Introduction: Only 58% of critically ill children in the United States are optimally sedated, with sedation-associated adverse events occurring in up to 70% of cases. Sedation-agitation assessment is conducted using validated qualitative scales such as the State Behavioral Scale (SBS) and Richmond Agitation Sedation Scale (RASS) but are subject to significant variability and infrequent measurement. The objective of this study is to evaluate the State Behavioral Scale in assessing patient state and making critical sedation decisions. Methods: Nine mechanically ventilated, critically ill children were recruited for this pilot study between 2023 and 2025. Patient electronic health record (EHR), continuous waveform vital sign data, and video recordings were obtained. EHR data included nurse-documented SBS scores and all continuous and intermittent analgosedation administered. SBS scores were retrospectively determined using video footage from the patient’s bedside in conjunction with their vitals waveform data. Scoring was performed by a pair of research assistants (M.D., O.M.) trained by a pediatric critical care nurse and physician and validated by a pediatric critical care physician. Retrospective SBS scores were assessed in 30-minute windows, during any patient stimulation, and at time of intermittent analgosedation administration. Results: In total, 855 hours of video were analyzed, with a mean of 95 hours and 191 retrospective SBS scores per patient. Retrospective SBS scores from patient video (Interrater reliability: Cohen’s kappa 0.775 and 0.873) showed poor agreement with nurse-documented SBS scores: MAE 1.10, RMSE 1.44, Pearson r=0.12, Cohen’s Kappa 0.05. Even in extreme nurse-documented agitation (SBS +2), 100% of retrospective assessments were SBS < +2. Vital signs showed weak correlations with retrospective SBS (Retro: HR: r=0.095, RR: r=0.324). Intermittent analgosedation PRN medication administration was commonly issued when not recommended based on retrospective SBS scores (Spearman rho =-0.021). Conclusions: The SBS scale demonstrates poor correlation with video sedation assessments, analgosedation medication decisions, and physiological parameters. Objective, data-driven assessment tools are critically needed to validate pediatric sedation decision-making and improve patient care.
Raghavan et al. (Sun,) studied this question.