Subcutaneous administration of fentanyl and midazolam to prevent withdrawal after prolonged sedation in children

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.

Evaluations of Morphine and Fentanyl for Mechanically Ventilated Patients With Respiratory Disorders in Intensive Care: A Systematic Review of Methodological Trends and Reporting Quality

BACKGROUND

Mechanically ventilated patients with respiratory disorders may require sedatives, such as opioids.

OBJECTIVES

To define methodological trends, gaps, and the reporting quality of the comparative clinical and economic evaluations of fentanyl and morphine in ventilated patients in the intensive care unit.

METHODS

We conducted a literature review of the MEDLINE, Embase, OVID, ScienceDirect, Springer Link, and EconLit databases, comparing studies in the management of ventilated patients with respiratory disorders in the intensive care unit using either fentanyl or morphine, or both. We assessed the methodological aspects of the literature characteristics and trends of, for example, modeling, data sources, cost calculation, and data analysis, appraising the quality of reporting via the CONsolidated Standards Of Reporting Trials, STrengthening the Reporting of OBservational studies in Epidemiology, and the Consolidated Health Economic Evaluation Reporting Standards checklists.

RESULTS

Among 1327 articles, 33 (comprising 22 in adults, 8 in neonates, and 3 in pediatrics) met the inclusion criteria. No head-to-head morphine versus fentanyl evaluations explicitly confined to subjects with respiratory conditions were undertaken. Studies relied on various scales to measure the sedation level as a primary study outcome, limiting the comparability of study conclusions. Seven articles of adults were identified to be economic studies from the hospital perspective. On the basis of different endpoints, the same sedation regimen performed differently in various studies. None of the randomized controlled trials, observational cohorts, or pharmacoeconomics studies met most of the assessed reporting quality criteria.

CONCLUSIONS

Our review identified poor reporting quality and high heterogeneity of methods used, potentially limiting the degree to which studies could be interpreted, decisions could be influenced, and findings could be generalized.

Differentiating Delirium From Sedative/Hypnotic-Related Iatrogenic Withdrawal Syndrome: Lack of Specificity in Pediatric Critical Care Assessment Tools

OBJECTIVES

To identify available assessment tools for sedative/hypnotic iatrogenic withdrawal syndrome and delirium in PICU patients, the evidence supporting their use, and describe areas of overlap between the components of these tools and the symptoms of anticholinergic burden in children.

DATA SOURCES

Studies were identified using PubMed and EMBASE from the earliest available date until July 3, 2016, using a combination of MeSH terms "delirium," "substance withdrawal syndrome," and key words "opioids," "benzodiazepines," "critical illness," "ICU," and "intensive care." Review article references were also searched.

STUDY SELECTION

Human studies reporting assessment of delirium or iatrogenic withdrawal syndrome in children 0-18 years undergoing critical care. Non-English language, exclusively adult, and neonatal intensive care studies were excluded.

DATA EXTRACTION

References cataloged by study type, population, and screening process.

DATA SYNTHESIS

Iatrogenic withdrawal syndrome and delirium are both prevalent in the PICU population. Commonly used scales for delirium and iatrogenic withdrawal syndrome assess signs and symptoms in the motor, behavior, and state domains, and exhibit considerable overlap. In addition, signs and symptoms of an anticholinergic toxidrome (a risk associated with some common PICU medications) overlap with components of these scales, specifically in motor, cardiovascular, and psychiatric domains.

CONCLUSIONS

Although important studies have demonstrated apparent high prevalence of iatrogenic withdrawal syndrome and delirium in the PICU population, the overlap in these scoring systems presents potential difficulty in distinguishing syndromes, both clinically and for research purposes.

Extended-release of opioids using fentanyl-based polymeric nanoparticles for enhanced pain management

Fentanyl-terminated polyesters provide linear release of therapeutics with an effective antinociceptive effect in vivo.

Dexmedetomidine in the Treatment of Withdrawal Syndromes in Cardiothoracic Surgery Patients

Dexmedetomidine (Precedex, Abbott Laboratories, Abbott Park, IL) is an• 2adrenergic agonist that possesses a high ratio of specificity for the• 2versus the• 1receptor. It is currently approved for the provision of sedation during mechanical ventilation in adults. Given previous experience with clonidine for the treatment of substance withdrawal and the preliminary anecdotal experience with dexmedetomidine, it appears that dexmedetomidine may be a useful agent for treatment of substance withdrawal in the intensive care setting. The authors present their experience with the use of dexmedetomidine to control withdrawal behavior in 3 patients following cardiothoracic surgery. Previous reports regarding the use of dexmedetomidine to treat withdrawal and its potential application in this clinical arena are reviewed.

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.

Tolerance and Withdrawal Issues with Sedatives in the Intensive Care Unit

Prolonged use of sedative medications continues to be a concern for critical care practitioners, with potential adverse effects including tolerance and withdrawal. The amount of sedatives required in critically ill patients can be lessened and tolerance delayed with the use of pain and/or sedation scales to reach the desired effect. The current recommendation for prolonged sedation is to wean patients from the medications over several days to reduce the risk of drug withdrawal. It is important to identify patients at risk for iatrogenic withdrawal and create a treatment strategy.

Using skin for drug delivery and diagnosis in the critically ill

Skin offers easy access, convenience and non-invasiveness for drug delivery and diagnosis. In principle, these advantages of skin appear to be attractive for critically ill patients given potential difficulties that may be associated with oral and parenteral access in these patients. However, the profound changes in skin physiology that can be seen in these patients provide a challenge to reliably deliver drugs or provide diagnostic information. Drug delivery through skin may be used to manage burn injury, wounds, infection, trauma and the multisystem complications that rise from these conditions. Local anaesthetics and analgesics can be delivered through skin and may have wide application in critically ill patients. To ensure accurate information, diagnostic tools require validation in the critically ill patient population as information from other patient populations may not be applicable.

Opioid analgesia in mechanically ventilated children: results from the multicenter Measuring Opioid Tolerance Induced by Fentanyl study

OBJECTIVE

To examine the clinical factors associated with increased opioid dose among mechanically ventilated children in the pediatric intensive care unit.

DESIGN

Prospective, observational study with 100% accrual of eligible patients.

SETTING

Seven pediatric intensive care units from tertiary-care children's hospitals in the Collaborative Pediatric Critical Care Research Network.

PATIENTS

Four hundred nineteen children treated with morphine or fentanyl infusions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data on opioid use, concomitant therapy, demographic and explanatory variables were collected. Significant variability occurred in clinical practices, with up to 100-fold differences in baseline opioid doses, average daily or total doses, or peak infusion rates. Opioid exposure for 7 or 14 days required doubling of the daily opioid dose in 16% patients (95% confidence interval 12%-19%) and 20% patients (95% confidence interval 16%-24%), respectively. Among patients receiving opioids for longer than 3 days (n = 225), this occurred in 28% (95% confidence interval 22%-33%) and 35% (95% confidence interval 29%-41%) by 7 or 14 days, respectively. Doubling of the opioid dose was more likely to occur following opioid infusions for 7 days or longer (odds ratio 7.9, 95% confidence interval 4.3-14.3; p < 0.001) or co-therapy with midazolam (odds ratio 5.6, 95% confidence interval 2.4-12.9; p < 0.001), and it was less likely to occur if morphine was used as the primary opioid (vs. fentanyl) (odds ratio 0.48, 95% confidence interval 0.25-0.92; p = 0.03), for patients receiving higher initial doses (odds ratio 0.96, 95% confidence interval 0.95-0.98; p < 0.001), or if patients had prior pediatric intensive care unit admissions (odds ratio 0.37, 95% confidence interval 0.15-0.89; p = 0.03).

CONCLUSIONS

Mechanically ventilated children require increasing opioid doses, often associated with prolonged opioid exposure or the need for additional sedation. Efforts to reduce prolonged opioid exposure and clinical practice variation may prevent the complications of opioid therapy.

Tolerance and withdrawal from prolonged opioid use in critically ill children

OBJECTIVE

After prolonged opioid exposure, children develop opioid-induced hyperalgesia, tolerance, and withdrawal. Strategies for prevention and management should be based on the mechanisms of opioid tolerance and withdrawal.

PATIENTS AND METHODS

Relevant manuscripts published in the English language were searched in Medline by using search terms "opioid," "opiate," "sedation," "analgesia," "child," "infant-newborn," "tolerance," "dependency," "withdrawal," "analgesic," "receptor," and "individual opioid drugs." Clinical and preclinical studies were reviewed for data synthesis.

RESULTS

Mechanisms of opioid-induced hyperalgesia and tolerance suggest important drug- and patient-related risk factors that lead to tolerance and withdrawal. Opioid tolerance occurs earlier in the younger age groups, develops commonly during critical illness, and results more frequently from prolonged intravenous infusions of short-acting opioids. Treatment options include slowly tapering opioid doses, switching to longer-acting opioids, or specifically treating the symptoms of opioid withdrawal. Novel therapies may also include blocking the mechanisms of opioid tolerance, which would enhance the safety and effectiveness of opioid analgesia.

CONCLUSIONS

Opioid tolerance and withdrawal occur frequently in critically ill children. Novel insights into opioid receptor physiology and cellular biochemical changes will inform scientific approaches for the use of opioid analgesia and the prevention of opioid tolerance and withdrawal.

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.

[Weaning from the ventilator modalities and consequences]

Only few studies have focused on the issues raised by discontinuing sedation in ICU patients. Several lines of evidence allow defining the risk factors for the occurrence of a weaning syndrome due to discontinuation of sedatives and analgesics in ICU patients. These primarily include a prolonged (more than seven days) period of continuous intravenous administration of high doses of hypnotics and opioids. Weaning from sedation is tightly linked to weaning from the ventilator and this area should be the target of research work in the near future.

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.

Consensus guidelines on sedation and analgesia in critically ill children

OBJECTIVE

The United Kingdom Paediatric Intensive Care Society Sedation, Analgesia and Neuromuscular Blockade Working Group is a multi-disciplinary expert panel created to produce consensus guidelines on sedation and analgesia in critically ill children and forward knowledge in these areas. Sedation and analgesia are recognised as important areas of critical care practice and adult clinical practice guidelines in these fields remain amongst the most popular of those produced by the Society of Critical Care Medicine. However, similar clinical practice guidelines have not previously been produced for the critically ill paediatric patient.

DESIGN

A modified Delphi technique was used to allow the Working Group to anonymously consider draft recommendations in three Delphi rounds with predetermined levels of agreement. This process was supported by a total of four consensus conferences. Once consensus had been reached, a systematic review of the available literature was carried out.

OUTCOME

A set of consensus guidelines was produced including 20 key recommendations, 10 relating to the provision of analgesia and 10 relating to the sedation of critically ill children. An evaluation of the existing literature supporting these recommendations is provided.

CONCLUSIONS

Multi-disciplinary consensus guidelines for maintenance sedation and analgesia in critically ill children have been successfully produced and are supported by levels of evidence (excluding sedation and analgesia for procedures and excluding neonates). The working group has highlighted the paucity of high-quality evidence in these important clinical areas and this emphasises the need for further randomised clinical trials in this area.

A prospective evaluation of opioid weaning in opioid-dependent pediatric critical care patients

Critically ill children are treated with opioid medication in an attempt to decrease stress and alleviate pain during prolonged pediatric intensive care. This treatment plan places children at risk for opioid dependency. Once dependent, children need to be weaned or risk development of a withdrawal syndrome on abrupt cessation of medication. We enrolled opioid-dependent children into a prospective, randomized trial of 5- versus 10-day opioid weaning using oral methadone. Children exposed to opioids for an average of 3 wk showed no difference in the number of agitation events requiring opioid rescue (3 consecutive neonatal abstinence scores >8 every 2 h) in either wean group. Most of the events requiring rescue occurred on day 5 and 6 of the wean in both treatment groups. Patients may be able to be weaned successfully in 5 days once converted to oral methadone, with a follow-up period after medication wean to observe for a delayed withdrawal syndrome.

Adverse responses: sedation, analgesia and neuromuscular blocking agents in critically ill children

Advanced practice nurses (APNs) prescribe sedation, analgesia, and neuromuscular blocking agents in the management of critically ill children. Although most children are unscathed from the use of the medications, some suffer adverse responses. This article elucidates adverse responses to these medications for the APN, including withdrawal syndrome, muscle weakness, decreased gastric motility, corneal abrasions, and costs associated with these morbidities.

Tolerance and Withdrawal Issues with Sedation

The stay in an ICU is a complex mixture of providing optimal care while keeping the patient safe. Means of reducing the anxiety associated with the ICU stay include frequent reorientation and maintenance of patient comfort with sedation supplemented by analgesia as needed. The most common agents used to provide sedation include benzodiazepines, propofol, and the newer dexmedetomidine. Others include barbiturate agents, neuroleptics, clonidine, etomidate, ketamine, and supplemental opioid analgesics for pain control. A common complication of sedation is tolerance, which can lead to withdrawal if the sedation is discontinued hastily. This article evaluates the occurrence of tolerance and withdrawal in the most commonly used sedatives in critically ill patients.

Opioid and benzodiazepine withdrawal symptoms in paediatric intensive care patients

The purposes of this prospective repeated measures study were to: (a) describe the occurrence of withdrawal symptoms with the use of a standardised protocol to slowly taper opioids and benzodiazepines; and (b) to test the predictive validity of an opioid and benzodiazepine withdrawal assessment scoring tool in critically ill infants and young children after prolonged opioid and benzodiazepine therapy. Fifteen children (6 weeks-28 months of age) with complex congenital heart disease and/or respiratory failure who received opioids and benzodiazepines for 4 days or greater were evaluated for withdrawal symptoms using a standardized assessment tool. Thirteen children showed moderate to severe withdrawal symptoms a median 3 days after commencement of tapering. Symptom intensity was not related to prior opioid or benzodiazepine exposure, extracorporeal membrane oxygenation (ECMO) therapy or length of tapering. Children who received fentanyl in addition to morphine more often exhibited signs of withdrawal. This study demonstrated that significant withdrawal symptoms occur in critically ill children even with the use of a standardised assessment tool and tapering management protocol. The predictive validity and utility of the Opioid and Benzodiazepine Withdrawal Score (OBWS) was adequate for clinical use, but areas for further improvement of the tool were identified. Problems with the clinical withdrawal prevention and management guidelines were also identified. More research is needed to establish the optimal methods for prevention and management of iatrogenic opioid and benzodiazepine withdrawal in paediatric critical care.

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

The aim of this study was to identify the optimal rates at which opioids and benzodiazepines should be weaned in order to prevent withdrawal reactions in the pediatric intensive care unit (PICU). This study follows an earlier investigation that developed a graphical analysis method for examining behavioral signs of withdrawal in relation to changes in opioid and benzodiazepine administration. This method was utilized in this present study for a prospective sample of all patients admitted to a tertiary/quaternary level PICU within a 4-week interval (n=27). The findings of this study indicate that the required rate of weaning (in order to prevent withdrawal reactions) is related to the number of days the child has been on a continuous infusion of opioids and/or benzodiazepines. Adverse withdrawal reactions were prevented when the daily rate of weaning did not exceed: 20% for children receiving continuous infusions for 1-3 days; 13-20% for 4-7 days; 8-13% for 8-14 days; 8% for 15-21 days; and 2-4% for more than 21 days of infusions. The authors recommend that the rate of weaning of opioids and benzodiazepines in critically ill children be tailored to the length of time the child received continuous infusions of these agents.

Managing sedation withdrawal in children who undergo prolonged PICU admission after discharge to the ward

Children who undergo a prolonged stay within the intensive care unit require adequate sedation and analgesia. During the recovery phase there will need to be a period of sedation withdrawal to prevent occurrence of an abstinence syndrome. We present a strategy developed within our hospital for managing this process which uses the resource of the Pain Service, along with guidelines to help prevent the development of withdrawal, and a plan for managing any signs of abstinence which occur.

Methadone dosage for prevention of opioid withdrawal in children

BACKGROUND

Opioids are frequently used for sedation in the Paediatric Intensive Care Unit (PICU). With time the dosing often increases because of tolerance. On cessation of the sedation there is a risk of the opioid withdrawal syndrome. The aim of our study was to evaluate methadone dosing as a risk factor for opioid withdrawal and to determine optimal dose and efficacy of methadone to prevent withdrawal.

METHOD

We undertook a clinical, retrospective, chart review study. Data were analysed from the quality improvement initiative database of a tertiary-care 18 bed PICU.

RESULTS

Data from 30 children who received an opioid infusion for >/=7 days and subsequently received methadone for opioid withdrawal (between January 2000 and July 2001) were analysed. Nurses documented the presence or absence of withdrawal signs daily. Our unit protocol has recommended converting the patient's opioid dose into fentanyl equivalents and a dose of methadone equal to the total daily dose of fentanyl to be given three times a day. Twenty patients had no or minimal withdrawal symptoms and 10 experienced significant withdrawal. Age, weight, PRISM score, lorazepam dose, muscle relaxant use and fentanyl dose were not statistically significantly between these groups. Receiver Operator Characteristics analysis showed that 80% of the suggested methadone dose was effective in minimizing withdrawal symptoms. The odds ratio for withdrawal with <80% of the predicted methadone dose was 21.

CONCLUSIONS

Inadequate methadone is a risk factor for opioid withdrawal. A daily starting methadone dose equivalent to 2.5 times the daily fentanyl dose is effective in minimizing withdrawal symptoms.

Enteral methadone to expedite fentanyl discontinuation and prevent opioid abstinence syndrome in the PICU

STUDY OBJECTIVE

To determine if enterally administered methadone can facilitate fentanyl discontinuation and prevent withdrawal in children at high risk for opioid abstinence syndrome.

DESIGN

Retrospective analysis.

SETTING

Pediatric intensive care unit (PICU) in a tertiary care children's hospital.

PATIENTS

Twenty-two children (aged 6.1 +/- 5.4 yrs) who received continuous fentanyl infusion for 9 days or longer.

INTERVENTION

Guidelines for initiating enteral methadone, rapidly tapering and discontinuing fentanyl infusions, and tapering methadone were implemented in the PICU. Development of opioid abstinence syndrome was evaluated during fentanyl and methadone dosage reductions and for 72 hours thereafter.

MEASUREMENTS AND MAIN RESULTS

Children received fentanyl by continuous infusion for 17.8 +/- 8.4 days. Peak fentanyl infusion rate was 5.9 +/- 3.8 microg/kg/hour, and the median cumulative dose was 1302 microg/kg (range 354-7535 microg/kg). Methadone 0.50 +/- 0.22 mg/kg/day was begun 1.6 +/- 1.9 days before tapering fentanyl. The fentanyl infusion rate on starting the taper was 5.0 +/- 3.6 microg/kg/hour. Fentanyl was tapered and discontinued in a median of 2.6 days (range 0-11.9 days). Twenty-one patients had no opioid abstinence syndrome during or after fentanyl taper. One patient experienced significant opioid withdrawal after fentanyl discontinuation, which resolved after reinstitution of fentanyl and increasing the dosage of methadone to 0.3 mg/kg every 6 hours. Overall, methadone was tapered and discontinued in 18.2 +/- 11.9 days without precipitating opioid abstinence syndrome.

CONCLUSION

Enteral administration of methadone may expedite fentanyl discontinuation and reduce the risk of withdrawal in critically ill children at high risk for opioid abstinence syndrome.

Efficacy of an enteral 10-day methadone wean to prevent opioid withdrawal in fentanyl-tolerant pediatric intensive care unit patients

OBJECTIVE

To demonstrate the efficacy of a 10-day, single daily dose, enteral methadone weaning protocol for the prevention of opioid withdrawal symptoms in pediatric patients after prolonged fentanyl exposure.

DESIGN

Prospective, observational study.

SETTING

Twenty-four-bed medical-surgical intensive care unit within a 222-bed pediatric teaching hospital.

PATIENTS

Twenty-nine children, aged 1 day to 19.8 yrs, who received methadone to prevent opioid withdrawal after prolonged continuous fentanyl infusion exposure.

INTERVENTIONS

Institution of a standardized methadone weaning protocol.

MEASUREMENTS AND MAIN RESULTS

All 29 patients had received a continuous fentanyl infusion; duration of exposure was 14.5 +/- 9.2 days, cumulative fentanyl dose was 1.93 +/- 1.53 mg/kg, and peak fentanyl infusion was 9.6 +/- 4.3 microg/kg per hr. Twenty-five (86%) of 29 patients successfully completed the methadone wean in 10 days. Withdrawal complications that required a weaning delay were seen in three patients, and one patient expired before completion. Sixteen patients were discharged to complete their weaning schedule at home without incident.

CONCLUSIONS

Opioid withdrawal symptoms in pediatric intensive care unit patients after prolonged fentanyl exposure can be avoided by using an enteral, 10-day, single daily dose methadone weaning protocol.

Tolerance, withdrawal, and physical dependency after long-term sedation and analgesia of children in the pediatric intensive care unit

OBJECTIVE

To describe the consequences of the prolonged administration of sedative and analgesic agents to the pediatric intensive care unit (PICU) patient. The problems to be investigated include tolerance, physical dependency, and withdrawal.

DATA SOURCES

A MEDLINE search was performed of literature published in the English language. Cross-reference searches were performed using the following terms: sedation, analgesia with PICU, children, physical dependency, withdrawal; tolerance with sedative, analgesics, benzodiazepines, opioids, inhalational anesthetic agents, nitrous oxide, ketamine, barbiturates, propofol, pentobarbital, phenobarbital.

STUDY SELECTION

Studies dealing with the problems of tolerance, physical dependency, and withdrawal in children in the PICU population were selected.

DATA EXTRACTION

All of the above-mentioned studies were reviewed in the current manuscript.

DATA SYNTHESIS

A case by case review is presented, outlining the reported problems of tolerance, physical dependency, and withdrawal after the use of sedative/analgesic agents in the PICU population. This is followed up by a review of the literature discussing current treatment options for these problems.

CONCLUSIONS

Tolerance, physical dependency, and withdrawal can occur after the prolonged administration of any agent used for sedation and analgesia in the PICU population. Important components in the care of such patients include careful observation to identify the occurrence of withdrawal signs and symptoms. Treatment options after prolonged administration of sedative/analgesic agents include slowly tapering the intravenous administration of these agents or, depending on the drug, switching to subcutaneous or oral administration.

Sedation and analgesia in paediatric intensive care units: a guide to drug selection and use

The indications for sedation in the paediatric intensive care unit (PICU) patient are varied ranging from short term use for various procedures to prolonged administration to provide comfort during mechanical ventilation. When faced with the decision to institute sedation, the healthcare provider must make three decisions: the agent to be used, the route of delivery, and the mode of administration (intermittent versus continuous). There are several agents that have been used to provide sedation in the PICU patient including the inhalational anaesthetic agents, benzodiazepines, opioids, ketamine, propofol, chloral hydrate, phenothiazines, and the barbiturates. This review describes the various agents for sedation and discusses their advantages and disadvantages as they pertain to the PICU. Consequences of and treatment strategies for long term problems with prolonged sedation including tolerance, physical dependency, and withdrawal are reviewed.