the surveyed units, and none reported the use of nurse-driven protocols [13,15-21]. Nevertheless, the monitoring, assessment, and documentation of pain and sedation were performed almost exclusively by bedside nurses. This finding highlights the pivotal role of nursing staff in daily sedation management and underscores the importance of involving them in the development of future protocols. Given their continuous presence at the bedside and direct involvement in patient care, nurses are well-positioned to provide valuable, evidence-based insights into appropriate levels of analgosedation. Moreover, prior studies have identified discrepancies in perceptions, barriers, and clinical practices between physicians and nurses. Addressing these differences will be essential for successfully implementing unified, multidisciplinary sedation protocols [22,23].

Furthermore, international guidelines now recommend incorporating nonpharmacologic strategies such as parental involvement, environmental controls, and sleep-preserving interventions to mitigate psychological stress in pediatric ICU patients [13]. While these factors may serve as valuable alternatives to reduce the use of analgosedative drugs, their implementation can be particularly challenging in the Korean context. In contrast to practices in many other countries, 24-hour family presence is generally not permitted, and highly restricted family visitation policies are common in Korean PICUs. Coupled with a low nurse-to-patient ratio, these limitations present substantial barriers to the implementation of light sedation strategies, highlighting notable gap between international recommendations and what is practically feasible in local settings.

International studies have also reported a shift away from minimal sedation practices during the coronavirus disease 2019 (COVID-19) pandemic, attributed to restricted family visitation, increased caregiver stress, and logistical barriers such as the burden of personal protective equipment [24]. These factors were associated with increased sedative use and a departure from previously established child-friendly sedation philosophies. The present study clearly illustrates that analgosedation strategies are influenced not only by clinical factors but also by external elements such as overall ICU practices, environmental conditions, cultural norms, and human resource structures. While these international insights are valuable, this study, as the first of its kind in Korea, does not permit a direct comparison of pre- and post-pandemic sedation practices.

The management of analgosedation in PICUs remains inherently complex, influenced by factors such as patient age, developmental stage, pharmacodynamics and pharmacokinetics, disease severity, staff-to-patient ratios, available medications, and the degree of family involvement [25,26]. In Korea, additional challenges include differences in drug approvals, supply chain issues, and the absence of structured family-centered care models. These variables highlight the urgent need for evidence-based, locally applicable analgosedation guidelines and underscore the importance of ongoing surveillance of clinical practices.

This study has several limitations. First, the survey included only attending pediatric intensivists and did not capture the perspectives of nursing staff, who play a crucial role in continuous bedside care as well as in the assessment and monitoring of pain and sedation. As a result, the study was unable to evaluate potential differences in perceptions or barriers regarding analgosedation between physicians and nurses. Previous research has shown that discrepancies between these professional groups can significantly influence both the implementation and effectiveness of protocolized sedation strategies. Including nurses in future surveys would provide a more comprehensive and accurate understanding of actual bedside practices and challenges. Second, although pediatric delirium has garnered increasing international attention as a critical outcome indicator in intensive care, this study did not assess current delirium monitoring or management practices in Korean PICUs [26,27]. Future research should seek to evaluate existing approaches to delirium screening, prevention, and treatment. Additional topics that warrant further investigation include sedation weaning protocols, validated withdrawal assessment tools, and inter-professional differences in attitudes toward recommended sedation strategies [28,29]. Despite these limitations, this study provides the first national overview of analgosedation practices in Korean PICUs and establishes a valuable foundation for future improvement.

In conclusion, while most units demonstrate alignment with recent international trends, notable inconsistencies remain in drug selection, protocol implementation, and monitoring approaches. The absence of standardized national guidelines and the limited involvement of nursing staff in protocol development highlight key areas for advancement. Moving forward there is a clear need for the development of evidence-based, Korea-specific analgosedation guidelines that not only address the use of analgesic and sedative agents, but also provide structured recommendations for tapering protocols and the assessment and management of iatrogenic withdrawal symptoms. Furthermore, regular monitoring and evaluation of clinical analgosedation practices will be essential to improving the quality, safety, and consistency of sedation management for critically ill pediatric patients.