A prospective study of adverse reactions to the weaning of opioids and benzodiazepines among critically ill children

Impact of Intravenous Methadone Dosing Schedule on Iatrogenic Withdrawal Syndrome in a Pediatric Intensive Care Unit

OBJECTIVE

To compare median Sophia Observation withdrawal Symptoms scale (SOS) scores between -intravenous methadone dosing scheduled every 6 hours or every 8 hours for iatrogenic withdrawal -syndrome (IWS).

METHODS

This single-center, retrospective chart review evaluated patients aged 4 weeks through 18 years treated with intravenous methadone for IWS. Children admitted to the pediatric intensive care unit (PICU) of a tertiary care children's hospital between August 2017 and July 2021 and treated for IWS for at least 48 hours were eligible for inclusion. Methadone dosing schedules were compared, with a primary outcome of median Sophia Observation withdrawal Symptoms (SOS) score during the first 24 hours after cessation of continuous fentanyl infusion. Secondary outcomes included PICU and general pediatric unit lengths of stay, extubation failure rates, and mortality.

RESULTS

Twenty patients met inclusion criteria, with 9 in the 6-hour dosing group. There was no difference in median SOS score, extubation failure, length of stay, or mortality between the 2 groups.

CONCLUSIONS

During the first 24 hours after cessation of continuous fentanyl, there appears to be no -difference in IWS severity, as determined by bedside nurse scoring, between patients treated with -intravenous methadone every 6 hours compared with every 8 hours.

Acute Pain Management Protocols in Pediatric Intensive Care Units

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.

Sedation Weaning Initiative Targeting Methadone Exposure: Single Center Improvements in Withdrawal Symptoms and Hospital Length of Stay for Pediatric Cardiac Critical Care

OBJECTIVES

Sedation and pain medications are necessary in the management of postoperative pediatric cardiac patients. Prolonged exposure to these medications can lead to negative side effects including withdrawal. We hypothesized that standardized weaning guidelines would decrease exposure to sedation medications and decrease withdrawal symptoms. The primary aim was to decrease average days of methadone exposure to within goal for moderate- and high-risk patients within 6 months.

DESIGN

Quality improvement methods were used to standardize sedation medication weaning in a pediatric cardiac ICU.

SETTING

This study took place at Duke Children's Hospital Pediatric Cardiac ICU in Durham, North Carolina from January 1, 2020, to December 31, 2021.

PATIENTS

Children less than 12 months old admitted to the pediatric cardiac ICU who underwent cardiac surgery.

INTERVENTIONS

Sedation weaning guidelines were implemented over the course of 12 months. Data were tracked every 6 months and compared with the 12 months pre-intervention. Patients were stratified into low, moderate, and high risk withdrawal categories based on duration of opioid infusion exposure.

MEASUREMENTS AND MAIN RESULTS

Total sample size was 94 patients in the moderate and high risk categories. Process measures included documentation of Withdrawal Assessment Tool scores and appropriate methadone prescription in patients which increased to 100% post-intervention. For outcome measures, we observed decreased dexmedetomidine infusion duration, decreased methadone wean duration, decreased frequency of elevated Withdrawal Assessment Tool scores, and decreased hospital length of stay post-intervention. For the primary aim, methadone wean duration consistently decreased after each study period. Our intervention did not adversely impact balancing measures.

CONCLUSIONS

A quality improvement initiative to standardize sedation weaning in a Pediatric Cardiac ICU was successfully implemented and was correlated with decreased duration of sedation medications, decreased withdrawal scores, and decreased length of stay.

Validation of the withdrawal assessment tool-1 (WAT-1) in pediatric cardiovascular patients on an inpatient unit

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.

Safety and effectiveness of parent- or nurse-controlled analgesia in neonates: a systematic review

OBJECTIVE

The aim of this systematic review was to determine the safety and effectiveness of parent- or nurse-controlled analgesia on neonatal patient outcomes. More specifically, the objective was to determine the effect of parent- or nurse-controlled analgesia on neonatal pain scores, analgesic use, and incidence of iatrogenic withdrawal syndrome, as well as any opioid-associated adverse events.

INTRODUCTION

Despite recent innovations in neonatology leading to significant improvements in short- and long-term outcomes for newborns requiring intensive care, optimal management of pain and distress remains a challenge for the treating multidisciplinary team. The inability of neonates to communicate pain easily, inconsistent practice among health professionals, insufficient analgesic prescriptions, and delays in medical reviews all impact effective pain management. Exploring the effect of parent- or nurse-controlled analgesia may identify a modality that negates these concerns and improves the pharmacological management of pain in newborns.

INCLUSION CRITERIA

This review considered experimental and observational studies evaluating the safety and effectiveness of parent- or nurse-controlled analgesia that included babies born at 23 weeks' gestation to four weeks post-term. The interventions considered for inclusion were any type of analgesia delivered by an infusion pump that allowed bolus dosing or a continuous analgesic infusion with bolus dosing as required. Studies using algorithms and protocols to guide timing and dosage were eligible for inclusion. Comparators included the standard management of pain for neonates in the newborn intensive care unit. A modification to the a priori protocol was made to include all neonates nursed outside of a neonatal intensive care unit to ensure all studies that examined the use of parent- or nurse-controlled analgesia in the neonatal population were included in the review.

METHODS

An extensive search of six major databases was conducted (CINAHL, Cochrane Library, Embase, PubMed, PsycINFO, and Web of Science). Studies published from 1997 to 2020 in English were considered for inclusion in this review. Databases searched for unpublished studies included MedNar and ProQuest Dissertations and Theses.

RESULTS

Fourteen studies were included in this review: two randomized controlled trials, six quasi-experimental studies, one case-control study, and five case series. There was considerable heterogeneity in the interventions and study outcome measures within the studies, resulting in an inability to statistically pool results. The small sample sizes and inability to distinguish data specific to neonates in six of the studies resulted in low quality of evidence for the safety and effectiveness of parent- or nurse-controlled analgesia in neonates. However, studies reporting neonatal data demonstrated low pain scores and a trend in reduced opioid consumption when parent- or nurse-controlled analgesia was used.

CONCLUSIONS

The use of parent- or nurse-controlled analgesia in the neonatal population has shown some effect in reducing the amount of opioid analgesia required without compromising pain relief or increasing the risk of adverse events. Due to the paucity of evidence available, certainty of the results is compromised; therefore, larger trials exploring the use of parent- or nurse-controlled analgesia in neonates and the development of nurse-led models for analgesia delivery are needed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018114382.

Efficacy of an Oxycodone-Propofol Combination versus a Fentanyl-Propofol Combination in Conscious Sedation during Therapeutic Endoscopic Retrograde Cholangiopancreatography in Elderly Patients

BACKGROUND

With a rapidly aging population, the need for endoscopic retrograde cholangiopancreatography (ERCP) is increasing. The commonly used sedation anesthesia in ERCP is a combination of propofol and fentanyl, even though fentanyl may cause some adverse reactions such as respiratory depression.

OBJECTIVES

This study aimed to evaluate the efficacy of oxycodone combined with propofol versus fentanyl combined with propofol for sedation anesthesia during ERCP.

METHODS

A total of 193 patients aged from 65 to 80 years undergoing ERCP were enrolled and randomized into two groups: an "oxycodone combined with propofol" group (group OP, n = 97) and a "fentanyl combined with propofol" group (group FP, n = 96). The rate of perioperative adverse events as well as the recovery time, patients' satisfaction, and endoscopists' satisfaction were noted.

RESULTS

There was no difference in the frequency of hypotension or bradycardia between the two groups, but there were more episodes of desaturation (SpO2 <90% for >10 s in 8.3%), postoperative nausea (7.3%), and vomiting (5.2%) in group FP than in group OP. Patients' satisfaction in group FP was lower than that in group OP. The recovery time was longer in group FP than in group OP.

CONCLUSIONS

Oxycodone combined with propofol was effective in ERCP, with a low incidence of perioperative adverse events.

The Impact of a Clonidine Transition Protocol on Dexmedetomidine Withdrawal in Critically Ill Pediatric Patients

OBJECTIVES

This study describes our experience with a clonidine transition protocol to prevent dexmedetomidine (DEX) withdrawal in critically ill pediatric patients.

METHODS

Retrospective review of electronic medical records of patients in the pediatric intensive care unit of a single tertiary children's hospital. All patients up to 19 years of age, who received concomitant DEX infusion and enteral clonidine between June 1, 2016, and May 31, 2018, were included.

RESULTS

Two of 24 encounters had DEX restarted for withdrawal (8.3%). Five of 14 encounters who were transitioned to clonidine 2 mcg/kg every 6 hours required an increased dose, and 1 of 10 encounters transitioned to clonidine 4 mcg/kg every 6 hours required an increased dose (36% vs 10%, p = 0.21). For encounters with clonidine dose increases, 5 of 6 had improvements in Withdrawal Assessment Tool-1 (WAT-1) scores. Of these 5 encounters, 4 had decreasing or stable opioid and sedative requirements and 1 was transitioned to methadone. No encounters required discontinuation of clonidine owing to adverse events. Two of 24 encounters met our safety endpoint. One received a fluid bolus during the clonidine transition with no change in clonidine dosing, while the other had clonidine dose decreased for asymptomatic bradycardia.

CONCLUSIONS

The 24 encounters in our retrospective study add to the limited literature available to describe dosing, initiation time, and duration of clonidine to prevent withdrawal from DEX in critically ill pediatric patients. Further research is needed to clarify the optimal dosing and duration of clonidine to prevent DEX withdrawal in pediatric patients.

Iatrogenic Opioid Withdrawal Syndrome in Critically Ill Patients: a Retrospective Cohort Study

BACKGROUND

Opioid withdrawal syndrome (OWS) may occur following the reduction or discontinuation of opioid analgesics. In critically ill pediatric patients, OWS is a common and clinically significant condition. However, OWS in adult patients has not been assessed in detail. Therefore, we aimed to investigate the incidence, risk factors, and clinical features of OWS in mechanically ventilated patients treated in an adult intensive care unit (ICU).

METHODS

This study was a retrospective evaluation of data from patients treated in the medical ICU for > 3 days and who received only one type of opioid analgesic. OWS was assessed over a 24 hours period from discontinuation or reduction (by > 50%) of continuous opioid infusion. OWS was defined as the presence of ≥ 3 central nervous system or autonomic nervous system symptoms.

RESULTS

In 126 patients treated with remifentanil (n = 58), fentanyl (n = 47), or morphine (n = 21), OWS was seen in 31.0%, 36.2%, and 9.5% of patients, respectively (P = 0.078). The most common symptom was a change in respiratory rate (remifentanil, 94.4%; fentanyl, 76.5%; morphine, 100%). Multivariate Cox-proportional hazards model showed that OWS was negatively associated with morphine treatment (hazard ratio [HR], 0.17; 95% confidence interval [CI], 0.037-0.743) and duration of opioid infusion (HR, 0.566; 95% CI, 0.451-0.712).

CONCLUSION

OWS is not uncommon in mechanically ventilated adult patients who received continuous infusion of opioids for > 3 days. The use of morphine may be associated with a decreased risk of OWS.

Implementation of an opioid weaning protocol to improve pain management, and to prevent or decrease iatrogenic withdrawal syndrome in the neonatal intensive care

AIM

The aim of this evidence implementation project was to improve pain assessment and management of the neonate receiving an opioid infusion, and to prevent or decrease the incidence of iatrogenic withdrawal syndrome (IWS).

METHODS

The current project was carried out in two intensive care areas of a 79 bed tertiary Neonatal Unit in Australia. A pre/postaudit design was utilized. Patient charts were reviewed to collect baseline audit data on pain assessments and titration of opioids. A weaning protocol was developed and implemented along with targeted staff education to align current practice with best practice recommendations. A postimplementation audit was then conducted to evaluate changes in practice.

RESULTS

A total of 32 charts (13 pre/19 post) were reviewed to evaluate pain assessment, titration of opioids, and the identification of any signs and symptoms of IWS. The results demonstrated an improvement in the completion of pain assessments by 34%, and 100% compliance to withdrawal assessment following the introduction of an IWS assessment tool. For neonates receiving analgesics for less than 4 days, adherence to the weaning schedule occurred in 75%. No clinical signs of IWS were seen in this cohort. For neonates receiving analgesics for greater than 4 days, adherence to the weaning schedule occurred in only 55%. Of those neonates where the protocol was not followed, 67% developed clinical signs of IWS.

CONCLUSION

Although this project demonstrated improvements in pain assessment and the identification of IWS, lack of adherence to the pain management policy and weaning tool has increased awareness of the importance of collaboration within the multidisciplinary team to improve outcomes. Several barriers were identified prior to implementation and various methods were employed to overcome these. Despite this, consistency of practice and change-management remain a challenge in clinical care.

Opioid tapering and weaning protocols in pediatric critical care units: a systematic review

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.

Interprofessional Team's Perception of Care Delivery After Implementation of a Pediatric Pain and Sedation Protocol

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.

Optimising drug dosing in patients receiving extracorporeal membrane oxygenation

Optimal pharmacological management during extracorporeal membrane oxygenation (ECMO) involves more than administering drugs to reverse underlying disease. ECMO is a complex therapy that should be administered in a goal-directed manner to achieve therapeutic endpoints that allow reversal of disease and ECMO wean, minimisation of complications (treatment of complications when they do occur), early interruption of sedation and rehabilitation, maximising patient comfort and minimising risks of delirium. ECMO can alter both the pharmacokinetics (PK) and pharmacodynamics (PD) of administered drugs and our understanding of these alterations is still evolving. Based on available data it appears that modern ECMO circuitry probably has a less significant impact on PK when compared with critical illness itself. However, these findings need further confirmation in clinical population PK studies and such studies are underway. The altered PD associated with ECMO is less understood and more research is indicated. Until robust dosing guidelines become available, clinicians will have to rely on the principles of drug dosing in critically ill and known PK alterations induced by ECMO itself. This article summarises the PK alterations and makes preliminary recommendations on possible dosing approaches.

Opioid and Benzodiazepine Weaning in Pediatric Patients: Review of Current Literature

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.

Iatrogenic Opioid Withdrawal in Critically Ill Patients: A Review of Assessment Tools and Management

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.

Withdrawal Assessment Tool-1 Monitoring in PICU: A Multicenter Study on Iatrogenic Withdrawal Syndrome

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.

Implementation of a Nurse-Driven Sedation Protocol in a PICU Decreases Daily Doses of Midazolam

OBJECTIVES

To evaluate the impact of a nurse-driven sedation protocol on the length of mechanical ventilation, total daily doses of sedatives, and complications of sedation.

DESIGN

A single-center prospective before and after study was conducted from October 2010 to December 2013.

SETTING

Twelve-bed surgical and medical PICU of the university-affiliated hospital in Nantes, France.

PATIENTS

A total of 235 patients, between 28 days and 18 years old, requiring mechanical ventilation for at least 24 hours were included in the study; data from 194 patients were analyzed.

INTERVENTIONS

During the first study phase, no protocol was used. During the second phase, patients were sedated according to a nurse-driven protocol.

MEASUREMENTS AND MAIN RESULTS

In the whole population, the length of mechanical ventilation did not differ between protocol and control groups (protocol, 4 [3-8] vs control, 5 [3-7.5]; p = 0.44). Analyzing age subgroups, the length of mechanical ventilation was significantly shorter in the protocol group than in the control group in children older than 12 months (4 [3-8] vs 5 [2.75-11.25] d; p = 0.04). Daily dose of midazolam decreased during the protocol phase compared with the control phase (1 [0.56-1.8] and 1.2 [0.85-2.4] mg/kg/d, respectively; p = 0.02). No differences were shown regarding other daily dose of drugs. In the control group, 68% of children had more than 20% of COMFORT-behavior scale assessment under the target (oversedation) versus 59% in the protocol group (p = 0.139).

CONCLUSIONS

Implementation of a nurse-driven sedation protocol in a PICU is feasible and safe, allowed a decrease in daily dose of benzodiazepines, and decreased the duration of mechanical ventilation in older patients.

Importance of the use of protocols for the management of analgesia and sedation in pediatric intensive care unit

Summary Introduction: Analgesia and sedation are essential elements in patient care in the intensive care unit (ICU), in order to promote the control of pain, anxiety and agitation, prevent the loss of devices, accidental extubation, and improve the synchrony of the patient with mechanical ventilation. However, excess of these medications leads to rise in morbidity and mortality. The ideal management will depend on the adoption of clinical and pharmacological measures, guided by scales and protocols. Objective: Literature review on the main aspects of analgesia and sedation, abstinence syndrome, and delirium in the pediatric intensive care unit, in order to show the importance of the use of protocols on the management of critically ill patients. Method: Articles published in the past 16 years on PubMed, Lilacs, and the Cochrane Library, with the terms analgesia, sedation, abstinence syndrome, mild sedation, daily interruption, and intensive care unit. Results: Seventy-six articles considered relevant were selected to describe the importance of using a protocol of sedation and analgesia. They recommended mild sedation and the use of assessment scales, daily interruptions, and spontaneous breathing test. These measures shorten the time of mechanical ventilation, as well as length of hospital stay, and help to control abstinence and delirium, without increasing the risk of morbidity and morbidity. Conclusion: Despite the lack of controlled and randomized clinical trials in the pediatric setting, the use of protocols, optimizing mild sedation, leads to decreased morbidity.

Pharmacotherapy during pediatric extracorporeal membrane oxygenation: a review

INTRODUCTION

Pediatric critical illness and associated alterations in organ function can change drug pharmacokinetics (PK). Extracorporeal membrane oxygenation (ECMO), a life-saving therapy for severe cardiac and/or respiratory failure, causes additional PK alterations that affect drug disposition.

AREAS COVERED

The purposes of this review are to discuss the PK changes that occur during ECMO, the associated therapeutic implications, and to review PK literature relevant to pediatric ECMO. We discuss various classes of drugs commonly used for pediatric patients on ECMO, including sedatives, analgesics, antimicrobials and cardiovascular drugs. Finally, we discuss future areas of research and recommend strategies for future pediatric ECMO pharmacologic investigations.

EXPERT OPINION

Clinicians caring for pediatric patients treated with ECMO must have an understanding of PK alterations that could lead to either therapeutic failures or increased drug toxicity during this life-saving therapy. Limited data currently exist for optimal drug dosing in pediatric populations who are treated with ECMO. While there are clear challenges to conducting and analyzing data associated with clinical pharmacokinetic-pharmacodynamic studies of children on ECMO, we present techniques to address these challenges. Improved understanding of the physiology and drug disposition during ECMO combined with PK-PD modeling will allow for more adaptable and individualized dosing schemes.

Impact of a Standardized Treatment Guideline for Pediatric Iatrogenic Opioid Dependence: A Quality Improvement Initiative

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.

Practice guidelines for sedation and analgesia management of critically ill children: a pilot study evaluating guideline impact and feasibility in the PICU

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.

Risk factors associated with iatrogenic opioid and benzodiazepine withdrawal in critically ill pediatric patients: a systematic review and conceptual model

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.

Clonidine in the sedation of mechanically ventilated children: a pilot randomized trial

PURPOSE

Clonidine is often used as a sedative in critically ill children, but its effectiveness has not been evaluated in a large, rigorous randomized controlled trial. Our objectives in this pilot trial were to assess the feasibility of a larger trial with respect to (1) effective screening, (2) recruitment, (3) timely drug administration, and (4) protocol adherence.

MATERIALS AND METHODS

This is a randomized, blinded, placebo-controlled pilot trial. Mechanically ventilated children received enteral clonidine 5 μg/kg or placebo every 6 hours; additional sedatives were at the discretion of attending physicians.

RESULTS

We enrolled 50 children. The median interquartile range (IQR) age was 2.5 (0.7-5.2) years, and Pediatric Risk of Mortality score on pediatric intensive care unit admission was 12 (8-15). In terms of feasibility outcomes, 90 (87%) of 104 eligible patients were approached for consent, and on average, 1.7 children were enrolled per month. Thirty-five (70%) were enrolled within 1 day of becoming eligible (mean, 1.2 days). Thereafter, 94% of doses were administered by protocol. Clinical outcomes and adverse effects were not significantly different between the groups.

CONCLUSIONS

This pilot trial demonstrated feasibility of a larger randomized controlled trial. Some important challenges emerged, allowing refinement of the study protocol and enrolment estimates. We recommend that future trials capitalize on the experience gained and use these results to design a larger trial focusing on clinically important outcomes.

Evaluation of a pharmacist-managed methadone taper*

OBJECTIVES

To evaluate the efficacy of a pharmacist-managed methadone taper as compared to previous prescribing practices.

DESIGN

Retrospective chart review with comparison to historical controls.

SETTING

Ninety-six-bed pediatric quaternary care facility with the majority of the patients in a 24-bed ICU.

PATIENTS

Thirty-two patients, 1 month to 16 years old, weaned off opioids using methadone prior to protocol initiation were compared with 20 patients, 1 month to 15 years old, weaned per the pharmacist-managed methadone taper protocol.

INTERVENTIONS

Implementation of a pharmacist-managed methadone tapering protocol.

MEASUREMENTS AND MAIN RESULTS

Patient age, gender, weight, and risk of withdrawal were similar between the groups (p = not significant). The average taper length before pharmacist intervention was 24.7 days; after implementation it was 15 days (p = 0.0026). There was no statistical difference in the number of additional doses of opioid required or withdrawal scores between the populations. Opioid infusions were stopped, on average, 1.54 days sooner in the intervention group (p = 0.0039). A decrease in hospital length of stay was also seen in the intervention group (p = 0.023).

CONCLUSIONS

A pharmacist-managed protocolized methadone taper facilitates discontinuing methadone sooner, discontinuing additional opioid infusions sooner, and may impact on the length of hospital stay. The protocol developed at the University of Minnesota Amplatz Children's Hospital has demonstrated that it is an effective method to wean pediatric patients from opioids.

Opioid withdrawal signs and symptoms in children: frequency and determinants

OBJECTIVES

The purpose of this study was to, in a pediatric population, describe the frequency of opioid withdrawal signs and symptoms and to identify factors associated with these opioid withdrawal signs and symptoms.

BACKGROUND

Opioids are used routinely in the pediatric intensive care population for analgesia, sedation, blunting of physiologic responses to stress, and safety. In children, physical dependence may occur in as little as 2-3 days of continuous opioid therapy. Once the child no longer needs the opioid, the medications are reduced over time.

METHODS

A prospective, descriptive study was conducted. The sample of 26 was drawn from all patients, ages 2 weeks to 21 years admitted to the Children's Hospital of Richmond pediatric intensive care unit (PICU) and who have received continuous infusion or scheduled opioids for at least 5 days. Data collected included: opioid withdrawal score (WAT-1), opioid taper rate (total dose of opioid per day in morphine equivalents per kilogram [MEK]), pretaper peak MEK, pretaper cumulative MEK, number of days of opioid exposure prior to taper, and age.

RESULTS

Out of 26 enrolled participants, only 9 (45%) had opioid withdrawal on any given day. In addition, there was limited variability in WAT-1 scores. The most common symptoms notes were diarrhea, vomit, sweat, and fever.

CONCLUSIONS

For optimal opioid withdrawal assessments, clinicians should use a validated instrument such as the WAT-1 to measure for signs and symptoms of opioid withdrawal. Further research is indicated to examine risk factors for opioid withdrawal in children.

The role of systematic reviews in pharmacovigilance planning and Clinical Trials Authorisation application: example from the SLEEPS trial

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.

Use of methadone for prevention of opioid withdrawal in critically ill children

BACKGROUND

Opioids are commonly administered to critically ill children for analgesia and sedation, but many patients experience opioid withdrawal upon discontinuation. The authors' institution developed a protocol for using methadone to prevent opioid withdrawal in children who have received morphine by continuous IV infusion for 5 days or longer in the pediatric intensive care unit (PICU).

OBJECTIVES

The primary objectives were to determine if opioids were tapered according to the protocol and to determine the conversion ratio for IV morphine to oral methadone that was used. Secondary objectives were to describe the methadone dosage used and the clinical outcomes, to evaluate adjustments to methadone dosing, and to report the incidence of adverse effects.

METHODS

A retrospective analysis of charts was conducted for pediatric patients who had received morphine by continuous IV infusion for 5 days or longer followed by methadone in the PICU between May 2008 and August 2009. Validated scoring systems (the Withdrawal Assessment Tool and the State Behavioral Scale) were used to assess symptoms of withdrawal and degree of sedation, respectively.

RESULTS

Forty-three patients were included in the study, with median age of 8 months (range 0.25-201 months). For 31 patients (72%), the protocol was not used, and there were no patients for whom the protocol was followed to completion. The median duration of weaning was 10 days (range 0-91 days). The conversion ratio for IV morphine to oral methadone was 1:0.78 for anticipated 5-day weaning and 1:0.98 for anticipated 10-day weaning. During the first 10 days of weaning, 18 patients (42%) experienced withdrawal symptoms. The methadone dose was increased for 11 (26%) of the 43 patients. Patients were sedated for a median of 1 day (range 0-9 days), were comfortable for a median of 6.5 days (range 1-64 days), and were agitated for a median of 2.5 days (range 0-23 days). Naloxone was required for 2 patients.

CONCLUSIONS

The institution's methadone protocol was not followed consistently during the study period, and practices for transitioning from morphine by continuous IV infusion to methadone with tapering were also inconsistent. Further studies are needed to determine the optimal conversion ratio for morphine to methadone and the optimal tapering regimen to minimize withdrawal symptoms and adverse events.

Rebound increase in seizure susceptibility but not isolation-induced calls after single administration of clonazepam and Ro 19-8022 in infant rats

The purpose of our study was to determine whether a single administration of anticonvulsant doses of two ligands of benzodiazepine receptors, clonazepam and Ro 19-8022, leads to development of rebound phenomena in immature 12-day-old rats. Three tests were used: pentylenetetrazole (PTZ)-induced seizures, isolation-induced ultrasonic vocalizations, and motor performance. Susceptibility to the convulsant effects of PTZ decreased 24 hours, but increased 48 hours, after clonazepam administration. Ultrasonic vocalizations were completely suppressed 30 minutes and 3 hours after clonazepam; a moderate inhibitory effect persisted even at 48 hours. Motor abilities were slightly compromised up to 3 hours. Similar effects of Ro 19-8022 on PTZ-induced seizures and ultrasonic vocalizations were observed 24 and 48 hours after administration; motor performance was not affected. Rebound proconvulsant effects followed different time courses after administration of the two benzodiazepine receptor ligands in developing animals. Anxiolytic-like effects of these drugs were still present at the time when animals exhibited rebound proconvulsant effects.

Opioid tapering in children: a review of the literature

PURPOSE

To synthesize and critically analyze literature related to pediatric opioid withdrawal.

DESIGN

Critical review of literature related to pediatric opioid tapering and withdrawal.

METHODS

Studies published in peer-reviewed journals were systematically searched using Cochrane, MEDLINE, CINAHL, and PsychINFO. Articles meeting the inclusion criteria were reviewed and analyzed for themes and similarities.

FINDINGS

The majority of published research has focused on the episodic nature of withdrawal symptoms during opioid tapering. Only 1 study produced a valid and reliable pediatric opioid withdrawal symptom assessment-instrument and 1 study produced a valid and reliable pediatric opioid and benzodiazepine symptom assessment instrument. One study conducted in an adult and pediatric population analyzed the effect of the use of an opioid taper algorithm on occurrence and nature of opioid withdrawal symptoms.

CONCLUSIONS

The scope of research on pediatric opioid withdrawal is limited. Studies examining the effect of an opioid taper algorithm on incidence of withdrawal symptoms in children are sorely needed. Further validation of the 2 withdrawal assessment tools for children is warranted.

The ten commandments of pain assessment and management in preterm neonates

Despite advances in pain assessment and management, nonpharmacologic and pharmacologic analgesic therapies continue to be underutilized in managing both acute and procedural pain in preterm neonates. Untreated acute, recurrent, or chronic pain related to disease or medical care may have significant and lifelong physiologic and psychological consequences. Painful procedures in the NICU may be unavoidable, so it is vital that caregivers balance the painful, medically necessary care with evidence-based nonpharmacologic and pharmacologic strategies to relieve pain and stress. We present Ten Commandments of pain assessment and management in preterm neonates to promote the use of best practices and compassionate care in the NICU.

Opioid and benzodiazepine withdrawal syndromes in the paediatric intensive care unit: a review of recent literature

AIMS AND OBJECTIVES

This paper aims to critically review and analyse available literature to inform and advance patient care.

BACKGROUND

Withdrawal syndromes related to the routine administration of sedation and analgesia in paediatric intensive care unit (PICU) have been recognized since the 1990 s. Common symptoms include tremors, agitation, inconsolable crying and sleeplessness.

SEARCH STRATEGIES

A critical review was undertaken to assess developments in this area. Four databases were searched using Ovid Online. These were Ovid Medline, CINAHL, BNI and Embase. Key terms included were 'Paediatric', 'Sedation', 'Withdrawal' and 'Intensive care'.

INCLUSION AND EXCLUSION CRITERIA

Articles from 1980 onwards were reviewed for their relevance to paediatric iatrogenic withdrawal. Additionally, seminal work from the 1970s was included. Because of the scarcity of literature, relevant editorials and opinion pieces were included.

RESULTS

A total of 2,232,586 papers resulted from keyword searches. Use of Boolean operators to combine terms reduced the number of results to 62. Exclusion criteria reduced the number of suitable papers to 20. Tracking reference lists yielded a further 18 papers. In total, 38 papers were retrieved examining 1375 patients. Four papers surveyed drug usage on PICU, 14 listed withdrawal symptoms, 4 described the frequency of withdrawal in the PICU population, 9 described risk factors, 4 presented or validated clinical tools and 14 describe treatment strategies.

CONCLUSIONS

Withdrawal syndromes may affect 20% of exposed children and are related to infusion duration and total dose. Fifty-one symptoms are described in the literature. Future studies need accurate, validated clinical tools to be effective. Risk factors, signs and symptoms have been identified, and validation studies must now take place.

RELEVANCE TO CLINICAL PRACTICE

Withdrawal syndromes continue to be widespread and difficult to diagnose. Awareness of their causes and treatments should influence clinical decisions at the bedside.

Withdrawal symptoms in critically ill children after long-term administration of sedatives and/or analgesics: a first evaluation

OBJECTIVE

To establish frequencies of benzodiazepine and opioid withdrawal symptoms, and correlations with total doses and duration of administration.

DESIGN

A prospective, repeated-measures design.

SETTING

Two pediatric intensive care units in a university children's hospital.

PATIENTS

Seventy-nine children, aged 0 days to 16 yrs, who received intravenous midazolam and/or opioids for >5 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Pediatric intensive care unit nurses assessed withdrawal symptoms using the Sophia Benzodiazepine and Opioid Withdrawal Checklist, which includes all withdrawal symptoms (n = 24) described in the pediatric literature. Over 6 months, 2188 observations in 79 children were recorded. Forty-two percent of observations were performed within 24 hrs after tapering off or discontinuation of medication. Symptoms representing overstimulation of the central nervous system, such as anxiety, agitation, grimacing, sleep disturbance, increased muscle tension, and movement disorder, were observed in >10% of observations. Of symptoms reflecting gastrointestinal dysfunction, diarrhea and gastric retention were most frequently observed. Tachypnea, fever, sweating, and hypertension as manifestations of autonomic dysfunction were observed in >13% of observations. The Spearman's rank-correlation coefficient between total doses of midazolam and maximum sum score (of the Sophia Benzodiazepine and Opioid Withdrawal Checklist) was .51 (p < 0.001). The correlation between total doses of opioids and the maximum sum score was .39 (p < 0.01). A significant correlation (.52; p < 0.001) was also found between duration of use and maximum sum score.

CONCLUSIONS

This is the first study to report frequencies of all 24 withdrawal symptoms observed in children after decrease or discontinuation of benzodiazepines and/or opioids. Agitation, anxiety, muscle tension, sleeping <1 hr, diarrhea, fever, sweating, and tachypnea were observed most frequently. Longer duration of use and high dosing are risk factors for development of withdrawal symptoms in children.

Children's factual and delusional memories of intensive care

RATIONALE

Delusional memories are significantly associated with post-traumatic stress in adult patients after intensive care.

OBJECTIVES

In this study, we attempted to establish whether this relationship was found in children. We also examined the association between factual memory and distress.

METHODS

One hundred two consecutive children, aged between 7 and 17 years, were interviewed about their pediatric intensive care unit (PICU) experience 3 months after discharge from a PICU. Principal measures were the ICU Memory Tool (a checklist of intensive care memories) and an abbreviated version of the Impact of Event Scale (a screen for post-traumatic stress disorder).

MEASUREMENTS AND MAIN RESULTS

In total, 64 of 102 (63%) children reported at least one factual memory of their admission and 33 of 102 (32%) reported delusional memories, including disturbing hallucinations. Traumatic brain injury was negatively associated with factual memory (odds ratio, 0.23; 95% confidence interval [CI], 0.09-0.58; P = 0.002). Longer duration of opiates/benzodiazepines was associated with delusional memory (odds ratio, 4.98; 95% CI, 1.3-20.0; P = 0.023). Post-traumatic stress scores were higher in children reporting delusional memories (adjusted difference, 3.0; 95% CI, 0.06-5.9; P = 0.045) when illness severity and emergency status were controlled for. Factual memory was not significantly associated with post-traumatic stress.

CONCLUSIONS

This study indicates that delusional memories are reported by almost one-third of children and are associated both with the duration of opiates/benzodiazepines and risk of post-traumatic stress. More research is needed on the presence of delusional memories and associated risk factors in children receiving intensive care treatment.

Withdrawal symptoms in children after long-term administration of sedatives and/or analgesics: a literature review. "Assessment remains troublesome"

BACKGROUND

Prolonged administration of benzodiazepines and/or opioids to children in a pediatric intensive care unit (PICU) may induce physiological dependence and withdrawal symptoms.

OBJECTIVE

We reviewed the literature for relevant contributions on the nature of these withdrawal symptoms and on availability of valid scoring systems to assess the extent of symptoms.

METHODS

The databases PubMed, CINAHL, and Psychinfo (1980-June 2006) were searched using relevant key terms.

RESULTS

Symptoms of benzodiazepine and opioid withdrawal can be classified in two groups: central nervous system effects and autonomic dysfunction. However, symptoms of the two types show a large overlap for benzodiazepine and opioid withdrawal. Symptoms of gastrointestinal dysfunction in the PICU population have been described for opioid withdrawal only. Six assessment tools for withdrawal symptoms are used in children. Four of these have been validated for neonates only. Two instruments are available to specifically determine withdrawal symptoms in the PICU: the Sedation Withdrawal Score (SWS) and the Opioid Benzodiazepine Withdrawal Scale (OBWS). The OBWS is the only available assessment tool with prospective validation; however, the sensitivity is low.

CONCLUSIONS

Withdrawal symptoms for benzodiazepines and opioids largely overlap. A sufficiently sensitive instrument for assessing withdrawal symptoms in PICU patients needs to be developed.