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Riggs BJ, Carpenter JL. Pediatric Neurocritical Care: Maximizing Neurodevelopmental Outcomes Through Specialty Care. Pediatr Neurol 2023; 149:187-198. [PMID: 37748977 DOI: 10.1016/j.pediatrneurol.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/27/2023] [Accepted: 08/04/2023] [Indexed: 09/27/2023]
Abstract
The field of pediatric neurocritical care (PNCC) has expanded and evolved over the last three decades. As mortality from pediatric critical care illness has declined, morbidity from neurodevelopmental disorders has expanded. PNCC clinicians have adopted a multidisciplinary approach to rapidly identify neurological injury, implement neuroprotective therapies, minimize secondary neurological insults, and establish transitions of care, all with the goal of improving neurocognitive outcomes for their patients. Although there are many aspects of PNCC and adult neurocritical care (NCC) medicine that are similar, elemental difference between adult and pediatric medicine has contributed to a divergent evolution of the respective fields. The low incidence of pediatric critical care illness, the heterogeneity of neurological insults, and the limited availability of resources all shape the need for a PNCC clinical care model that is distinct from the established paradigm adopted by the adult neurocritical care community at large. Considerations of neurodevelopment are fundamental in pediatrics. When neurological injury occurs in a child, the neurodevelopmental stage at the time of insult alters the impact of the neurological disease. Developmental variables contribute to a range of outcomes for seemingly similar injuries. Despite the relative infancy of the field of PNCC, early reports have shown that implementation of a specialized PNCC service elevates the quality and safety of care, promotes education and communication, and improves outcomes for children with acute neurological injuries. The multidisciplinary approach of PNCC clinicians and researchers also promotes a culture that emphasizes the importance of quality improvement and education initiatives, as well as development of and adherence to evidence-based guidelines and family-focused care models.
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Affiliation(s)
- Becky J Riggs
- Division of Pediatric Critical Care Medicine, Oregon Health & Science University, Portland, Oregon.
| | - Jessica L Carpenter
- Division of Pediatric Neurology, University of Maryland Medical Center, Baltimore, Maryland
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Kleinhans A. Acute Pain Management Protocols in Pediatric Intensive Care Units. Crit Care Nurs Clin North Am 2023; 35:247-254. [PMID: 37532378 DOI: 10.1016/j.cnc.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
Pediatric pain has historically been difficult to assess and even more difficult to treat. It is encouraging that there is current research regarding pain control in pediatric patients that provide evidence for treating pediatric pain. Patients in a pediatric intensive care setting demonstrate a great deal of patient variability with regard to patient diagnosis, age, developmental level, weight, and amount of pain control needed. The use of an evidence-based protocol for pediatric pain control can decrease variability in pain control and decrease potential adverse effects such as respiratory depression, constipation, withdrawal, delirium, and developmental delays while allowing for patient variability.
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Affiliation(s)
- Alicia Kleinhans
- University of Houston and Baylor College of Medicine, 219 Marshall Street Apartment 117, Houston, TX 77006, USA.
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3
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McAlister S, Connor JA, Engstrand S, McLellan MC. Validation of the withdrawal assessment tool-1 (WAT-1) in pediatric cardiovascular patients on an inpatient unit. J SPEC PEDIATR NURS 2023; 28:e12404. [PMID: 36808815 DOI: 10.1111/jspn.12404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/21/2022] [Accepted: 02/06/2023] [Indexed: 02/22/2023]
Abstract
PURPOSE Sedation and analgesia are administered to critically ill patients, which may result in physical dependence and subsequent iatrogenic withdrawal. The Withdrawal Assessment Tool-1 (WAT-1) was developed and validated as an objective measurement of pediatric iatrogenic withdrawal in intensive care units (ICUs), with a WAT-1 score ≥ 3 indicative of withdrawal. This study's objectives were to test interrater reliability and validity of the WAT-1 in pediatric cardiovascular patients in a non-ICU setting. DESIGN AND METHODS This prospective observational cohort study was conducted on a pediatric cardiac inpatient unit. WAT-1 assessments were performed by the patient's nurse and a blinded expert nurse rater. Intra-class correlation coefficients were calculated, and Kappa statistics were estimated. A two-sample, one-sided test of proportions of weaning (n = 30) and nonweaning (n = 30) patients with a WAT-1 ≥3 were compared. RESULTS Interrater reliability was low (K = 0.132). The WAT-1 area under the receiver operating curve was 0.764 (95% confidence interval; ± 0.123). There was a significantly higher proportion (50%, p = 0.009) of weaning patients with WAT-1 scores ≥3 compared to the nonweaning patients (10%). The WAT-1 elements of moderate/severe uncoordinated/repetitive movement and loose, watery stools were significantly higher in the weaning population. PRACTICE IMPLICATIONS Methods to improve interrater reliability warrant further examination. The WAT-1 had good discrimination at identifying withdrawal in cardiovascular patients on an acute cardiac care unit. Frequent nurse re-education may increase accurate tool use. The WAT-1 tool may be used in the management of iatrogenic withdrawal in pediatric cardiovascular patients in a non-ICU setting.
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Affiliation(s)
- Sarah McAlister
- Advanced Practice Nurse, Acute Cardiac Care Unit, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jean A Connor
- Director Nursing Research Cardiovascular, Critical Care & Perioperative Patient Services, Boston Children's Hospital, Assistant Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Shannon Engstrand
- Senior Program Coordinator, Cardiovascular, Critical Care & Perioperative Patient Services, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mary C McLellan
- Clinical Inquiry Coordinator, Staff Nurse III, Acute Cardiac Care Unit, Boston Children's Hospital, Boston, Massachusetts, USA
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Geslain G, Ponsin P, Lãzãrescu AM, Tridon C, Robin N, Riaud C, Orliaguet G. Incidence of iatrogenic withdrawal syndrome and associated factors in surgical pediatric intensive care. Arch Pediatr 2023; 30:14-19. [PMID: 36481162 DOI: 10.1016/j.arcped.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/24/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Iatrogenic withdrawal syndrome (IWS) is a complication of prolonged sedation/analgesia in pediatric intensive care unit (PICU) patients. The epidemiology of IWS is poorly understood, as validated diagnostic tools are rarely used. The main objective of our study was to use the WAT-1 score to assess the incidence of IWS in our unit. The secondary objectives were to evaluate the consequences of IWS, associated factors, and management modalities. MATERIAL AND METHODS From July 2018 to January 2019, 48 children receiving endotracheal ventilation and sedation/analgesia by continuous infusion (>48 h) of benzodiazepines and/or opioids were included. As soon as sedation/analgesia was decreased and until 72 h after its complete discontinuation, the WAT-1 score was determined every 12 h. Substitution therapy was used for 98% of patients upon opioid and/or benzodiazepine withdrawal. IWS was defined as a WAT-1 score ≥3. Factors associated with IWS were assessed by univariate analysis. RESULTS IWS occurred in 25 (52%) patients. IWS was associated with a higher number of ventilator-associated pneumonia episodes (17 [68%] vs. one [4%]) and a longer PICU stay (13 [7; 25] vs. 9.0 [5.0; 10.5]) (p<0.001). Overall, 11 patients developed IWS after less than 5 days of sedation/analgesia. Severe head injury was associated with IWS (p = 0.03). Neither sedation discontinuation nor IWS prevention was standardized. CONCLUSION The high incidence and adverse consequences of IWS require improved prevention. Risk groups should be defined and a standardized withdrawal protocol established. The occurrence of IWS should be monitored routinely using a validated score.
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Affiliation(s)
- G Geslain
- Pediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; University of Paris, Paris, France.
| | - P Ponsin
- Department of Pediatric Anesthesia and Intensive Care, University Hospital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - A M Lãzãrescu
- Department of Pediatric Anesthesia and Intensive Care, University Hospital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - C Tridon
- Department of Pediatric Anesthesia and Intensive Care, University Hospital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - N Robin
- Department of Pediatric Anesthesia and Intensive Care, University Hospital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - C Riaud
- Department of Pediatric Anesthesia and Intensive Care, University Hospital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - G Orliaguet
- University of Paris, Paris, France; Department of Pediatric Anesthesia and Intensive Care, University Hospital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France; EA7323: Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, Hôpitaux Universitaires Paris Centre, University of Paris, Paris, France
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Tessari A, Sperotto F, Pece F, Pettenuzzo G, Porcellato N, Poletto E, Mondardini MC, Pettenazzo A, Daverio M, Amigoni A. Is ketamine infusion effective and safe as an adjuvant of sedation in the PICU? Results from the Ketamine Infusion Sedation Study (KISS). Pharmacotherapy 2022. [PMID: 36567489 DOI: 10.1002/phar.2754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/08/2022] [Accepted: 10/11/2022] [Indexed: 12/27/2022]
Abstract
STUDY OBJECTIVE We aimed to evaluate the efficacy and safety of ketamine in ensuring comfort and sparing conventional drugs when used as an adjuvant for analgesia and sedation in the Pediatric Intensive Care Unit (PICU) as a continuous infusion (≥12 h). DESIGN Observational prospective study. SETTING Tertiary-care-center PICU. PATIENTS All consecutive patients <18 years who received ketamine for ≥12 h between January 2019 and July 2021. INTERVENTIONS ketamine infusion for ≥12 h. MEASUREMENTS AND MAIN RESULTS Seventy-seven patients (median age 16 months, Interquartile Range (IQR) 7-43) were enrolled. Twenty-six percent of patients (n = 20) were paralyzed, while 74% (n = 57) were not. The median infusion duration was 90 h (IQR 39-193), with doses between 15 (IQR 15-20) and 30 μg/kg/min (IQR 20-50). At 24 h of ketamine infusion, values of COMFORT-B-Scale (CBS) were significantly lower compared with values pre-ketamine (p < 0.001). Simultaneously, doses/kg/h of opioids and benzodiazepines significantly decreased at 24 h (p < 0.001 and p = 0.002, respectively), while doses/kg/h of propofol (p = 0.500) and dexmedetomidine (p = 0.072) did not significantly change. Seventy-four percent of non-paralyzed patients (42/57) had a decrease in CBS ≥2 points with no increase of concomitant analgosedation drugs. Among paralyzed patients (n = 20), 13 (65%) had no increase of concomitant analgosedation within 24 h after ketamine initiation. Overall, 55/77 (71%) of patients responded to ketamine. The mean and maximum ketamine infusion dosages were significantly higher in the non-responders (p = 0.021 and 0.028, respectively). Eleven patients had adverse events potentially related to ketamine (hypersalivation, systemic hypertension, dystonia/dyskinesia, tachycardia, and agitation) and six patients required intervention (dose reduction, suspension, or pharmacologic therapy). None of the patients developed delirium during ketamine infusion. CONCLUSIONS Ketamine used as a continuous infusion in the PICU might represent a valid strategy to ensure comfort and spare opioids and benzodiazepines in difficult-to-sedate PICU patients. Adverse events are minor and easily reversible. Future study will be needed to investigate long-term outcomes.
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Affiliation(s)
- Anna Tessari
- Pediatric Intensive Care Unit, Department of Women and Children's Health, University Hospital of Padua, Padua, Italy
| | - Francesca Sperotto
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Federico Pece
- Pediatric Intensive Care Unit, San Bortolo Hospital, Vicenza, Italy
| | - Giulia Pettenuzzo
- Pediatric Intensive Care Unit, Department of Women and Children's Health, University Hospital of Padua, Padua, Italy
| | - Nicola Porcellato
- Pediatric Intensive Care Unit, Department of Women and Children's Health, University Hospital of Padua, Padua, Italy
| | - Elisa Poletto
- Pediatric Intensive Care Unit, San Bortolo Hospital, Vicenza, Italy
| | | | - Andrea Pettenazzo
- Pediatric Intensive Care Unit, Department of Women and Children's Health, University Hospital of Padua, Padua, Italy
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Women and Children's Health, University Hospital of Padua, Padua, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women and Children's Health, University Hospital of Padua, Padua, Italy
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dos Santos IN, Peano CTG, Soares ES, Cimarosti HI. Iatrogenic Withdrawal Syndrome in Critically Ill Neonates: A Review of Mechanisms, Assessment, Management, and Prevention. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1758873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
AbstractConsidering that neonatal pain is a relevant matter given its implications and consequences, many neonates, particularly those undergoing critical care, are subjected to analgo-sedation therapies, which commonly includes treatment with opioids and benzodiazepines. These drugs, however, can induce tolerance and dependency, leading to the development of the so-called iatrogenic withdrawal syndrome (IWS) which is observed following discontinuation of these therapeutic agents particularly when utilized for a prolonged period of time (≥5 days). IWS consists of signs and symptoms manifested especially in young children, such as term and premature newborns in the neonatal intensive care unit, who are less capable of metabolizing and eliminating these drugs, compared with older patients. In this study, we review assessment tools that were developed to identify, evaluate, and manage children affected by IWS. The studies reviewed demonstrate that optimal management of IWS includes consideration of alternate routes of drug administration, the need for adequate time for drug tapering, and also the presence of planned rescue therapy when encountering cases refractory to ongoing management. Equally important is prevention of IWS which can be accomplished with the implementation of drug rotation protocols and, adherence to evidenced-based guidelines which facilitate an overall decline in the use and duration of opioids and benzodiazepines. Finally, our review strongly supports the need for more research on IWS in neonates given their increased susceptibility and sparse published data for this age group.
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Affiliation(s)
- Isaque Nilton dos Santos
- Department of Pharmacology, Center for Biological Sciences, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
- Postgraduate Program in Pharmacology, Center for Biological Sciences, UFSC, Florianopolis, Santa Catarina, Brazil
| | - Carolina Teixeira Goulart Peano
- Department of Pharmacology, Center for Biological Sciences, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
- Postgraduate Program in Pharmacology, Center for Biological Sciences, UFSC, Florianopolis, Santa Catarina, Brazil
| | - Ericks Sousa Soares
- Department of Pharmacology, Center for Biological Sciences, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
- Postgraduate Program in Pharmacology, Center for Biological Sciences, UFSC, Florianopolis, Santa Catarina, Brazil
| | - Helena Iturvides Cimarosti
- Department of Pharmacology, Center for Biological Sciences, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
- Postgraduate Program in Pharmacology, Center for Biological Sciences, UFSC, Florianopolis, Santa Catarina, Brazil
- Postgraduate Program in Neuroscience, Center for Biological Sciences, UFSC, Florianopolis, Santa Catarina, Brazil
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Moradi J, Mikhail M, Lee LA, Traube C, Sarti AJ, Choong K. Lived Experiences of Delirium in Critically Ill Children: A Qualitative Study. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1758695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AbstractThe aim of this study was to understand the lived experiences of delirium in critically ill children. We conducted phenomenological qualitative interviews with critically ill pediatric survivors aged 0 to 18 years who had experienced delirium, along with their family caregivers and health care providers, from pediatric intensive care units in two tertiary care children's hospitals in Canada. Cases were identified if they had a Cornell Assessment of Pediatric Delirium (CAPD) score of ≥ 9 for at least 48 hours. Thirteen interviews were conducted, representing 10 index patients with delirium (age range: 7 weeks to 17 years). Participants shared experiences that were divided into themes of delirium symptoms, the impact of delirium, and their experience with the care of delirium. Within each theme, subthemes were identified. Symptoms of delirium included hallucinations, fluctuating symptoms, and lack of eye contact. Children were often described as “not himself/herself.” Delirium had long-lasting impact on patients; memories remained prominent even after the hospital stay. Family members and health care providers often felt helpless and ill-prepared to manage delirium. The delirium experience had significant impact on loved ones, causing persistent and vicarious suffering after the critical illness course. Family members and health care providers prioritized nonpharmacological strategies, family presence, and education as key strategies for delirium management. The lived experience of delirium in both infants and older children is physically, psychologically, and emotionally distressing. Given the traumatic long-term consequences, there is an urgent need to target delirium education, management, and prevention to improve long-term outcomes in PICU survivors and their families.
Trial Registration number: NCT04168515.
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Affiliation(s)
- Jasmin Moradi
- Department of Pediatric Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Mirriam Mikhail
- Department of Pediatrics, Toronto Sick Children's Hospital, Toronto, Ontario, Canada
| | - Laurie A. Lee
- Alberta Children's Hospital, University of Calgary, Pediatric Critical Care, Calgary, AB, Canada
| | - Chani Traube
- Department of Pediatric Critical Care, Weill Cornell Medical College, New York, New York, United States
| | - Aimee J. Sarti
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Karen Choong
- Department of Pediatric Critical Care, McMaster University, Hamilton, Ontario, Canada
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Crisamore KR, Empey PE, Pelletier JH, Clark RSB, Horvat CM. Patient-Specific Factors Associated with Dexmedetomidine Dose Requirements in Critically Ill Children. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1753537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
AbstractThe objective of this study was to evaluate patient-specific factors associated with dexmedetomidine dose requirements during continuous infusion. A retrospective cross-sectional analysis of electronic health record-derived data spanning 10 years for patients admitted with a primary respiratory diagnosis at a quaternary children's hospital and who received a dexmedetomidine continuous infusion (n = 346 patients) was conducted. Penalized regression was used to select demographic, clinical, and medication characteristics associated with a median daily dexmedetomidine dose. Identified characteristics were included in multivariable linear regression models and sensitivity analyses. Critically ill children had a median hourly dexmedetomidine dose of 0.5 mcg/kg/h (range: 0.1–1.8), median daily dose of 6.7 mcg/kg/d (range: 0.9–38.4), and median infusion duration of 1.6 days (range: 0.25–5.0). Of 26 variables tested, 15 were selected in the final model with days of dexmedetomidine infusion (β: 1.9; 95% confidence interval [CI]: 1.6, 2.3), median daily morphine milligram equivalents dosing (mg/kg/d) (β: 0.3; 95% CI: 0.1, 0.5), median daily ketamine dosing (mg/kg/d) (β: 0.2; 95% CI: 0.1, 0.3), male sex (β: −1.1; 95% CI: −2.0, −0.2), and non-Black reported race (β: −1.2; 95% CI: −2.3, −0.08) significantly associated with median daily dexmedetomidine dose. Approximately 56% of dose variability was explained by the model. Readily obtainable information such as demographics, concomitant medications, and duration of infusion accounts for over half the variability in dexmedetomidine dosing. Identified factors, as well as additional environmental and genetic factors, warrant investigation in future studies to inform precision dosing strategies.
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Affiliation(s)
- Karryn R. Crisamore
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
| | - Philip E. Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Jonathan H. Pelletier
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
| | - Robert S. B. Clark
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
| | - Christopher M. Horvat
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
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Lui A, Kumar KK, Grant GA. Management of Severe Traumatic Brain Injury in Pediatric Patients. FRONTIERS IN TOXICOLOGY 2022; 4:910972. [PMID: 35812167 PMCID: PMC9263560 DOI: 10.3389/ftox.2022.910972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/10/2022] [Indexed: 11/23/2022] Open
Abstract
The optimal management of severe traumatic brain injury (TBI) in the pediatric population has not been well studied. There are a limited number of research articles studying the management of TBI in children. Given the prevalence of severe TBI in the pediatric population, it is crucial to develop a reference TBI management plan for this vulnerable population. In this review, we seek to delineate the differences between severe TBI management in adults and children. Additionally, we also discuss the known molecular pathogenesis of TBI. A better understanding of the pathophysiology of TBI will inform clinical management and development of therapeutics. Finally, we propose a clinical algorithm for the management and treatment of severe TBI in children using published data.
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Affiliation(s)
- Austin Lui
- Touro University College of Osteopathic Medicine, Vallejo, CA, United States
| | - Kevin K. Kumar
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
- Division of Pediatric Neurosurgery, Lucile Packard Children’s Hospital, Palo Alto, CA, United States
| | - Gerald A. Grant
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
- Division of Pediatric Neurosurgery, Lucile Packard Children’s Hospital, Palo Alto, CA, United States
- Department of Neurosurgery, Duke University, Durham, NC, United States
- *Correspondence: Gerald A. Grant,
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Smith HAB, Besunder JB, Betters KA, Johnson PN, Srinivasan V, Stormorken A, Farrington E, Golianu B, Godshall AJ, Acinelli L, Almgren C, Bailey CH, Boyd JM, Cisco MJ, Damian M, deAlmeida ML, Fehr J, Fenton KE, Gilliland F, Grant MJC, Howell J, Ruggles CA, Simone S, Su F, Sullivan JE, Tegtmeyer K, Traube C, Williams S, Berkenbosch JW. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatr Crit Care Med 2022; 23:e74-e110. [PMID: 35119438 DOI: 10.1097/pcc.0000000000002873] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
RATIONALE A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available. OBJECTIVE To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility. DESIGN The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to. METHODS Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence. RESULTS The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements. CONCLUSIONS The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.
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Affiliation(s)
- Heidi A B Smith
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
- Division of Pediatric Cardiac Anesthesiology, Vanderbilt University Medical Center, Department of Anesthesiology, Nashville, TN
| | - James B Besunder
- Division of Pediatric Critical Care, Akron Children's Hospital, Akron, OH
- Department of Pediatrics, Northeast Ohio Medical University, Akron, OH
| | - Kristina A Betters
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK
- The Children's Hospital at OU Medical Center, Oklahoma City, OK
| | - Vijay Srinivasan
- Departments of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Anne Stormorken
- Pediatric Critical Care, Rainbow Babies Children's Hospital, Cleveland, OH
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH
| | - Elizabeth Farrington
- Betty H. Cameron Women's and Children's Hospital at New Hanover Regional Medical Center, Wilmington, NC
| | - Brenda Golianu
- Division of Pediatric Anesthesia and Pain Management, Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
| | - Aaron J Godshall
- Department of Pediatrics, AdventHealth For Children, Orlando, FL
| | - Larkin Acinelli
- Division of Critical Care Medicine, Johns Hopkins All Children's Hospital, St Petersburg, FL
| | - Christina Almgren
- Lucile Packard Children's Hospital Stanford Pain Management, Palo Alto, CA
| | | | - Jenny M Boyd
- Division of Pediatric Critical Care, N.C. Children's Hospital, Chapel Hill, NC
- Division of Pediatric Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael J Cisco
- Division of Pediatric Critical Care Medicine, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA
| | - Mihaela Damian
- Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA
- Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Mary L deAlmeida
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA
- Division of Pediatric Critical Care, Emory University School of Medicine, Atlanta, GA
| | - James Fehr
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
- Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA
| | | | - Frances Gilliland
- Division of Cardiac Critical Care, Johns Hopkins All Children's Hospital, St Petersburg, FL
- College of Nursing, University of South Florida, Tampa, FL
| | - Mary Jo C Grant
- Primary Children's Hospital, Pediatric Critical Care Services, Salt Lake City, UT
| | - Joy Howell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | | | - Shari Simone
- University of Maryland School of Nursing, Baltimore, MD
- Pediatric Intensive Care Unit, University of Maryland Medical Center, Baltimore, MD
| | - Felice Su
- Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA
- Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Janice E Sullivan
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Chani Traube
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - Stacey Williams
- Division of Pediatric Critical Care, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - John W Berkenbosch
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY
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11
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Walton RAL, Enders BD. Suspected benzodiazepine withdrawal-associated seizures in 3 young dogs undergoing mechanical ventilation. J Vet Emerg Crit Care (San Antonio) 2022; 32:800-804. [PMID: 35708738 PMCID: PMC9796509 DOI: 10.1111/vec.13221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/16/2021] [Accepted: 05/19/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To describe new onset of generalized seizures in 3 young dogs following cessation of a benzodiazepine-containing sedation protocol to facilitate mechanical ventilation (MV) for hypoxemia. SERIES SUMMARY Three dogs under 5 months of age underwent MV due to severe hypoxemia. All 3 dogs were sedated with a constant rate infusion of benzodiazepines as part of their sedation protocol to facilitate MV. All 3 dogs had an acute onset of generalized seizures within 36 hours of sedation cessation and weaning from MV. All 3 dogs' seizures were successfully managed with a slow, tapering course of benzodiazepines. One dog was additionally treated with levetiracetam at the time of initial seizure activity, which was discontinued 1 year following discharge and absence of ongoing seizure activity. All 3 dogs were discharged successfully with no reports of ongoing seizures or neurologic deficits after discharge. NEW OR UNIQUE INFORMATION PROVIDED Young dogs managed with benzodiazepines to facilitate MV may have acute onset of generalized seizures following cessation, which can be successfully managed with short-term benzodiazepine therapy. The 3 cases in this series demonstrated a positive outcome and were successfully managed following acute onset of generalized seizure activity post-MV.
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Affiliation(s)
- Rebecca A. L. Walton
- Department of Veterinary Clinical SciencesCollege of Veterinary MedicineIowa State UniversityAmesIowaUSA
| | - Brittany D. Enders
- Department of Clinical SciencesCollege of Veterinary MedicineNorth Carolina State UniversityRaleighNorth CarolinaUSA
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12
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Zaccagnini M, Ataman R, Nonoyama ML. The Withdrawal Assessment Tool to identify iatrogenic withdrawal symptoms in critically ill paediatric patients: A COSMIN systematic review of measurement properties. J Eval Clin Pract 2021; 27:976-988. [PMID: 33590613 DOI: 10.1111/jep.13539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES The Withdrawal Assessment Tool (WAT-1) is one of the most widely used clinician-reported outcome measures to evaluate iatrogenic withdrawal symptoms (IWS) in critically ill children. However, the WAT-1's measurement properties have not been aggregated. Aggregating psychometric research on the WAT-1 will enhance appropriate use, and outline gaps for future empirical research. The aim of this systematic review is to critically appraise, compare, and summarize the measurement properties and evidence quality, and describe the interpretability and feasibility of the WAT-1 for identifying IWS symptoms in critically ill children. METHODS A systematic search of Medline, Embase and CINAHL was conducted from inception to 15 April 2020. Study inclusion/exclusion, data extraction, and measurement property evidence and the modified GRADE quality scoring were applied according to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines. RESULTS Six studies were included in the review. There was sufficient, high-quality evidence for reliability, structural validity, criterion validity, measurement error, construct validity, and feasibility. More information is required to support the WAT-1's content validity, responsiveness, internal consistency, cross-cultural validity, and interpretability according to COSMIN guidelines. CONCLUSION The results of this review indicate that the WAT-1 is a precise, easy to use measure of IWS in critically ill children despite some measurement property inconsistencies and gaps in the publication record. More information is required to support its content validity, responsiveness, internal consistency, cross-cultural validity, and interpretability.
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Affiliation(s)
- Marco Zaccagnini
- School of Physical and Occupational Therapy, McGill University, Montréal, Québec, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Québec, Canada.,Department of Respiratory Therapy, McGill University Health Centre, Montréal, Québec, Canada
| | - Rebecca Ataman
- School of Physical and Occupational Therapy, McGill University, Montréal, Québec, Canada.,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, Québec, Canada
| | - Mika Laura Nonoyama
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada.,Respiratory Therapy & Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Physical Therapy & Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
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13
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Isaac L, van den Hoogen NJ, Habib S, Trang T. Maternal and iatrogenic neonatal opioid withdrawal syndrome: Differences and similarities in recognition, management, and consequences. J Neurosci Res 2021; 100:373-395. [PMID: 33675100 DOI: 10.1002/jnr.24811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/01/2021] [Indexed: 11/12/2022]
Abstract
Opioids are potent analgesics used to manage pain in both young and old, but the increased use in the pregnant population has significant individual and societal implications. Infants dependent on opioids, either through maternal or iatrogenic exposure, undergo neonatal opioid withdrawal syndrome (NOWS), where they may experience withdrawal symptoms ranging from mild to severe. We present a detailed and original review of NOWS caused by maternal opioid exposure (mNOWS) and iatrogenic opioid intake (iNOWS). While these two entities have been assessed entirely separately, recognition and treatment of the clinical manifestations of NOWS overlap. Neonatal risk factors such as age, genetic predisposition, drug type, and clinical factors like type of opioid, cumulative dose of opioid exposure, and disease status affect the incidence of both mNOWS and iNOWS, as well as their severity. Recognition of withdrawal is dependent on clinical assessment of symptoms, and the use of clinical assessment tools designed to determine the need for pharmacotherapy. Treatment of NOWS relies on a combination of non-pharmacological therapies and pharmacological options. Long-term consequences of opioids and NOWS continue to generate controversy, with some evidence of anatomic brain changes, but conflicting animal and human clinical evidence of significant cognitive or behavioral impacts on school-age children. We highlight the current knowledge on clinically relevant recognition, treatment, and consequences of NOWS, and identify new advances in clinical management of the neonate. This review brings a unique clinical perspective and critically analyzes gaps between the clinical problem and our preclinical understanding of NOWS.
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Affiliation(s)
- Lisa Isaac
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nynke J van den Hoogen
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
| | - Sharifa Habib
- Department of Neonatology, Hospital for Sick Children, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Tuan Trang
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
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14
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Geven BM, Maaskant JM, Ward CS, van Woensel JBM. Dexmedetomidine and Iatrogenic Withdrawal Syndrome in Critically Ill Children. Crit Care Nurse 2021; 41:e17-e23. [PMID: 33560432 DOI: 10.4037/ccn2021462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Iatrogenic withdrawal syndrome is a well-known adverse effect of sedatives and analgesics commonly used in patients receiving mechanical ventilation in the pediatric intensive care unit, with an incidence of up to 64.6%. When standard sedative and analgesic treatment is inadequate, dexmedetomidine may be added. The effect of supplemental dexmedetomidine on iatrogenic withdrawal syndrome is unclear. OBJECTIVE To explore the potentially preventive effect of dexmedetomidine, used as a supplement to standard morphine and midazolam regimens, on the development of iatrogenic withdrawal syndrome in patients receiving mechanical ventilation in the pediatric intensive care unit. METHODS This retrospective observational study used data from patients on a 10-bed general pediatric intensive care unit. Iatrogenic withdrawal syndrome was measured using the Sophia Observation withdrawal Symptoms-scale. RESULTS In a sample of 102 patients, the cumulative dose of dexmedetomidine had no preventive effect on the development of iatrogenic withdrawal syndrome (P = .19). After correction for the imbalance in the baseline characteristics between patients who did and did not receive dexmedetomidine, the cumulative dose of midazolam was found to be a significant risk factor for iatrogenic withdrawal syndrome (P < .03). CONCLUSION In this study, supplemental dexmedetomidine had no preventive effect on iatrogenic withdrawal syndrome in patients receiving sedative treatment in the pediatric intensive care unit. The cumulative dose of midazolam was a significant risk factor for iatrogenic withdrawal syndrome.
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Affiliation(s)
- Barbara M Geven
- Barbara M. Geven is a pediatric intensive care nurse and clinical epidemiologist, Amsterdam UMC/Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands
| | - Jolanda M Maaskant
- Jolanda M. Maaskant is a senior nurse researcher and clinical epidemiologist, Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam UMC/University of Amsterdam
| | - Catherine S Ward
- Catherine S. Ward is a general and pediatric anesthesiologist, Amsterdam UMC/Emma Children's Hospital
| | - Job B M van Woensel
- Job B.M. van Woensel is medical director of the pediatric intensive care unit, Amsterdam UMC/Emma Children's Hospital
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15
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Conrad P, Meyer S, Whiting J, Connor JA. Iatrogenic withdrawal syndrome in specialty pediatric critical care. Appl Nurs Res 2020; 55:151284. [DOI: 10.1016/j.apnr.2020.151284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/01/2020] [Accepted: 05/07/2020] [Indexed: 11/28/2022]
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16
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Tiacharoen D, Lertbunrian R, Veawpanich J, Suppalarkbunlue N, Anantasit N. Protocolized Sedative Weaning vs Usual Care in Pediatric Critically Ill Patients: A Pilot Randomized Controlled Trial. Indian J Crit Care Med 2020; 24:451-458. [PMID: 32863639 PMCID: PMC7435087 DOI: 10.5005/jp-journals-10071-23465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Aims The prolonged use of benzodiazepines and opioids can lead to an increase in the incidence of withdrawal syndrome. One of the known risk factors is the lack of a sedative-weaning protocol. This study established a sedative-weaning protocol and compared this protocol with the usual care of weaning in high-risk critically ill children. Materials and methods This was an open-label, randomized controlled trial in a tertiary-care hospital. We recruited children aged 1 month to 18 years who had received intravenous sedative or analgesic drugs for at least 5 days. The exclusion criteria were patients who had already experienced the withdrawal syndrome. We established a weaning protocol. Eligible patients were randomly divided into the protocolized (intervention) and usual care (control) groups. The primary objective was to determine the prevalence of the withdrawal syndrome compared between two groups. Results Thirty eligible patients were enrolled (19 in the intervention and 11 in the control group). Baseline characteristics were not significantly different between both the groups. The prevalence of the withdrawal syndrome was 84% and 81% of patients in the intervention and control group, respectively. The duration of the initial weaning phase was shorter in the intervention group than in the control group (p value = 0.026). The cumulative dose of morphine solution for rescue therapy in the intervention group was statistically lower than that in the control group (p value = 0.016). Conclusion The implementation of the sedative-weaning protocol led to a significant reduction in the percentage of withdrawal days and length of intensive care unit stay without any adverse drug reactions. External validation would be needed to validate this protocol. ClinicalTrials.gov identifier NCT03018977 How to cite this article Tiacharoen D, Lertbunrian R, Veawpanich J, Suppalarkbunlue N, Anantasit N. Protocolized Sedative Weaning vs Usual Care in Pediatric Critically Ill Patients: A Pilot Randomized Controlled Trial. Indian J Crit Care Med 2020;24(6):451–458.
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Affiliation(s)
- Duangtip Tiacharoen
- Division of Pediatric Critical Care, Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine, Thammasat University Hospital, Pathumthani, Thailand
| | - Rojjanee Lertbunrian
- Division of Pediatric Critical Care, Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jarin Veawpanich
- Division of Pediatric Critical Care, Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nattanicha Suppalarkbunlue
- Clinical Pharmacy Department, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nattachai Anantasit
- Division of Pediatric Critical Care, Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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17
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Ávila-Alzate JA, Gómez-Salgado J, Romero-Martín M, Martínez-Isasi S, Navarro-Abal Y, Fernández-García D. Assessment and treatment of the withdrawal syndrome in paediatric intensive care units: Systematic review. Medicine (Baltimore) 2020; 99:e18502. [PMID: 32000360 PMCID: PMC7004796 DOI: 10.1097/md.0000000000018502] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Sedoanalgesia secondary iatrogenic withdrawal syndrome (IWS) in paediatric intensive units is frequent and its assessment is complex. Therapies are heterogeneous, and there is currently no gold standard method for diagnosis. In addition, the assessment scales validated in children are scarce. This paper aims to identify and describe both the paediatric diagnostic and assessment tools for the IWS and the treatments for the IWS in critically ill paediatric patients. METHODS A systematic review was conducted according to the PRISMA guidelines. This review included descriptive and observational studies published since 2000 that analyzed paediatric scales for the evaluation of the iatrogenic withdrawal syndrome and its treatments. The eligibility criteria included neonates, newborns, infants, pre-schoolers, and adolescents, up to age 18, who were admitted to the paediatric intensive care units with continuous infusion of hypnotics and/or opioid analgesics, and who presented signs or symptoms of deprivation related to withdrawal and prolonged infusion of sedoanalgesia. RESULTS Three assessment scales were identified: Withdrawal Assessment Tool-1, Sophia Observation Withdrawal Symptoms, and Opioid and Benzodiazepine Withdrawal Score. Dexmedetomidine, methadone and clonidine were revealed as options for the treatment and prevention of the iatrogenic withdrawal syndrome. Finally, the use of phenobarbital suppressed symptoms of deprivation that are resistant to other drugs. CONCLUSIONS The reviewed scales facilitate the assessment of the iatrogenic withdrawal syndrome and have a high diagnostic quality. However, its clinical use is very rare. The treatments identified in this review prevent and effectively treat this syndrome. The use of validated iatrogenic withdrawal syndrome assessment scales in paediatrics clinical practice facilitates assessment, have a high diagnostic quality, and should be encouraged, also ensuring nurses' training in their usage.
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Affiliation(s)
| | - Juan Gómez-Salgado
- Department of Sociology, Social Work and Public Health, University School of Social Work, Huelva
- Safety and Health Postgraduate Programme, Universidad Espíritu Santo, Guayaquil, Ecuador
| | | | - Santiago Martínez-Isasi
- CLINURSID Research Group, Nursing Department, University of Santiago de Compostela, Santiago de Compostela, Galicia
| | - Yolanda Navarro-Abal
- Department of Social, Developmental and Education Psychology, University of Huelva
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18
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Sanlorenzo LA, Cooper WO, Dudley JA, Stratton S, Maalouf FI, Patrick SW. Increased Severity of Neonatal Abstinence Syndrome Associated With Concomitant Antenatal Opioid and Benzodiazepine Exposure. Hosp Pediatr 2019; 9:569-575. [PMID: 31262946 DOI: 10.1542/hpeds.2018-0227] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Polysubstance use is common among opioid-using women, yet its association with pharmacotherapy for neonatal abstinence syndrome (NAS) remains unclear. We hypothesized that benzodiazepine exposure would increase risk of an infant developing pharmacologically treated NAS. METHODS We conducted a retrospective cohort study of maternal-infant dyads enrolled in Tennessee Medicaid, using individual-level data linkage of vital records and administrative (ie, outpatient, inpatient, and prescription) data from 2009 to 2011. These data underwent chart review from 2013 to 2016 to obtain clinically relevant exposure data (eg, toxicology testing). The association of antenatal exposures with pharmacologically treated NAS was evaluated by using multivariable logistic regression, controlling for maternal and infant factors and clustered by hospital. RESULTS Among 112 029 maternal-infant dyads, we confirmed 822 cases of NAS, of which 598 (72.7%) were cases of pharmacologically treated NAS. Infants who developed pharmacologically treated NAS were more likely to have been exposed to antenatal benzodiazepines compared with infants with confirmed NAS not treated pharmacologically (40.9% vs 30.8%; P = .008). In adjusted analyses, benzodiazepine exposure was associated with greater risk of developing pharmacologically treated NAS (odds ratio: 1.51; 95% confidence interval: 1.04-2.21). Alternatively, exposure to tobacco, marijuana, cocaine, gabapentin, and selective serotonin reuptake inhibitors were not associated with increased risk of developing pharmacologically treated NAS. CONCLUSIONS Among a population of infants with intrauterine polysubstance exposure, benzodiazepine exposure was an independent predictor of an infant developing pharmacologically treated NAS. Obtaining history of antenatal benzodiazepine exposure among opioid-exposed infants may allow for risk stratification and development of personalized care plans.
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Affiliation(s)
- Lauren A Sanlorenzo
- Departments of Pediatrics and .,Mildred Stahlman Division of Neonatology and.,Vanderbilt Center for Child Health Policy, Nashville, Tennessee; and
| | - William O Cooper
- Departments of Pediatrics and.,Vanderbilt Center for Child Health Policy, Nashville, Tennessee; and.,Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Judith A Dudley
- Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shannon Stratton
- Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Faouzi I Maalouf
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon
| | - Stephen W Patrick
- Departments of Pediatrics and.,Mildred Stahlman Division of Neonatology and.,Vanderbilt Center for Child Health Policy, Nashville, Tennessee; and.,Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
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19
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Liu Z, Ge X. The sedation practices of paediatric intensive care unit nurses and the influencing factors in China. Nurs Crit Care 2019; 24:306-312. [PMID: 31140704 DOI: 10.1111/nicc.12426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 02/09/2019] [Accepted: 02/20/2019] [Indexed: 02/02/2023]
Abstract
Nurses play a key role in administering sedation to mechanically ventilated children, which impacts children's psychological, physiological and cognitive changes in the paediatric intensive care unit. This study aimed to survey the sedation practices of paediatric intensive care unit nurses on mechanically ventilated children in China and explored the influencing factors. A cross-sectional survey was conducted based on electronic questionnaires comprised of the Nurse Sedation Practices Scale (Chinese version) in 14 different types of paediatric intensive care units of 11 academic hospitals in China from 15 February to 15 April 2017. A convenience sample of 495 nurses [73·4% response rate, (674)] completed the survey. Seven units applied Ramsay Sedation Scale as a sedative assessment tool. The majority of the nurses used observed behaviours and physiological changes of the ventilated children as indicators to assess the sedation level, and they had a positive attitude and intention, which may influence practice positively, whereas high clinical workload and the lack of communication between the nurses and families might hinder practice. The practice of sedation varied greatly in different regions, and the respondents of the northwest region scored lower. Paediatric nurses in China rarely used a validated paediatric instrument to assess sedation, and most nurses relied on physiological and behavioural cues. The quality of sedation training, nursing workload and regional economic disparity affected the sedation practice. The restricted visiting policy and lack of clearly defined nursing responsibilities around sedation may hinder effective sedation assessment and management. This study found that there was no paediatric-validated tool popularized in paediatric intensive care units in China and explored influencing factors. We suggest that a validated tool, high-quality training and hospital's policy, such as visiting regulation, should be promoted to improve the sedation practice.
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Affiliation(s)
- Zuojia Liu
- Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, National Children's Medical Center (Shanghai), Shanghai, China
| | - Xiaohua Ge
- Doctor Student, Director, Department of Nursing, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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20
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Best KM, Asaro LA, Curley MAQ. Sedation Management for Critically Ill Children with Pre-Existing Cognitive Impairment. J Pediatr 2019; 206:204-211.e1. [PMID: 30527750 PMCID: PMC6389364 DOI: 10.1016/j.jpeds.2018.10.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/29/2018] [Accepted: 10/23/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To compare current analgesia and sedation management practices between critically ill children with pre-existing cognitive impairment and critically ill neurotypical children, including possible indicators of therapeutic efficacy. STUDY DESIGN This study used secondary analysis of prospective data from the RESTORE clinical trial, with 2449 children admitted to the pediatric intensive care unit and receiving mechanical ventilation for acute respiratory failure. Subjects with a baseline Pediatric Cerebral Performance Category ≥3 were defined as subjects with cognitive impairment, and differences between groups were explored using regression methods accounting for pediatric intensive care unit as a cluster variable. RESULTS This study identified 412 subjects (17%) with cognitive impairment. Compared with neurotypical subjects, subjects with cognitive impairment were older (median, years, 6.2 vs 1.4; P < .001) with more severe pediatric acute respiratory distress syndrome (40% vs 33%; P = .009). They received significantly lower cumulative doses of opioids (median, mg/kg, 14.2 vs 16.2; P < .001) and benzodiazepines (10.6 vs 14.4; P < .001). Three nonverbal subjects with cognitive impairment received no analgesia or sedation. Subjects with cognitive impairment were assessed as having more study days awake and calm and fewer study days with an episode of pain. They were less likely to be assessed as having inadequate pain/sedation management or unplanned endotracheal/invasive tube removal. Subjects with cognitive impairment had more documented iatrogenic withdrawal symptoms than neurotypical subjects. CONCLUSIONS Subjects with cognitive impairment in this study received less medication, but it is unclear whether they have authentically lower analgesic and/or sedative requirements or are vulnerable to inadequate assessment of discomfort because of the lack of validated assessment tools. We recommend the development of pain and sedation assessment tools specific to this patient population.
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Affiliation(s)
- Kaitlin M Best
- Department of Nursing, Respiratory Care and Neurodiagnostic Services, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lisa A Asaro
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Martha A Q Curley
- The Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Family and Community Health, School of Nursing, Department of Anesthesia and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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21
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22
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Bichaff P, Setani KT, Motta EHG, Delgado AF, Carvalho WB, Luglio M. Opioid tapering and weaning protocols in pediatric critical care units: a systematic review. ACTA ACUST UNITED AC 2019; 64:909-915. [PMID: 30517238 DOI: 10.1590/1806-9282.64.10.909] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 01/20/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Opioid abstinence syndrome is common in the pediatric intensive care environment because sedation is often needed during the children's treatment. There is no specific guideline regarding the management of these patients; and lately, methadone is an important drug for the prevention of abstinence symptoms during the weaning of opioids. This study gathers the available research to establish the initial dose of methadone, the rate of taper and tools to recognize this syndrome and act promptly. METHODS A systematic review was made from data of four different databases. Forty-nine articles of observational and experimental studies were selected based on the inclusion criteria (critical pediatric patients in acute use of opioids) and exclusion criteria (previous chronic use of opioids, other medications). The data regarding specific themes were separated in sections: initial dose of methadone, use of protocols in clinical practice, abstinence scales and adjuvant drugs. RESULTS The articles showed a great heterogeneity of ways to calculate the initial dose of methadone. The pediatric intensive care units of the study had different weaning protocols, with a lower incidence of abstinence when a pre-defined sequence of tapering was used. The Withdrawal Assessment Tool - 1 was the most used scale for tapering the opioids, with good sensitivity and specificity for signs and symptoms. CONCLUSION There is still little evidence of other medications that can help prevent the abstinence syndrome of opioids. This study tries to promote a better practice during opioid weaning.
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Affiliation(s)
- Pedro Bichaff
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo (SP), Brasil
| | - Karina T Setani
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo (SP), Brasil
| | - Emiliana H G Motta
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo (SP), Brasil
| | - Artur F Delgado
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo (SP), Brasil
| | - Werther B Carvalho
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo (SP), Brasil
| | - Michele Luglio
- Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo (SP), Brasil
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23
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Evaluation of IV to Enteral Benzodiazepine Conversion Calculations in a Pediatric Intensive Care Setting. Pediatr Crit Care Med 2018; 19:e569-e575. [PMID: 30080777 DOI: 10.1097/pcc.0000000000001687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate if institutionally established calculations for transitioning continuous IV midazolam to enteral benzodiazepines maintain Withdrawal Assessment Tool-Version 1 scores equal to or less than preconversion values. DESIGN Retrospective cohort study evaluating the effectiveness and safety of benzodiazepine conversion calculations embedded within an institution-specific clinical pathway for sedation and weaning of mechanically ventilated pediatric patients. SETTING A 55-bed, mixed-medical, noncardiac surgical PICU in a tertiary care children's hospital. PATIENTS All patients age 6 months to 18 years who received continuous midazolam for 5 days or longer while mechanically ventilated for 5-21 days and were then converted to either enteral diazepam or lorazepam following extubation (or return to baseline ventilator settings in tracheostomy-dependent patients) between January 1, 2015, and June 30, 2016. INTERVENTIONS Benzodiazepine conversion calculations were applied according to institutional clinical pathway guidance. MEASUREMENTS AND MAIN RESULTS Withdrawal Assessment Tool-Version 1 scores were compared pre and post benzodiazepine conversion. Patient demographics, benzodiazepine dose escalations, as needed benzodiazepine requirements, and severe adverse events within 48 hours of conversion were assessed. Seventy-one patient encounters were analyzed (median age, 2.5 yr; interquartile range, 1.2-5.3). The median Withdrawal Assessment Tool-Version 1 scores pre conversion and post conversion were not significantly different (1 [interquartile range, 0.75-2] and 1 [interquartile range, 0.25-2], respectively, p = 0.1). As needed benzodiazepine doses were administered in 38% of encounters post conversion, but escalation of a scheduled enteral benzodiazepine regimen was only required in 2.8% of encounters. Post conversion, one patient (1.4%) had increased seizure activity, and four patients (5.6%) required fluid boluses secondary to tachycardia or dehydration, but not hypotension. CONCLUSIONS These findings suggest that standardized benzodiazepine conversions successfully achieved consistent Withdrawal Assessment Tool-Version 1 scores compared with preconversion values. Severe adverse events associated with oversedation and/or withdrawal were minimal and confounded by underlying disease states.
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In Vitro Adsorption of Analgosedative Drugs in New Extracorporeal Membrane Oxygenation Circuits. Pediatr Crit Care Med 2018; 19:e251-e258. [PMID: 29419606 DOI: 10.1097/pcc.0000000000001484] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Evaluate drug disposition of sedatives and analgesics in the Xenios/Novalung extracorporeal membrane oxygenation circuits. DESIGN In vitro experimental study. SETTING Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands. SUBJECTS Nine closed-loop extracorporeal membrane oxygenation circuits, made up of the iLA Activve console with four different iLA Activve kits: two X-lung kits, two iLA-Activve iLA kits, two MiniLung kits, and three MiniLung petite kits. INTERVENTIONS The circuits were primed with fresh whole blood and maintained under physiologic conditions (pH/temperature) throughout 24 hours. Paracetamol, morphine, midazolam, fentanyl, and sufentanil were injected as standard age-related doses into nine closed-loop extracorporeal membrane oxygenation circuits. MEASUREMENTS AND MAIN RESULTS Pre-membrane (P2) blood samples were obtained prior to drug injection and after injection at 2, 10, 30, 180, 360 minutes, and at 24 hours. A control sample at 2 minutes was collected for spontaneous drug degradation testing at 24 hours. Two hundred sixteen samples were analyzed. After correction for the spontaneous drug degradation, the mean drug loss at 24 hours was paracetamol 49%, morphine 51%, midazolam 40%, fentanyl 84%, sufentanil 83%. Spontaneous degradation was paracetamol 6%, morphine 0%, midazolam 11%, fentanyl 4%, and sufentanil 0%. The decline of drug concentration over time was more pronounced for the more lipophilic drugs. CONCLUSIONS Loss of highly lipophilic drugs in the extracorporeal membrane oxygenation circuits at 24 hours was remarkable. Drug loss is comparable with other hollow fiber extracorporeal membrane oxygenation systems but less than in silicone-based membranes especially in the first hours after injection.
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Staveski SL, Wu M, Tesoro TM, Roth SJ, Cisco MJ. Interprofessional Team's Perception of Care Delivery After Implementation of a Pediatric Pain and Sedation Protocol. Crit Care Nurse 2018; 37:66-76. [PMID: 28572103 DOI: 10.4037/ccn2017538] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Pain and agitation are common experiences of patients in pediatric cardiac intensive care units. Variability in assessments by health care providers, communication, and treatment of pain and agitation creates challenges in management of pain and sedation. OBJECTIVES To develop guidelines for assessment and treatment of pain, agitation, and delirium in the pediatric cardiac intensive unit in an academic children's hospital and to document the effects of implementation of the guidelines on the interprofessional team's perception of care delivery and team function. METHODS Before and after implementation of the guidelines, interprofessional team members were surveyed about the members' perception of analgesia, sedation, and delirium management RESULTS: Members of the interprofessional team felt more comfortable with pain and sedation management after implementation of the guidelines. Team members reported improvements in team communication on patients' comfort. Members thought that important information was less likely to be lost during transfer of care. They also noted that the team carried out comfort management plans and used pharmacological and nonpharmacological therapies better after implementation of the guidelines than they did before implementation. CONCLUSIONS Guidelines for pain and sedation management were associated with perceived improvements in team function and patient care by members of the interprofessional team.
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Affiliation(s)
- Sandra L Staveski
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio. .,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California. .,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California. .,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford. .,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California.
| | - May Wu
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
| | - Tiffany M Tesoro
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
| | - Stephen J Roth
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
| | - Michael J Cisco
- Sandra L. Staveski is an assistant professor at Cincinnati Children's Hospital Medical Center, Department of Research in Patient Services, and the Heart Institute, Cincinnati, Ohio.,May Wu is a clinical pharmacist at Lucile Packard Children's Hospital Stanford, Palo Alto, California.,Tiffany M. Tesoro is a clinical pharmacist in the cardiovascular intensive care unit and coordinates the PGY-1 pharmacy residency program at Lucile Packard Children's Hospital-Stanford. She is also an assistant clinical professor, School of Pharmacy, University of California, San Francisco, California.,Stephen J. Roth is chief of the division of pediatric cardiology and professor of pediatrics (cardiology), Stanford University School of Medicine, Stanford, California, and the director of the children's heart center at Lucile Packard Children's Hospital Stanford.,Michael J. Cisco is a clinical assistant professor of pediatrics, Pediatric Critical Care Medicine, University of San Francisco School of Medicine, San Francisco, California, and an attending physician in the pediatric cardiac intensive care unit, University of California San Francisco-Benioff Children's Hospital, San Francisco, California
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Haenecour AS, Seto W, Urbain CM, Stephens D, Laussen PC, Balit CR. Prolonged Dexmedetomidine Infusion and Drug Withdrawal In Critically Ill Children. J Pediatr Pharmacol Ther 2017; 22:453-460. [PMID: 29290746 DOI: 10.5863/1551-6776-22.6.453] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To characterise the incidence, symptoms and risk factors for withdrawal associated with prolonged dexmedetomidine infusion in paediatric critically ill patients. METHODS Retrospective chart review in the paediatric intensive care unit and the cardiac critical care unit of a single tertiary children's hospital. Patients up to 18 years old, who received dexmedetomidine for longer than 48 hours were included. RESULTS A total of 52 patients accounted for 68 unique dexmedetomidine treatment courses of more than 48 hours. We identified 24 separate episodes of withdrawal in the 68 dexmedetomidine courses (incidence 35%). Of these episodes 38% occurred in patients who were weaned from dexmedetomidine alone while the remaining occurred in patients who had concurrent weans of opioids and/or benzodiazepines. Most common symptoms were agitation, fever, vomiting/retching, loose stools and decreased sleep. The symptoms occurred during the latter part of the wean or after discontinuation of dexmedetomidine. A cumulative dose of dexmedetomidine of 107 mcg/kg prior to initiation of wean was more likely associated with withdrawal (this equates to a dexmedetomidine infusion running at 1 mcg/kg/hr over 4 days). Duration of opioid use was an additional risk factor for withdrawal. The use of clonidine, as a transition from dexmedetomidine, did not protect against withdrawal (p = 1). CONCLUSIONS A withdrawal syndrome may occur after prolonged infusion of dexmedetomidine. As all our patients were also exposed to opioids this may be affected by the duration of opioid use. We identified a cumulative dose of 107 micrograms/kg of dexmedetomidine beyond which withdrawal symptoms were more likely (which equates to 4 days of use at a dose of 1 mcg/kg/hr). A protocol for weaning should be considered in this circumstance.
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Affiliation(s)
- Astrid S Haenecour
- Department of Critical Care Medicine (ASH, WS, PCL, CRB), The Hospital for Sick Children, Toronto, Canada; Department of Pharmacy (WS), The Hospital for Sick Children, Toronto, Canada; Department of Diagnostic Imaging and Neuroscience & Mental Health Program (CMU), The Hospital for Sick Children Research Institute, Toronto, Canada; Department of Clinical research services (DS), The Hospital for Sick Children, Toronto, Canada; and University of Toronto (DRB, PCL, WS), Toronto, Ontario, Canada
| | - Winnie Seto
- Department of Critical Care Medicine (ASH, WS, PCL, CRB), The Hospital for Sick Children, Toronto, Canada; Department of Pharmacy (WS), The Hospital for Sick Children, Toronto, Canada; Department of Diagnostic Imaging and Neuroscience & Mental Health Program (CMU), The Hospital for Sick Children Research Institute, Toronto, Canada; Department of Clinical research services (DS), The Hospital for Sick Children, Toronto, Canada; and University of Toronto (DRB, PCL, WS), Toronto, Ontario, Canada
| | - Charline M Urbain
- Department of Critical Care Medicine (ASH, WS, PCL, CRB), The Hospital for Sick Children, Toronto, Canada; Department of Pharmacy (WS), The Hospital for Sick Children, Toronto, Canada; Department of Diagnostic Imaging and Neuroscience & Mental Health Program (CMU), The Hospital for Sick Children Research Institute, Toronto, Canada; Department of Clinical research services (DS), The Hospital for Sick Children, Toronto, Canada; and University of Toronto (DRB, PCL, WS), Toronto, Ontario, Canada
| | - Derek Stephens
- Department of Critical Care Medicine (ASH, WS, PCL, CRB), The Hospital for Sick Children, Toronto, Canada; Department of Pharmacy (WS), The Hospital for Sick Children, Toronto, Canada; Department of Diagnostic Imaging and Neuroscience & Mental Health Program (CMU), The Hospital for Sick Children Research Institute, Toronto, Canada; Department of Clinical research services (DS), The Hospital for Sick Children, Toronto, Canada; and University of Toronto (DRB, PCL, WS), Toronto, Ontario, Canada
| | - Peter C Laussen
- Department of Critical Care Medicine (ASH, WS, PCL, CRB), The Hospital for Sick Children, Toronto, Canada; Department of Pharmacy (WS), The Hospital for Sick Children, Toronto, Canada; Department of Diagnostic Imaging and Neuroscience & Mental Health Program (CMU), The Hospital for Sick Children Research Institute, Toronto, Canada; Department of Clinical research services (DS), The Hospital for Sick Children, Toronto, Canada; and University of Toronto (DRB, PCL, WS), Toronto, Ontario, Canada
| | - Corrine R Balit
- Department of Critical Care Medicine (ASH, WS, PCL, CRB), The Hospital for Sick Children, Toronto, Canada; Department of Pharmacy (WS), The Hospital for Sick Children, Toronto, Canada; Department of Diagnostic Imaging and Neuroscience & Mental Health Program (CMU), The Hospital for Sick Children Research Institute, Toronto, Canada; Department of Clinical research services (DS), The Hospital for Sick Children, Toronto, Canada; and University of Toronto (DRB, PCL, WS), Toronto, Ontario, Canada
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Fenn NE, Plake KS. Opioid and Benzodiazepine Weaning in Pediatric Patients: Review of Current Literature. Pharmacotherapy 2017; 37:1458-1468. [PMID: 28891099 DOI: 10.1002/phar.2026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pediatric opioid and benzodiazepine withdrawal are avoidable complications of pain and sedation management that is well described in the literature. To prevent withdrawal from occurring, practitioners regularly use a steady decrease of pain and sedation medications, also known as a weaning or tapering schedule. The weaning schedule is highly variable based on clinician preference and is usually dependent on the clinician. The purposes of this review are to evaluate the current literature on the process of opioid and benzodiazepine weaning in pediatric patients and to assess the various standardized protocols used to decrease withdrawal occurrences. We conducted a search of the PubMed, MEDLINE, Cochrane Library, Cumulative Index of Nursing and Allied Health (CINAHL), Academic Search Premier, and PsycInfo databases. Studies were included if they described a wean or taper in pediatric patients aged 18 years or younger. Studies describing neonatal abstinence syndrome were excluded from the review. A total of 97 studies published between 2000 and 2014 were retrieved; of those, 15 studies met the inclusion criteria. Studies were evaluated for selection of withdrawal assessment tool, wean protocol summary, preferred weaning agents, benzodiazepine withdrawal, and wean-at-home regimen. The most common opioid-weaning protocol approaches described a 10-20% dose decrease per day. Benzodiazepine weaning was not regularly standardized or described. The use of a standardized opioid-weaning protocol reduced withdrawal rates compared with nonstandardized weaning plans. Benzodiazepine weaning was inconsistently evaluated and may have affected study outcomes. Identified areas of improvement include the use of newer withdrawal assessment tools validated in the older pediatric population and standardized withdrawal assessment and reporting.
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Affiliation(s)
- Norman E Fenn
- Purdue University College of Pharmacy, West Lafayette, Indiana
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Fagin A, Palmieri TL. Considerations for pediatric burn sedation and analgesia. BURNS & TRAUMA 2017; 5:28. [PMID: 29051890 PMCID: PMC5641993 DOI: 10.1186/s41038-017-0094-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 07/25/2017] [Indexed: 12/13/2022]
Abstract
Burn patients experience anxiety and pain in the course of their injury, treatment, and recovery. Hence, treatment of anxiety and pain is paramount after burn injury. Children, in particular, pose challenges in anxiety and pain management due to their unique physiologic, psychologic, and anatomic status. Burn injuries further complicate pain management and sedation as such injuries can have effects on medication response and elimination. Burn injuries further complicate pain management and sedation as such injuries can have effects on medication response and elimination. The purpose of this review is to describe the challenges associated with management of anxiety, pain, and sedation in burned children and to describe the different options for treatment of anxiety and pain in burned children.
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Affiliation(s)
- Alice Fagin
- Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR 72202 USA
| | - Tina L Palmieri
- Shriners Hospitals for Children Northern California and University of California Davis, 2425 Stockton Blvd, Suite 718, Sacramento, CA USA
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Chiu AW, Contreras S, Mehta S, Korman J, Perreault MM, Williamson DR, Burry LD. Iatrogenic Opioid Withdrawal in Critically Ill Patients: A Review of Assessment Tools and Management. Ann Pharmacother 2017; 51:1099-1111. [PMID: 28793780 DOI: 10.1177/1060028017724538] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To (1) provide an overview of the epidemiology, clinical presentation, and risk factors of iatrogenic opioid withdrawal in critically ill patients and (2) conduct a literature review of assessment and management of iatrogenic opioid withdrawal in critically ill patients. DATA SOURCES We searched MEDLINE (1946-June 2017), EMBASE (1974-June 2017), and CINAHL (1982-June 2017) with the terms opioid withdrawal, opioid, opiate, critical care, critically ill, assessment tool, scale, taper, weaning, and management. Reference list of identified literature was searched for additional references as well as www.clinicaltrials.gov . STUDY SELECTION AND DATA EXTRACTION We restricted articles to those in English and dealing with humans. DATA SYNTHESIS We identified 2 validated pediatric critically ill opioid withdrawal assessment tools: (1) Withdrawal Assessment Tool-Version 1 (WAT-1) and (2) Sophia Observation Withdrawal Symptoms Scale (SOS). Neither tool differentiated between opioid and benzodiazepine withdrawal. WAT-1 was evaluated in critically ill adults but not found to be valid. No other adult tool was identified. For management, we identified 5 randomized controlled trials, 2 prospective studies, and 2 systematic reviews. Most studies were small and only 2 studies utilized a validated assessment tool. Enteral methadone, α-2 agonists, and protocolized weaning were studied. CONCLUSION We identified 2 validated assessment tools for pediatric intensive care unit patients; no valid tool for adults. Management strategies tested in small trials included methadone, α-2 agonists, and protocolized sedation/weaning. We challenge researchers to create validated tools assessing specifically for opioid withdrawal in critically ill children and adults to direct management.
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Affiliation(s)
- Ada W Chiu
- 1 Peace Arch Hospital, Fraser Health Authority, White Rock, British Columbia, Canada
| | - Sofia Contreras
- 2 Hospital Universitari de Bellvitge, L'Hospitalet de Llobretat, Barcelona, Spain
| | - Sangeeta Mehta
- 3 Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada
| | - Jennifer Korman
- 3 Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada
| | - Marc M Perreault
- 4 The Montreal General Hospital-McGill University Health Center, Montreal, Quebec, Canada
| | - David R Williamson
- 5 Université de Montréal, Montreal, Quebec, Canada.,6 Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | - Lisa D Burry
- 3 Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada.,7 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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Withdrawal Assessment Tool-1 Monitoring in PICU: A Multicenter Study on Iatrogenic Withdrawal Syndrome. Pediatr Crit Care Med 2017; 18:e86-e91. [PMID: 28157809 DOI: 10.1097/pcc.0000000000001054] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Withdrawal syndrome is an adverse reaction of analgesic and sedative therapy, with a reported occurrence rate between 17% and 57% in critically ill children. Although some factors related to the development of withdrawal syndrome have been identified, there is weak evidence for the effectiveness of preventive and therapeutic strategies. The main aim of this study was to evaluate the frequency of withdrawal syndrome in Italian PICUs, using a validated instrument. We also analyzed differences in patient characteristics, analgesic and sedative treatment, and patients' outcome between patients with and without withdrawal syndrome. DESIGN Observational multicenter prospective study. SETTING Eight Italian PICUs belonging to the national PICU network Italian PICU network. PATIENTS One hundred thirteen patients, less than 18 years old, mechanically ventilated and treated with analgesic and sedative therapy for five or more days. They were admitted in PICU from November 2012 to May 2014. INTERVENTIONS Symptoms of withdrawal syndrome were monitored with Withdrawal Assessment Tool-1 scale. MEASUREMENTS AND MAIN RESULTS The occurrence rate of withdrawal syndrome was 64.6%. The following variables were significantly different between the patients who developed withdrawal syndrome and those who did not: type, duration, and cumulative dose of analgesic therapy; duration and cumulative dose of sedative therapy; clinical team judgment about analgesia and sedation's difficulty; and duration of analgesic weaning, mechanical ventilation, and PICU stay. Multivariate logistic regression analysis revealed that patients receiving morphine as their primary analgesic were 83% less likely to develop withdrawal syndrome than those receiving fentanyl or remifentanil. CONCLUSIONS Withdrawal syndrome was frequent in PICU patients, and patients with withdrawal syndrome had prolonged hospital treatment. We suggest adopting the lowest effective dose of analgesic and sedative drugs and frequent reevaluation of the need for continued use. Further studies are necessary to define common preventive and therapeutic strategies.
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Knowing Risk Factors for Iatrogenic Withdrawal Syndrome in Children May Still Leave Us Empty-Handed*. Crit Care Med 2017; 45:141-142. [DOI: 10.1097/ccm.0000000000002160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals. Intensive Care Med 2016; 42:972-86. [PMID: 27084344 PMCID: PMC4846705 DOI: 10.1007/s00134-016-4344-1] [Citation(s) in RCA: 241] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 03/23/2016] [Indexed: 01/12/2023]
Abstract
Background This position statement provides clinical recommendations for the assessment of pain, level of sedation, iatrogenic withdrawal syndrome and delirium in critically ill infants and children. Admission to a neonatal or paediatric intensive care unit (NICU, PICU) exposes a child to a series of painful and stressful events. Accurate assessment of the presence of pain and non-pain-related distress (adequacy of sedation, iatrogenic withdrawal syndrome and delirium) is essential to good clinical management and to monitoring the effectiveness of interventions to relieve or prevent pain and distress in the individual patient. Methods A multidisciplinary group of experts was recruited from the members of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). The group formulated clinical questions regarding assessment of pain and non-pain-related distress in critically ill and nonverbal children, and searched the PubMed/Medline, CINAHL and Embase databases for studies describing the psychometric properties of assessment instruments. Furthermore, level of evidence of selected studies was assigned and recommendations were formulated, and grade or recommendations were added on the basis of the level of evidence. Results An ESPNIC position statement was drafted which provides clinical recommendations on assessment of pain (n = 5), distress and/or level of sedation (n = 4), iatrogenic withdrawal syndrome (n = 3) and delirium (n = 3). These recommendations were based on the available evidence and consensus amongst the experts and other members of ESPNIC. Conclusions This multidisciplinary ESPNIC position statement guides professionals in the assessment and reassessment of the effectiveness of treatment interventions for pain, distress, inadequate sedation, withdrawal syndrome and delirium. Electronic supplementary material The online version of this article (doi:10.1007/s00134-016-4344-1) contains supplementary material, which is available to authorized users.
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Abdouni R, Reyburn-Orne T, Youssef TH, Haddad IY, Gerkin RD. Impact of a Standardized Treatment Guideline for Pediatric Iatrogenic Opioid Dependence: A Quality Improvement Initiative. J Pediatr Pharmacol Ther 2016; 21:54-65. [PMID: 26997929 DOI: 10.5863/1551-6776-21.1.54] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To determine whether utilization of a hospital-based clinical practice guideline for the care of pediatric iatrogenic opioid dependence (IOD) would promote a decrease in opioid exposure and improve management of opioid abstinence syndrome (AS). METHODS This study is a retrospective chart review of critically ill patients from a tertiary care children's hospital. Inclusion criteria included mechanically ventilated patients up to 18 years of age who received continuous opioid infusions for at least 7 days and any length of methadone administration. Data on IOD patients from January 2005 to June 2010 was divided into 3 periods: baseline, phase 1, and phase 2. Primary outcome was decrease in opioid exposure, measured by methadone duration of use and any additional opioid bolus doses used in AS management. Documentation of additional opioid bolus doses was regarded as a surrogate measure of AS. Secondary outcomes included total cumulative fentanyl dose, continuous fentanyl infusion duration of use, and hospital and pediatric intensive care unit length of stay. RESULTS There was a significant decrease in methadone duration of use in IOD patients from 15.3 ± 8.7 days at baseline to 9.5 ± 3.7 days during phase 1 (p = 0.002), to 8.1 ± 3.7 days on phase 2 (reduction not significant, p = 0.106) of this evaluation. Additional opioid bolus doses were significantly lower from baseline to phase 1 (5.5 ± 5.1 vs. 1.8 ± 2.3, p = 0.001) and from phase 1 to phase 2 (1.8 ± 2.3 vs. 0.2 ± 1.5, p = 0.003). For the remaining outcomes, differences were not observed among the evaluation periods, except for the total cumulative fentanyl dose, which was reduced from 2.8 ± 3.7 mg/kg at baseline to 1 ± 1 mg/kg only during phase 1 (p = 0.017). CONCLUSIONS Introduction of a standardized, hospital-based clinical practice guideline for children with IOD reduced the length of exposure to opioids and improved opioid AS management.
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Affiliation(s)
| | | | - Tarek H Youssef
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Vet NJ, Kleiber N, Ista E, de Hoog M, de Wildt SN. Sedation in Critically Ill Children with Respiratory Failure. Front Pediatr 2016; 4:89. [PMID: 27606309 PMCID: PMC4995367 DOI: 10.3389/fped.2016.00089] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 08/09/2016] [Indexed: 01/08/2023] Open
Abstract
This article discusses the rationale of sedation in respiratory failure, sedation goals, how to assess the need for sedation as well as effectiveness of interventions in critically ill children, with validated observational sedation scales. The drugs and non-pharmacological approaches used for optimal sedation in ventilated children are reviewed, and specifically the rationale for drug selection, including short- and long-term efficacy and safety aspects of the selected drugs. The specific pharmacokinetic and pharmacodynamic aspects of sedative drugs in the critically ill child and consequences for dosing are presented. Furthermore, we discuss different sedation strategies and their adverse events, such as iatrogenic withdrawal syndrome and delirium. These principles can guide clinicians in the choice of sedative drugs in pediatric respiratory failure.
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Affiliation(s)
- Nienke J Vet
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Niina Kleiber
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Erwin Ista
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Matthijs de Hoog
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Saskia N de Wildt
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pharmacology and Toxicology, Radboud University, Nijmegen, Netherlands
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Whelan KT, Heckmann MK, Lincoln PA, Hamilton SM. Pediatric Withdrawal Identification and Management. J Pediatr Intensive Care 2015; 4:73-78. [PMID: 31110855 DOI: 10.1055/s-0035-1556749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Sedation administered by continuous intravenous infusion is commonly used in the pediatric intensive care unit to facilitate and maintain safe care of children during critical illness. Prolonged use of sedatives, including opioids, benzodiazepines, and potentially other adjunctive agents, is known to cause withdrawal symptoms when they are stopped abruptly or weaned quickly. In this review, the common signs and symptoms of opioid, benzodiazepine, and dexmedetomidine withdrawal will be discussed. Current tools used to measure withdrawal objectively, as well as withdrawal prevention and management strategies, will be discussed.
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Affiliation(s)
- Katherine T Whelan
- Division of Cardiac Intensive Care, Department of Cardiovascular/Critical Care Nursing, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Maura K Heckmann
- Division of Critical Care, Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Patricia A Lincoln
- Department of Cardiovascular/Critical Care Nursing, Cardiovascular Intensive Care Unit, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Susan M Hamilton
- Department of Cardiovascular/Critical Care Nursing, Medical Surgical Intensive Care Unit, Boston Children's Hospital, Boston, Massachusetts, United States
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Keogh SJ, Long DA, Horn DV. Practice guidelines for sedation and analgesia management of critically ill children: a pilot study evaluating guideline impact and feasibility in the PICU. BMJ Open 2015; 5:e006428. [PMID: 25823444 PMCID: PMC4386214 DOI: 10.1136/bmjopen-2014-006428] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIMS The aim of this study was to develop and implement guidelines for sedation and analgesia management in the paediatric intensive care unit (PICU) and evaluate the impact, feasibility and acceptability of these as part of a programme of research in this area and as a prelude to future trial work. METHOD This pilot study used a pre-post design using a historical control. SETTING Two PICUs at different hospitals in an Australian metropolitan city. PARTICIPANTS Patients admitted to the PICU and ventilated for ≥24 h, aged more than 1 month and not admitted for seizure management or terminal care. INTERVENTION Guidelines for sedation and analgesia management for critically ill children including algorithm and assessment tools. OUTCOME VARIABLES In addition to key outcome variables (ventilation time, medication dose and duration, length of stay), feasibility outcomes data (recruitment, data collection, safety) were evaluated. Guideline adherence was assessed through chart audit and staff were surveyed about merit and the use of guidelines. RESULTS The guidelines were trialled for a total of 12 months on 63 patients and variables compared with the historical control group (n=75). Analysis revealed differences in median Morphine infusion duration between groups (pretest 3.63 days (87 h) vs post-test 2.83 days (68 h), p=0.05) and maximum doses (pretest 120 μg/kg/h vs post-test 97.5 μg/kg/h) with no apparent change to ventilation duration. Chart audit revealed varied use of tools, but staff were positive about the guidelines and their use in practice. CONCLUSIONS The sedation guidelines impacted on the duration and dosage of agents without any apparent impact on ventilation duration or length of stay. Furthermore, the guidelines appeared to be feasible and acceptable in clinical practice. The results of the study have laid the foundation for follow-up studies in withdrawal from sedation, point prevalence and longitudinal studies of sedation practices as well as drug trial work.
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Affiliation(s)
- Samantha J Keogh
- Nursing Research Services, Royal Children's Hospital, Brisbane, Queensland, Australia
- NHMRC Centre of Research Excellence in Nursing (NCREN)—Centre for Health Practice Innovation—Griffith Health Institute, Griffith University, Nathan, Australia
| | - Debbie A Long
- Paediatric Intensive Care Unit, Royal Children's Hospital, Brisbane, Queensland, Australia
- NHMRC Centre of Research Excellence in Nursing (NCREN)—Centre for Health Practice Innovation—Griffith Health Institute, Griffith University, Nathan, Australia
| | - Desley V Horn
- Paediatric Intensive Care Unit, Royal Children's Hospital, Brisbane, Queensland, Australia
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Risk factors associated with iatrogenic opioid and benzodiazepine withdrawal in critically ill pediatric patients: a systematic review and conceptual model. Pediatr Crit Care Med 2015; 16:175-83. [PMID: 25560429 PMCID: PMC5304939 DOI: 10.1097/pcc.0000000000000306] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Analgesia and sedation are common therapies in pediatric critical care, and rapid titration of these medications is associated with iatrogenic withdrawal syndrome. We performed a systematic review of the literature to identify all common and salient risk factors associated with iatrogenic withdrawal syndrome and build a conceptual model of iatrogenic withdrawal syndrome risk in critically ill pediatric patients. DATA SOURCES Multiple databases, including PubMed/Medline, EMBASE, CINAHL, and the Cochrane Central Registry of Clinical Trials, were searched using relevant terms from January 1, 1980, to August 1, 2014. STUDY SELECTION Articles were included if they were published in English and discussed iatrogenic withdrawal syndrome following either opioid or benzodiazepine therapy in children in acute or intensive care settings. Articles were excluded if subjects were neonates born to opioid- or benzodiazepine-dependent mothers, children diagnosed as substance abusers, or subjects with cancer-related pain; if data about opioid or benzodiazepine treatment were not specified; or if primary data were not reported. DATA EXTRACTION In total, 1,395 articles were evaluated, 33 of which met the inclusion criteria. To facilitate analysis, all opioid and/or benzodiazepine doses were converted to morphine or midazolam equivalents, respectively. A table of evidence was developed for qualitative analysis of common themes, providing a framework for the construction of a conceptual model. The strongest risk factors associated with iatrogenic withdrawal syndrome include duration of therapy and cumulative dose. Additionally, evidence exists linking patient, process, and system factors in the development of iatrogenic withdrawal syndrome. FINDINGS Most articles were prospective observational or interventional studies. CONCLUSIONS Given the state of existing evidence, well-designed prospective studies are required to better characterize iatrogenic withdrawal syndrome in critically ill pediatric patients. This review provides data to support the construction of a conceptual model of iatrogenic withdrawal syndrome risk that, if supported, could be useful in guiding future research.
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Amigoni A, Vettore E, Brugnolaro V, Brugnaro L, Gaffo D, Masola M, Marzollo A, Pettenazzo A. High doses of benzodiazepine predict analgesic and sedative drug withdrawal syndrome in paediatric intensive care patients. Acta Paediatr 2014; 103:e538-43. [PMID: 25131427 DOI: 10.1111/apa.12777] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 03/30/2014] [Accepted: 08/13/2014] [Indexed: 01/02/2023]
Abstract
AIM Critically ill children can develop withdrawal syndrome after prolonged analgesia and sedation in a paediatric intensive care unit (PICU), when treatment is stopped abruptly or reduced quickly. The aim of this study was to evaluate the incidence of withdrawal syndrome in patients after three or more days of analgesic or sedative drug therapy, using a validated scale. We also analysed the association between withdrawal syndrome and the patients' outcome and factors related to analgesia and sedation treatment. METHODS This prospective observational study analysed 89 periods of weaning from analgesia and sedation in 60 children between October 2010 and October 2011. Of these, 65% were less than six months old and 45% were admitted to the PICU after heart surgery. Withdrawal syndrome was assessed using the Withdrawal Assessment Tool-1 (WAT-1) scale. RESULTS The incidence of withdrawal syndrome was 37%, and the only variable that predicted its presence was the highest administered dose of benzodiazepine. The duration of weaning, Sophia Observational Withdrawal Symptom scale score and nurse judgment were also associated with positive WAT-1 scores. CONCLUSION Withdrawal syndrome should be considered after three or more days of analgesic or sedative treatment. A high dose of benzodiazepine increases the risk of developing withdrawal symptoms.
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Affiliation(s)
- A Amigoni
- Pediatric Intensive Care Unit; Department of Pediatrics; University-Hospital; Padua Italy
| | - E Vettore
- Department of Pediatrics; University-Hospital; Padua Italy
| | - V Brugnolaro
- Department of Pediatrics; University-Hospital; Padua Italy
| | - L Brugnaro
- Education and Training Department; University-Hospital; Padua Italy
| | - D Gaffo
- Pediatric Intensive Care Unit; Department of Pediatrics; University-Hospital; Padua Italy
| | - M Masola
- Pediatric Intensive Care Unit; Department of Pediatrics; University-Hospital; Padua Italy
| | - A Marzollo
- Pediatric Intensive Care Unit; Department of Pediatrics; University-Hospital; Padua Italy
| | - A Pettenazzo
- Pediatric Intensive Care Unit; Department of Pediatrics; University-Hospital; Padua Italy
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Giby K, Vaillancourt R, Varughese N, Vadeboncoeur C, Pouliot A. Use of methadone for opioid weaning in children: prescribing practices and trends. Can J Hosp Pharm 2014; 67:149-56. [PMID: 24799725 DOI: 10.4212/cjhp.v67i2.1342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Kazim Giby
- , BSc, is with the Pharmacy Department, Children's Hospital of Eastern Ontario, and the University of Ottawa, Ottawa, Ontario
| | - Régis Vaillancourt
- , OMM, CD, BPharm, PharmD, FCSHP, FFIP, is with the Pharmacy Department, Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Nisha Varughese
- , PharmD, is with the Pharmacy Department, Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Christina Vadeboncoeur
- , MD, is with the Pediatric Palliative Care Outreach Team, Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Annie Pouliot
- , PhD, is with the Pharmacy Department, Children's Hospital of Eastern Ontario, Ottawa, Ontario
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Abstract
The interplay of pain, discomfort, and fear can cause agitation in critically ill children. Therefore, sedation and analgesia are essential components in the intensive care unit setting and are best managed with a multidisciplinary team approach. No one standard approach exists to assess and manage pain and anxiety. Many tools are available for the assessment of pain and sedation, but each tool has its advantages and disadvantages. Clinicians should consider adopting a validated tool for routine continuous assessment. Multiple pharmacological therapies are available to manage pain, anxiety, fear, and agitation. Dosing of these agents can be influenced by age-related pharmacokinetic and pharmacodynamic changes. Agents should be selected on the basis of the child's disease state, desired level of sedation, and cardiac and respiratory status.
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Psychometric evaluation of the Sophia Observation withdrawal symptoms scale in critically ill children. Pediatr Crit Care Med 2013; 14:761-9. [PMID: 23962832 DOI: 10.1097/pcc.0b013e31829f5be1] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The Sophia Observation withdrawal Symptoms scale is an instrument for screening benzodiazepine and opioid withdrawal syndrome in pediatric critical care patients. The objectives of this study were to establish cutoff scores and to test sensitivity to change. Second, risk factors for withdrawal syndrome were explored. DESIGN Prospective observational study with repeated measures. SETTING Level IV ICU at a university children's hospital. PATIENTS A total of 154 children with median age 5 months (interquartile range, 0-42 mo) who received continuous infusion of benzodiazepines and/or opioids for 5 or more days. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Nurses repeatedly applied the Sophia Observation withdrawal Symptoms scale and the Numeric Rating Scale withdrawal when children were weaned off benzodiazepines and opioids. The latter represents the nurse's expert opinion. We analyzed 3,754 paired assessments; the median number per child was 15 (interquartile range, 7-31) over a median of 5 days (interquartile range, 3-11 d). Sensitivity and specificity were 0.83 and 0.93, respectively, for the Sophia Observation withdrawal Symptoms scale cutoff score of 4 or higher against a Numeric Rating Scale-withdrawal score of 4 or higher. Sensitivity to change was determined by comparing 156 Sophia Observation withdrawal Symptoms scale assessments (n = 51 patients) before and after additional sedatives or opioids. Multilevel regression analysis showed a mean decline of 1.5 points (at score range 0-15) after intervention (p < 0.0001). Logistic regression analysis identified duration of preweaning of midazolam, duration of weaning of midazolam, duration of preweaning of morphine, duration of weaning of morphine, and number of additional sedatives/opioids as statistically significant risk factors for withdrawal syndrome in these children. CONCLUSIONS The Sophia Observation withdrawal Symptoms scale is a valid tool with good psychometric properties to assess withdrawal symptoms in PICU patients.
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Abstract
PURPOSE OF REVIEW This review will summarize the symptoms, evaluation, and treatment of neonatal and iatrogenic withdrawal syndromes. RECENT FINDINGS Buprenorphine is emerging as the drug of choice for maintaining opioid-dependent women during pregnancy, because of its association with less severe withdrawal symptoms. Recent findings suggest it may be the drug of choice for treating the opioid-exposed neonate as well. SUMMARY Healthcare workers should be cognizant of the risk factors for neonatal abstinence syndrome (NAS), as well as its symptoms, so that nonpharmalogic and pharmacologic therapies can be initiated. With increased emphasis on pain control in children, it is likely that iatrogenic withdrawal will continue to be a concern, and healthcare workers should understand the similarities and differences between this and NAS.
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Vega L, Sanchez-de-Toledo J, Gran F, Ortega J, Pujol M, Balcells J. Prevención del síndrome de abstinencia en el postoperatorio de trasplante cardiaco: utilidad de la dexmedetomidina. Rev Esp Cardiol 2013. [DOI: 10.1016/j.recesp.2013.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Prevention of opioid withdrawal syndrome after pediatric heart transplantation: usefulness of dexmedetomidine. ACTA ACUST UNITED AC 2013; 66:593-5. [PMID: 24776215 DOI: 10.1016/j.rec.2013.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 01/25/2013] [Indexed: 11/20/2022]
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Gamble C, Wolf A, Sinha I, Spowart C, Williamson P. The role of systematic reviews in pharmacovigilance planning and Clinical Trials Authorisation application: example from the SLEEPS trial. PLoS One 2013; 8:e51787. [PMID: 23554852 PMCID: PMC3598865 DOI: 10.1371/journal.pone.0051787] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 11/07/2012] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Adequate sedation is crucial to the management of children requiring assisted ventilation on Paediatric Intensive Care Units (PICU). The evidence-base of randomised controlled trials (RCTs) in this area is small and a trial was planned to compare midazolam and clonidine, two sedatives widely used within PICUs neither of which being licensed for that use. The application to obtain a Clinical Trials Authorisation from the Medicines and Healthcare products Regulatory Agency (MHRA) required a dossier summarising the safety profiles of each drug and the pharmacovigilance plan for the trial needed to be determined by this information. A systematic review was undertaken to identify reports relating to the safety of each drug. METHODOLOGY/PRINCIPAL FINDINGS The Summary of Product Characteristics (SmPC) were obtained for each sedative. The MHRA were requested to provide reports relating to the use of each drug as a sedative in children under the age of 16. Medline was searched to identify RCTs, controlled clinical trials, observational studies, case reports and series. 288 abstracts were identified for midazolam and 16 for clonidine with full texts obtained for 80 and 6 articles respectively. Thirty-three studies provided data for midazolam and two for clonidine. The majority of data has come from observational studies and case reports. The MHRA provided details of 10 and 3 reports of suspected adverse drug reactions. CONCLUSIONS/SIGNIFICANCE No adverse reactions were identified in addition to those specified within the SmPC for the licensed use of the drugs. Based on this information and the wide spread use of both sedatives in routine practice the pharmacovigilance plan was restricted to adverse reactions. The Clinical Trials Authorisation was granted based on the data presented in the SmPC and the pharmacovigilance plan within the clinical trial protocol restricting collection and reporting to adverse reactions.
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Affiliation(s)
- Carrol Gamble
- Clinical Trials Research Centre, University of Liverpool, Liverpool, Merseyside, United Kingdom.
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de Graaf J, van Lingen RA, Valkenburg AJ, Weisglas-Kuperus N, Jebbink LG, Wijnberg-Williams B, Anand KJS, Tibboel D, van Dijk M. Does neonatal morphine use affect neuropsychological outcomes at 8 to 9 years of age? Pain 2012; 154:449-458. [PMID: 23352760 DOI: 10.1016/j.pain.2012.12.006] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 11/22/2012] [Accepted: 12/06/2012] [Indexed: 10/27/2022]
Abstract
Morphine is widely used to treat severe pain in neonatal intensive care unit patients. Animal studies suggest adverse long-term side effects of neonatal morphine, but a follow-up study of 5-year-old children who participated in a morphine-placebo controlled trial as newborns found no such effects on the child's general functioning. This study indicated that morphine may negatively affect response inhibition, a domain of executive functions. Therefore, we performed a second follow-up study in the same population at the age of 8 to 9 years, focused on the child's general functioning in terms of intelligence, visual motor integration, and behavior and on executive functions. Children in the morphine group showed significantly less externalizing problems according to the parents but more internalizing behavior according to the teachers, but only after adjustment for intelligence quotient (IQ), potential confounders using a propensity score, and additional open-label morphine. Morphine-treated children showed significantly fewer problems with executive functions in daily life as rated by parents for the subscales inhibition and organization of materials and for planning/organizing as rated by the teachers. After adjustment for IQ and the propensity score, executive functioning as rated by the parents remained statistically significantly better in the morphine-treated group. The influence of the additional morphine given was not of a significant influence for any of the outcome variables. Overall, the present study demonstrates that continuous morphine infusion of 10 μg/kg/h during the neonatal period does not harm general functioning and may even have a positive influence on executive functions at 8 to 9 years.
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Affiliation(s)
- Joke de Graaf
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands Princess Amalia Department of Pediatrics, Department of Neonatology, Isala Clinics, Zwolle, The Netherlands Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands Department of Medical Psychology, Isala Clinics, Zwolle, The Netherlands Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
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Pentobarbital withdrawal and treatment in an infant in the pediatric cardiac intensive care unit. J Clin Anesth 2012; 25:62-5. [PMID: 23246494 DOI: 10.1016/j.jclinane.2012.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 05/14/2012] [Accepted: 06/04/2012] [Indexed: 11/23/2022]
Abstract
Withdrawal syndromes following administration of sedative and analgesic infusions represent a significant morbidity that is described increasingly in the pediatric critical care literature. However, there are few descriptions of pentobarbital withdrawal symptoms and their treatment in the pediatric population. We describe an infant receiving multiple sedative and analgesic medications, including pentobarbital, who was resistant to our institution's standard weaning protocol, but whose severe withdrawal symptoms responded dramatically to phenobarbital loading and maintenance.
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Heil SH, Gaalema DE, Johnston AM, Sigmon SC, Badger GJ, Higgins ST. Infant pupillary response to methadone administration during treatment for neonatal abstinence syndrome: a feasibility study. Drug Alcohol Depend 2012; 126:268-71. [PMID: 22682657 PMCID: PMC3467317 DOI: 10.1016/j.drugalcdep.2012.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 05/07/2012] [Accepted: 05/08/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Pupil diameter is a frequently assessed objective index of the pharmacodynamic effects of opioids in adults, but to our knowledge has never been examined in infants. Such a measure could improve assessment and treatment of neonates exposed to opioids in utero. The present study examined changes in pupil diameter after opioid administration in opioid-exposed infants who required pharmacological treatment for neonatal abstinence syndrome (NAS) to test the feasibility of using pupil diameter as a measure of opioid effects in these infants. METHODS Ten infants (2-7 days old) receiving methadone (0.4-0.5 mg every 12 h) for the treatment of NAS participated. A picture of one of each infant's eyes was taken under controlled illumination conditions with a standard digital camera just prior to dosing and 0-1, 2-4, 5-7, and 8-10h after dosing. The diameters of the pupil and iris were measured and relative pupil diameter (pupil diameter expressed as a percentage of iris diameter) was analyzed. RESULTS Mean (±SE) relative pupil diameter decreased significantly after dosing from 41±2% to 29±2%. After dosing, a significant increasing linear trend was observed over time, with values of 29±2%, 33±3%, 38±3%, and 41±3% at 0-1, 2-4, 5-7, and 8-10h after dosing. CONCLUSIONS Infant pupils respond to opioid administration in the same sensitive, orderly manner as is commonly observed in adults. Pupil diameter appears to be an objective, sensitive measure of neonatal response to opioids that may be a useful complement to, or perhaps at times a replacement for, observer-rated scale scores.
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Affiliation(s)
- Sarah H Heil
- Department of Psychiatry, University of Vermont, USA.
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Buijs EAB, Zwiers AJM, Ista E, Tibboel D, de Wildt SN. Biomarkers and clinical tools in critically ill children: are we heading toward tailored drug therapy? Biomark Med 2012; 6:239-57. [PMID: 22731898 DOI: 10.2217/bmm.12.28] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
In pediatric critical care, validated biomarkers are essential for guiding drug therapy. The aim of this article is to present examples of current biomarker developments in its full breadth, including biochemical substances, physiological measurements and clinical scoring tools, with a focus on the field of circulatory, renal and neurophysiologic failure. Within each field we consecutively discuss the rationale for the selected biomarkers, studies in critically ill children, biomarker validation stage and biomarker use or potential use in drug studies and clinical drug dosing. This article demonstrates that there is paucity of properly validated biomarkers. Nevertheless, recent developments in, for instance, the field of sepsis, point us toward a future wherein, for critically ill children, drug therapy may be personalized using proteomic profiling instead of a small number of biomarkers, in order to establish a personal and dynamic disease profile.
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Affiliation(s)
- Erik A B Buijs
- Intensive Care & Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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