Patient, Process, and System Predictors of Iatrogenic Withdrawal Syndrome in Critically Ill Children*:

A systematic review of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal syndrome in pediatric intensive care

Introduction

This systematic review aimed to evaluate the quality of clinical practice guidelines (CPGs) and recommendations for managing pain, sedation, delirium, and iatrogenic withdrawal syndrome in pediatric intensive care (PICU). The objectives included evaluating the quality of recommendations, synthesizing recommendations, harmonizing the strength of the recommendation (SoR) and the certainty of evidence (CoE), and assessing the relevance of supporting evidence.

Methods

A comprehensive search in four electronic databases (Medline, Embase.com, CINAHL and JBI EBP Database), 9 guideline repositories, and 13 professional societies was conducted to identify CPGs published from January 2010 to the end of May 2023 in any language. The quality of CPGs and recommendations was assessed using the AGREE II and AGREE-REX instruments. Thematic analysis was used to synthesize recommendations, and the GRADE SoR and CoE harmonization method was used to interpret the credibility of summary recommendations.

Results

A total of 18 CPGs and 170 recommendations were identified. Most CPGs were of medium-quality, and three were classified as high. A total of 30 summary recommendations were synthesized across each condition, focused on common management approaches. There was inconsistency in the SoRs and CoE for summary recommendations, those for assessment showed the highest consistency, the remaining were conditional, inconsistent, inconclusive, and lacked support from evidence.

Conclusion

This systematic review provides an overview of the quality of CPGs for these four conditions in the PICU. While three CPGs achieved high-quality ratings, the overall findings reveal gaps in the evidence base of recommendations, patient and family involvement, and resources for implementation. The findings highlight the need for more rigorous and evidence-based approaches in the development and reporting of CPGs to enhance their trustworthiness. Further research is necessary to enhance the quality of recommendations for this setting. The results of this review can provide a valuable foundation for future CPG development.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=274364, PROSPERO (CRD42021274364).

Opioid, sedative, preadmission medication and iatrogenic withdrawal risk in UK adult critically ill patients: a point prevalence study

BACKGROUND

Iatrogenic withdrawal syndrome, after exposure medication known to cause withdrawal is recognised, yet under described in adult intensive care.

AIM

To investigate, opioid, sedation, and preadmission medication practice in critically ill adults with focus on aspects associated with iatrogenic withdrawal syndrome.

METHOD

One-day point prevalence study in UK intensive care units (ICUs). We collected ICU admission medication and/or substances with withdrawal potential, sedation policy, opioid and sedative use, dose, and duration.

RESULTS

Thirty-seven from 39 participating ICUs contributed data from 386 patients. The prevalence rate for parenteral opioid and sedative medication was 56.1% (212 patients). Twenty-three ICUs (59%) had no sedation/analgesia policy, and no ICUs screened for iatrogenic withdrawal. Patient admission medications with withdrawal-potential included antidepressants or antipsychotics (43, 20.3%) and nicotine (41, 19.3%). Of 212 patients, 202 (95.3%) received opioids, 163 (76.9%) sedatives and 153 (72.2%) both. Two hundred and two (95.3%) patients received opioids: 167 (82.7%) by continuous infusions and 90 (44.6%) patients for longer than 96-h. One hundred and sixty-three (76.9%) patients received sedatives: 157 (77.7%) by continuous infusions and 74 (45.4%) patients for longer than 96-h.

CONCLUSION

Opioid sedative and admission medication with iatrogenic withdrawal syndrome potential prevalence rates were high, and a high proportion of ICUs had no sedative/analgesic policies. Nearly half of patients received continuous opioids and sedatives for longer than 96-h placing them at high risk of iatrogenic withdrawal. No participating unit reported using a validated tool for iatrogenic withdrawal assessment.

Implementation of an algorithm for tapering analgosedation reduces iatrogenic withdrawal syndrome in pediatric intensive care

BACKGROUND

Proper analgosedation is a cornerstone in the treatment of critically ill patients in Pediatric Intensive Care Units (PICUs). Medications, such as fentanyl, morphine, and midazolam, are essential to safe and respectful care. The use of these medications over time may lead to side effects such as iatrogenic withdrawal syndrome (IWS) in the tapering phase. The aim of the study was to test an algorithm for tapering analgosedation to reduce the prevalence of IWS in two Norwegian PICUs at Oslo University Hospital.

METHODS

A cohort of mechanically ventilated patients from newborn to 18 years with continuous infusions of opioids and benzodiazepines for 5 days or more were included consecutively from May 2016 to December 2021. A pre- and posttest design, with an intervention phase using an algorithm for tapering analgosedation after the pretest, was used. The ICU staffs were trained in using the algorithm after the pretest. The primary outcome was a reduction in IWS. The Withdrawal Assessment Tool-1 (WAT-1) was used to identify IWS. A WAT-1 score ≥3 indicates IWS.

RESULTS

We included 80 children, 40 in the baseline group, and 40 in the intervention group. Age and diagnosis did not differ between the groups. The prevalence of IWS was 95% versus 52.5% in the baseline group versus the intervention group, and the peak WAT-1 median was 5.0 (IQR 4-6.8) versus 3.0 (IQR 2.0-6.0) (p = .012). Based on SUM WAT-1 ≥ 3, which describes the burden over time better, we demonstrated a reduction of IWS, from a median of 15.5 (IQR 8.25-39) to a median of 3 (IQR 0-20) (p = <.001).

CONCLUSION

We suggest using an algorithm for tapering analgosedation in PICUs since the prevalence of IWS was significantly lower in the intervention group in our study.

Assessment and management of iatrogenic withdrawal syndrome and delirium in pediatric intensive care units across Europe: An ESPNIC survey

INTRODUCTION

Analgesia and sedation are essential for the care of children in the pediatric intensive care unit (PICU); however, when prolonged, they may be associated with iatrogenic withdrawal syndrome (IWS) and delirium. We sought to evaluate current practices on IWS and delirium assessment and management (including non-pharmacologic strategies as early mobilization) and to investigate associations between the presence of an analgosedation protocol and IWS and delirium monitoring, analgosedation weaning, and early mobilization.

METHODS

We conducted a multicenter cross-sectional survey-based study collecting data from one experienced physician or nurse per PICU in Europe from January to April 2021. We then investigated differences among PICUs that did or did not follow an analgosedation protocol.

RESULTS

Among 357 PICUs, 215 (60%) responded across 27 countries. IWS was systematically monitored with a validated scale in 62% of PICUs, mostly using the Withdrawal Assessment Tool-1 (53%). The main first-line treatment for IWS was a rescue bolus with interruption of weaning (41%). Delirium was systematically monitored in 58% of PICUs, mostly with the Cornell Assessment of Pediatric Delirium scale (48%) and the Sophia Observation Scale for Pediatric Delirium (34%). The main reported first-line treatment for delirium was dexmedetomidine (45%) or antipsychotic drugs (40%). Seventy-one percent of PICUs reported to follow an analgosedation protocol. Multivariate analyses adjusted for PICU characteristics showed that PICUs using a protocol were significantly more likely to systematically monitor IWS (odds ratio [OR] 1.92, 95% confidence interval [CI] 1.01-3.67) and delirium (OR 2.00, 95% CI 1.07-3.72), use a protocol for analgosedation weaning (OR 6.38, 95% CI 3.20-12.71) and promote mobilization (OR 3.38, 95% CI 1.63-7.03).

CONCLUSIONS

Monitoring and management of IWS and delirium are highly variable among European PICUs. The use of an analgosedation protocol was associated with an increased likelihood of monitoring IWS and delirium, performing a structured analgosedation weaning and promoting mobilization. Education on this topic and interprofessional collaborations are highly needed to help reduce the burden of analgosedation-associated adverse outcomes.

Effectiveness, quality and implementation of pain, sedation, delirium, and iatrogenic withdrawal syndrome algorithms in pediatric intensive care: a systematic review and meta-analysis

Background

Pain, sedation, delirium, and iatrogenic withdrawal syndrome are conditions that often coexist, algorithms can be used to assist healthcare professionals in decision making. However, a comprehensive review is lacking. This systematic review aimed to assess the effectiveness, quality, and implementation of algorithms for the management of pain, sedation, delirium, and iatrogenic withdrawal syndrome in all pediatric intensive care settings.

Methods

A literature search was conducted on November 29, 2022, in PubMed, Embase, CINAHL and Cochrane Library, ProQuest Dissertations & Theses, and Google Scholar to identify algorithms implemented in pediatric intensive care and published since 2005. Three reviewers independently screened the records for inclusion, verified and extracted data. Included studies were assessed for risk of bias using the JBI checklists, and algorithm quality was assessed using the PROFILE tool (higher % = higher quality). Meta-analyses were performed to compare algorithms to usual care on various outcomes (length of stay, duration and cumulative dose of analgesics and sedatives, length of mechanical ventilation, and incidence of withdrawal).

Results

From 6,779 records, 32 studies, including 28 algorithms, were included. The majority of algorithms (68%) focused on sedation in combination with other conditions. Risk of bias was low in 28 studies. The average overall quality score of the algorithm was 54%, with 11 (39%) scoring as high quality. Four algorithms used clinical practice guidelines during development. The use of algorithms was found to be effective in reducing length of stay (intensive care and hospital), length of mechanical ventilation, duration of analgesic and sedative medications, cumulative dose of analgesics and sedatives, and incidence of withdrawal. Implementation strategies included education and distribution of materials (95%). Supportive determinants of algorithm implementation included leadership support and buy-in, staff training, and integration into electronic health records. The fidelity to algorithm varied from 8.2% to 100%.

Conclusions

The review suggests that algorithm-based management of pain, sedation and withdrawal is more effective than usual care in pediatric intensive care settings. There is a need for more rigorous use of evidence in the development of algorithms and the provision of details on the implementation process.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021276053, PROSPERO [CRD42021276053].

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.

Nonpulmonary Treatments for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

To provide an updated review of the literature on nonpulmonary treatments for pediatric acute respiratory distress syndrome (PARDS) from the Second Pediatric Acute Lung Injury Consensus Conference.

DATA SOURCES

MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost).

STUDY SELECTION

Searches were limited to children with PARDS or hypoxic respiratory failure focused on nonpulmonary adjunctive therapies (sedation, delirium management, neuromuscular blockade, nutrition, fluid management, transfusion, sleep management, and rehabilitation).

DATA EXTRACTION

Title/abstract review, full-text review, and data extraction using a standardized data collection form.

DATA SYNTHESIS

The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-five studies were identified for full-text extraction. Five clinical practice recommendations were generated, related to neuromuscular blockade, nutrition, fluid management, and transfusion. Thirteen good practice statements were generated on the use of sedation, iatrogenic withdrawal syndrome, delirium, sleep management, rehabilitation, and additional information on neuromuscular blockade and nutrition. Three research statements were generated to promote further investigation in nonpulmonary therapies for PARDS.

CONCLUSIONS

These recommendations and statements about nonpulmonary treatments in PARDS are intended to promote optimization and consistency of care for patients with PARDS and identify areas of uncertainty requiring further investigation.

Incidence of iatrogenic withdrawal syndrome and associated factors in surgical pediatric intensive care

BACKGROUND

Iatrogenic withdrawal syndrome (IWS) is a complication of prolonged sedation/analgesia in pediatric intensive care unit (PICU) patients. The epidemiology of IWS is poorly understood, as validated diagnostic tools are rarely used. The main objective of our study was to use the WAT-1 score to assess the incidence of IWS in our unit. The secondary objectives were to evaluate the consequences of IWS, associated factors, and management modalities.

MATERIAL AND METHODS

From July 2018 to January 2019, 48 children receiving endotracheal ventilation and sedation/analgesia by continuous infusion (>48 h) of benzodiazepines and/or opioids were included. As soon as sedation/analgesia was decreased and until 72 h after its complete discontinuation, the WAT-1 score was determined every 12 h. Substitution therapy was used for 98% of patients upon opioid and/or benzodiazepine withdrawal. IWS was defined as a WAT-1 score ≥3. Factors associated with IWS were assessed by univariate analysis.

RESULTS

IWS occurred in 25 (52%) patients. IWS was associated with a higher number of ventilator-associated pneumonia episodes (17 [68%] vs. one [4%]) and a longer PICU stay (13 [7; 25] vs. 9.0 [5.0; 10.5]) (p<0.001). Overall, 11 patients developed IWS after less than 5 days of sedation/analgesia. Severe head injury was associated with IWS (p = 0.03). Neither sedation discontinuation nor IWS prevention was standardized.

CONCLUSION

The high incidence and adverse consequences of IWS require improved prevention. Risk groups should be defined and a standardized withdrawal protocol established. The occurrence of IWS should be monitored routinely using a validated score.

Pediatric delirium is associated with increased brain injury marker levels in cardiac surgery patients

Despite global consensus on the importance of screening pediatric delirium, correlations between pediatric delirium during acute brain injury and adult delirium are unclear. Therefore, we hypothesized that similar pediatric biomarkers reflect acute brain injury as in adult delirium. We observed pediatric cardiac surgery patients from neonatal age to 18 years, who were admitted to our pediatric intensive care unit after cardiovascular operations between October 2019 to June 2020, up to post-operative day 3 (4 days total). We recorded age, sex, risk score (Risk Adjustment in Congenital Heart Surgery [RACHS-1]), midazolam/dexmedetomidine/fentanyl dosage, and pediatric Sequential Organ Failure Assessment (pSOFA). Richmond Agitation-Sedation Scale (RASS), Cornell Assessment of Pediatric Delirium (CAPD), Face, Leg, Activity, Consolability (FLACC) behavioral scale, and Withdrawal Assessment Tool (WAT-1) scales were used and serum sampling for neuron specific enolase (NSE) was conducted. Consciousness status was considered hierarchical (coma > delirium > normal) and associations between conscious status and NSE were conducted by hierarchical Bayesian modeling. We analyzed 134 data points from 40 patients (median age 12 months). In the multi-regression model, NSE was positively associated with coma [posterior odds ratio (OR) = 1.1, 95% credible interval (CrI) 1.01-1.19] while pSOFA [posterior OR = 1.63, 95% CrI 1.17-2.5], midazolam [posterior OR = 1.02, 95% CrI 1.01-1.04], and dexmedetomidine [posterior OR = 9.52, 95% CrI 1.02-108.85] were also associated. We also evaluated consciousness state probability at each NSE concentration and confirmed both that consciousness was hierarchically sorted and CAPD scores were also associated with NSE [posterior OR = 1.32, 95% CrI 1.09-1.58]. "Eye contact" (r = 0.55) was the most correlated component with NSE within the pain, withdrawal syndrome, and PD items. PD within the hierarchy of consciousness (coma, delirium, normal) and CAPD scores are associated with brain injury marker levels. Using pediatric delirium assessment tools for monitoring brain injury, especially eye contact, is a reliable method for observing PD.

Weaning Dexmedetomidine in Non-ICU Areas: An Implementation Effort

OBJECTIVES

To develop and implement clinical practice guidelines for safely weaning dexmedetomidine infusions in non-ICU areas.

DESIGN

Development, implementation, and analysis of effectiveness of clinical practice guidelines.

SETTING

Quaternary care academic free-standing pediatric hospital.

PATIENTS

Children, otherwise medically ready for transfer to non-ICU areas, who were undergoing a planned wean of a dexmedetomidine infusion.

INTERVENTIONS

Subject matter experts developed evidence-based guidelines for weaning dexmedetomidine in patients whose critical phase of illness had resolved.

MEASUREMENTS AND MAIN RESULTS

Searches identified no prospective studies of dexmedetomidine weaning. We identified two retrospective reviews of withdrawal symptoms and one on the use of clonidine. There were case studies on withdrawal symptoms. Guidelines were piloted on a cohort of 24 patients while in the ICU. The guidelines were then implemented in non-ICU areas for patients undergoing dexmedetomidine weaning after ICU transfer. Over a 2-year period (October 1, 2018, to September 30, 2020), 63 patients (1 mo to 18 yr old) successfully weaned dexmedetomidine in non-ICU areas. The median time to discontinuation of dexmedetomidine after transfer to non-ICU areas was 5.8 days (interquartile range, 4.75-15 d). Fifty-eight percent (n = 41) of all patients were considered high risk for dexmedetomidine withdrawal based on the dose, duration of exposure, and the risk of experiencing physiologic detriment with more than mild withdrawal. Twenty-nine patients (46%) exhibited no signs or symptoms of withdrawal while weaning per guidelines. For those with signs and symptoms of withdrawal, the most common were tachycardia (n = 26, 40%), agitation (n = 9, 14%), and hypertension (n = 9, 11%).

CONCLUSIONS

Weaning dexmedetomidine in non-ICU areas is feasible and can be accomplished safely even among pediatric patients at high risk for withdrawal using standardized weaning guidelines. At our institution, implementation was associated with reduced ICU length of stay for patients recovering from critical illness.

Recommendations for analgesia and sedation in critically ill children admitted to intensive care unit

We aim to develop evidence-based recommendations for intensivists caring for children admitted to intensive care units and requiring analgesia and sedation. A panel of national paediatric intensivists expert in the field of analgesia and sedation and other specialists (a paediatrician, a neuropsychiatrist, a psychologist, a neurologist, a pharmacologist, an anaesthesiologist, two critical care nurses, a methodologist) started in 2018, a 2-year process. Three meetings and one electronic-based discussion were dedicated to the development of the recommendations (presentation of the project, selection of research questions, overview of text related to the research questions, discussion of recommendations). A telematic anonymous consultation was adopted to reach the final agreement on recommendations. A formal conflict-of-interest declaration was obtained from all the authors. Eight areas of direct interest and one additional topic were considered to identify the best available evidence and to develop the recommendations using the Evidence-to-Decision framework according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. For each recommendation, the level of evidence, the strength of the recommendation, the benefits, the harms and the risks, the benefit/harm balance, the intentional vagueness, the values judgement, the exclusions, the difference of the opinions, the knowledge gaps, and the research opportunities were reported. The panel produced 17 recommendations. Nine were evaluated as strong, 3 as moderate, and 5 as weak. Conclusion: a panel of national experts achieved consensus regarding recommendations for the best care in terms of analgesia and sedation in critically ill children.

2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility

RATIONALE

A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available.

OBJECTIVE

To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility.

DESIGN

The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to.

METHODS

Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence.

RESULTS

The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements.

CONCLUSIONS

The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.

Analgesia in the Neurosurgical Intensive Care Unit

Acute pain in neurosurgical patients is an important issue. Opioids are the most used for pain treatment in the neurosurgical ICU. Potential side effects of opioid use such as oversedation, respiratory depression, hypercapnia, worsening intracranial pressure, nausea, and vomiting may be problems and could interfere with neurologic assessment. Consequently, reducing opioids and use of non-opioid analgesics and adjuvants (N-methyl-D-aspartate antagonists, α2 -adrenergic agonists, anticonvulsants, corticosteroids), as well as non-pharmacological therapies were introduced as a part of a multimodal regimen. Local and regional anesthesia is effective in opioid reduction during the early postoperative period. Among non-opioid agents, acetaminophen and non-steroidal anti-inflammatory drugs are used frequently. Adverse events associated with opioid use in neurosurgical patients are discussed. Larger controlled studies are needed to find optimal pain management tailored to neurologically impaired neurosurgical patients.

Four-in-One: A Comprehensive Checklist for the Assessment of Pain, Undersedation, Iatrogenic Withdrawal and Delirium in the PICU: A Delphi Study

OBJECTIVES

Children's pain, undersedation, iatrogenic withdrawal syndrome and delirium often have overlapping symptoms, which makes it difficult to decide why a child in the PICU is not comfortable. Validated assessment tools for these conditions are available, but regular assessment with multiple instruments may be too time-consuming. Therefore, we aimed to develop a new holistic instrument-the mosaIC checklist-that incorporates the assessment of the four conditions.

MATERIALS AND METHODS

We conducted a two-rounds international Delphi study among experts working in PICUs worldwide to find cues that in combination or separately are relevant for the four conditions.

RESULTS

In the first Delphi round, 38 of the 48 enrolled participants (79%) completed a questionnaire; in the second round 32 of 48 (67%). Eventually, 46 cues in eight categories (e.g., facial, vocal/verbal, body movements, sleep /behavioral state, posture/muscle tone, agitation, physiological and contextual) were found relevant. Thirty-three (72%) were considered relevant for pain, 24 for undersedation (52%), 35 for iatrogenic withdrawal syndrome (76%) and 28 (61%) for pediatric delirium. Thirteen cues (28%) were considered relevant for all four conditions; 11's (24%) for only one condition.

CONCLUSION

This Delphi study is the first step in developing a 4-in-1 comprehensive checklist to assess pain, undersedation, iatrogenic withdrawal syndrome and delirium in a holistic manner. Further validation is needed before the checklist can be applied in practice. Application of the mosaIC checklist could help determine what condition is most likely to cause a child's discomfort-and at the same time help reduce the PICU staff's registration burden.

Dexmedetomidine for prevention of opioid/benzodiazepine withdrawal syndrome in pediatric intensive care unit: Interim analysis of a randomized controlled trial

STUDY OBJECTIVE

Withdrawal syndrome (WS) may be a critical drawback of opioid/benzodiazepine weaning in children. The most effective intervention to reduce WS prevalence is yet to be determined. Dexmedetomidine (DEX) was estimated to be effective in reducing WS-related symptoms, but no randomized trial has been conducted to prove its efficacy so far. We aimed to evaluate the efficacy and safety of DEX in reducing the occurrence of WS.

DESIGN AND SETTING

This was an adaptive randomized double-blind placebo-controlled trial conducted at three Italian Pediatric Intensive Care Units (PICUs).

PATIENTS

It included children admitted to PICU, undergoing at least five days of opioids/benzodiazepines continuous infusion, and ready to start the analgosedation weaning.

INTERVENTION

Twenty-four hours before the start of weaning, an infusion of DEX/placebo was started. WS symptoms were monitored using the Withdrawal-Assessment-Tool-version-1 (WAT-1). In case of WS symptoms (WAT-1 ≥ 3) an opioid/benzodiazepine bolus was given and the DEX/placebo infusion-rate was increased.

MEASUREMENTS

The primary outcome measure was the prevalence of WS. Secondary outcomes were the trend of WAT-1 over time, number of rescue doses, length of weaning and PICU-stay, and onset of adverse events (AEs).

MAIN RESULTS

Forty-five patients were enrolled, of whom 5 dropped-out and 40 entered the interim analysis. There were no significant baseline differences between groups. WS prevalence did not significantly differ between groups (77.8% DEX vs 90.9% placebo, p = 0.381). By generalized linear mixed modeling, the WAT-1 trend showed a significant increase per unit of time in the DEX arm (estimate 0.27, CI 0.07-0.47, p = 0.009) compared to placebo. Most frequent AEs were hemodynamic, and all of them happened in the DEX arm.

CONCLUSIONS

A continuous infusion of DEX, started 24 h before the analgosedation weaning and increased based on WS signs, was not able to significantly modify the prevalence of WS in children who received at least five days of opioids/benzodiazepines treatment compared to placebo.

Weaning Analgosedation in Patients Requiring Prolonged Mechanical Ventilation

Although research supports the minimization of sedation in mechanically ventilated patients, many patients with severe acute respiratory distress syndrome (ARDS) receive prolonged opioid and sedative infusions. ICU teams face the challenge of weaning these medications, balancing the risks of sedation with the potential to precipitate withdrawal symptoms. In this article, we use a clinical case to discuss our approach to weaning analgosedation in patients recovering from long-term mechanical ventilation. We believe that a protocolized, multimodal weaning strategy implemented by a multidisciplinary care team is required to reduce potential harm from both under- and over-sedation. At present, there is no strong randomized clinical trial evidence to support a particular weaning strategy in adult ICU patients, but appraisal of the existing literature in adults and children can guide decision-making to enhance the recovery of these patients.

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.

Rosland G, Egerod I, Bentsen GK. Iatrogenic withdrawal syndrome frequently occurs in paediatric intensive care without algorithm for tapering of analgosedation

BACKGROUND

Analgesics and sedatives are key elements to reduce physiological and psychological stress associated with treatment in paediatric intensive care. Prolonged drug use may induce tolerance and development of iatrogenic withdrawal syndrome (IWS) during the tapering phase. Our primary aim was to describe the prevalence of IWS among critically ill ventilated patients in two Norwegian paediatric intensive care units (PICUs), and secondary to investigate what motivated bedside nurses to administer additional drug doses.

METHODS

Mechanically ventilated patients (n = 40) from newborn to eighteen years of age, with continuous infusions of opioids and benzodiazepines for 5 days or more, were included consecutively from May 2016 to June 2018. By using Withdrawal Assessment Tool-1 (WAT-1) twice daily we recorded the prevalence of IWS. Additionally, we recorded signs and symptoms that led bedside nurses to administration extra bolus medication.

RESULTS

Peak WAT-1 score indicated an IWS prevalence of 95% in this selected group. The first days of the tapering phase were most critical for IWS. The most frequent symptoms triggering administration of additional bolus doses were agitation/restlessness, and thiopental and propofol were the bolus drugs used most frequently.

CONCLUSIONS

IWS affected 95% of the children having received infusions of opioids and benzodiazepines for 5 days or more in PICUs without a tapering protocol for these drugs. This calls for implementation and testing of such weaning protocols.

Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit

Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.

Maternal and iatrogenic neonatal opioid withdrawal syndrome: Differences and similarities in recognition, management, and consequences

Opioids are potent analgesics used to manage pain in both young and old, but the increased use in the pregnant population has significant individual and societal implications. Infants dependent on opioids, either through maternal or iatrogenic exposure, undergo neonatal opioid withdrawal syndrome (NOWS), where they may experience withdrawal symptoms ranging from mild to severe. We present a detailed and original review of NOWS caused by maternal opioid exposure (mNOWS) and iatrogenic opioid intake (iNOWS). While these two entities have been assessed entirely separately, recognition and treatment of the clinical manifestations of NOWS overlap. Neonatal risk factors such as age, genetic predisposition, drug type, and clinical factors like type of opioid, cumulative dose of opioid exposure, and disease status affect the incidence of both mNOWS and iNOWS, as well as their severity. Recognition of withdrawal is dependent on clinical assessment of symptoms, and the use of clinical assessment tools designed to determine the need for pharmacotherapy. Treatment of NOWS relies on a combination of non-pharmacological therapies and pharmacological options. Long-term consequences of opioids and NOWS continue to generate controversy, with some evidence of anatomic brain changes, but conflicting animal and human clinical evidence of significant cognitive or behavioral impacts on school-age children. We highlight the current knowledge on clinically relevant recognition, treatment, and consequences of NOWS, and identify new advances in clinical management of the neonate. This review brings a unique clinical perspective and critically analyzes gaps between the clinical problem and our preclinical understanding of NOWS.

Dexmedetomidine and Iatrogenic Withdrawal Syndrome in Critically Ill Children

BACKGROUND

Iatrogenic withdrawal syndrome is a well-known adverse effect of sedatives and analgesics commonly used in patients receiving mechanical ventilation in the pediatric intensive care unit, with an incidence of up to 64.6%. When standard sedative and analgesic treatment is inadequate, dexmedetomidine may be added. The effect of supplemental dexmedetomidine on iatrogenic withdrawal syndrome is unclear.

OBJECTIVE

To explore the potentially preventive effect of dexmedetomidine, used as a supplement to standard morphine and midazolam regimens, on the development of iatrogenic withdrawal syndrome in patients receiving mechanical ventilation in the pediatric intensive care unit.

METHODS

This retrospective observational study used data from patients on a 10-bed general pediatric intensive care unit. Iatrogenic withdrawal syndrome was measured using the Sophia Observation withdrawal Symptoms-scale.

RESULTS

In a sample of 102 patients, the cumulative dose of dexmedetomidine had no preventive effect on the development of iatrogenic withdrawal syndrome (P = .19). After correction for the imbalance in the baseline characteristics between patients who did and did not receive dexmedetomidine, the cumulative dose of midazolam was found to be a significant risk factor for iatrogenic withdrawal syndrome (P < .03).

CONCLUSION

In this study, supplemental dexmedetomidine had no preventive effect on iatrogenic withdrawal syndrome in patients receiving sedative treatment in the pediatric intensive care unit. The cumulative dose of midazolam was a significant risk factor for iatrogenic withdrawal syndrome.

Treatment of benzodiazepine withdrawal syndrome in a severe traumatic brain injury patient

Prolonged exposure to benzodiazepines (BDZ) may contribute towards physical dependence, which is manifested by iatrogenic Benzodiazepine Withdrawal Syndrome (BWS), a condition often underdiagnosed. Current evidence recommends precluding BDZ infusion as sedation in the intensive care unit to avoid possible withdrawal and delirium issues. Administration of dexmedetomidine should be considered to facilitate weaning in patients with BWS.

Strategies for the Prevention and Treatment of Iatrogenic Withdrawal from Opioids and Benzodiazepines in Critically Ill Neonates, Children and Adults: A Systematic Review of Clinical Studies

BACKGROUND

Critically ill patients are at high risk of iatrogenic withdrawal syndrome (IWS), due to exposure to high doses or prolonged periods of opioids and benzodiazepines.

PURPOSE

To examine pharmacological management strategies designed to prevent and/or treat IWS from opioids and/or benzodiazepines in critically ill neonates, children and adults.

METHODS

We included non-randomised studies of interventions (NRSI) and randomised controlled trials (RCTs), reporting on interventions to prevent or manage IWS in critically ill neonatal, paediatric and adult patients. Database searching included: PubMed, CINAHL, Embase, Cochrane databases, TRIP, CMA Infobase and NICE evidence. Additional grey literature was examined. Study selection and data extraction were performed in duplicate. Data collected included: population, definition of opioid, benzodiazepine or mixed IWS, its assessment and management (drug or strategy, route of administration, dosage and titration), previous drug exposures and outcomes measures. Methodological quality assessment was performed by two independent reviewers using the Cochrane risk of bias tool for RCTs and the ROBINS-I tool for NRSI. A qualitative synthesis of the results is provided. For the subset of studies evaluating multifaceted protocolised care, we meta-analysed results for 4 outcomes and examined the quality of evidence using GRADE post hoc.

RESULTS

Thirteen studies were eligible, including 10 NRSI and 3 RCTs; 11 of these included neonatal and paediatric patients exclusively. Eight studies evaluated multifaceted protocolised interventions, while 5 evaluated individual components of IWS management (e.g. clonidine or methadone at varying dosages, routes of administration and duration of tapering). IWS was measured using an appropriate tool in 6 studies. Ten studies reported upon occurrence of IWS, showing significant reductions (n = 4) or no differences (n = 6). Interventions failed to impact duration of mechanical ventilation, ICU length of stay, and adverse effects. Impact on opioid and/or benzodiazepine total doses and duration showed no differences in 4 studies, while 3 showed opioid and benzodiazepine cumulative doses were significantly reduced by 20-35% and 32-66%, and treatment durations by 1.5-11 and 19 days, respectively. Variable effects on intervention drug exposures were found. Weaning durations were reduced by 6-12 days (n = 4) for opioids and/or methadone and by 13 days (n = 1) for benzodiazepines. In contrast, two studies using interventions centred on transition to enteral routes or longer tapering durations found significant increases in intervention drug exposures. Interventions had overall non-significant effects on additional drug requirements (except for one study). Included studies were at high risk of bias, relating to selection, detection and reporting bias.

CONCLUSION

Interventions for IWS management fail to impact duration of mechanical ventilation or ICU length of stay, while effect on occurrence of IWS and drug exposures is inconsistent. Heterogeneity in the interventions used and methodological issues, including inappropriate and/or subjective identification of IWS and bias due to study design, limited the conclusions.

A nurse-driven analgesia and sedation protocol reduces length of PICU stay and cumulative dose of benzodiazepines after corrective surgery for tetralogy of Fallot

PURPOSE

Analgesia and sedation protocols are reported to reduce the requirement of sedative and analgesic agents, duration of mechanical ventilation, and length of pediatric intensive care unit (PICU) stay. However, these studies often were conducted based on inhomogeneous cohorts. The aim of this study was the evaluation of a nurse-driven analgesia and sedation protocol in a homogenous population of infants following corrective surgery for tetralogy of Fallot (TOF).

DESIGN AND METHODS

This retrospective analysis was conducted in a cardiac PICU of a tertiary referral center. Two cohorts of patients who underwent corrective surgery for TOF below the age of 7 months, were retrospectively evaluated before and after implementation of a nurse-driven analgesia and sedation protocol. We compared peak and cumulative doses of midazolam, morphine, and clonidine, length of PICU stay and time on mechanical ventilation.

RESULTS

A total of 33 patients were included in the preimplementation period and 32 during the postimplementation period. Implementation of the nurse-driven analgesia and sedation protocol had no effect on time on mechanical ventilation (72 hr [24-141] vs. 49 hr [24-98]), but significantly on length of PICU stay (7 days [5-14] vs. 5 days [4-7]). Cumulative doses of midazolam (7.37 mg/kg [4.70-17.65] vs. 5.0 mg/kg [2.70-9.12]) as well as peak doses of midazolam (0.22 mg·kg^-1 ·hr^-1 [0.20-0.33] vs. 0.15 mg·kg^-1 ·hr^-1 [0.13-0.20]) and morphine (50.0 µg·kg^-1 ·hr^-1 [39.7-79.9] vs. 42.5 µg·kg^-1 ·hr^-1 [29.7-51.8]) were significantly reduced. The postimplemantation group showed no increase in postoperative complications and adverse events.

PRACTICE IMPLICATIONS

The implementation of a nurse-driven analgesia and sedation protocol is safe in infants following corrective surgery for TOF. It reduces significantly the length of PICU stay, cumulative and peak doses of midazolam and peak doses of morphine.

Withdraw Sedation Gently or Face Withdrawal Syndrome!

How to cite this article: Poddar B. Withdraw Sedation Gently or Face Withdrawal Syndrome! Indian J Crit Care Med 2020;24(6):381-382.

Survey of analgesia and sedation in pediatric intensive care units in Japan

BACKGROUND

High-quality evidence of analgesia and sedation management in pediatric intensive care units (PICUs) is lacking.

METHODS

An online survey concerning the institutional management of pain, sedation, delirium, and withdrawal syndrome, as well as non-pharmacological interventions to reduce pain and / or to provide comfort, was conducted with the medical directors of 31 PICUs in Japan. The survey was conducted from September to November 2016.

RESULTS

The response rate was 77% (24/31). Pain was routinely assessed in nine (38%) PICUs. Self-report pain scales were used in 14 (58%) PICUs. Observational pain scales for children who were unable to self-report were used in only one PICU. Physician-driven analgesia protocols were used in two (8%) PICUs. Although sedation scales for intubated patients were used in 15 (63%) PICUs, they were used for the goal-directed sedation management in nine (38%). Nurse-driven sedation protocols were used in two (8%) PICUs. Five (21%) PICUs used delirium assessment tools, and delirium screening was not routinely done in any PICU. Five (21%) PICUs regularly used withdrawal assessment tools for a high-risk group of patients with withdrawal syndrome. Non-pharmacological interventions for analgesia and comfort were frequently practiced for mechanically ventilated patients.

CONCLUSIONS

This study is the first survey conducted by physicians regarding pain and agitation management in PICUs in Japan, and the results revealed great diversity in practice. The implementation strategies to assess pain, delirium, and withdrawal syndrome, as well as to set goals regarding sedation level, are lacking. Protocols for analgesia and sedation management are uncommon.

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.

Sedation withdrawal following single stage laryngotracheal reconstruction: Does dexmedetomidine help?

OBJECTIVES

Single-stage laryngotracheal reconstruction (SS-LTR) requires a period of post-operative intubation, during which time adequate sedation is needed to ensure graft healing. Commonly used agents include benzodiazepines, opioids, and more recently, dexmedetomidine, a centrally-acting α₂ adrenoreceptor. This study aims to compare withdrawal outcomes between various sedation regimens following SS-LTR.

METHODS

Retrospective chart review of 56 patients who underwent SS-LTR between 2008 and 2018 at a tertiary free-standing children's hospital was performed. Of 47 patients with complete records, 18 patients received dexmedetomidine for >75% of their intubation period with midazolam (DexWM), 9 received dexmedetomidine for >75% without midazolam (DexWOM), and 20 received dexmedetomidine for <75% with midazolam (noDex).

RESULTS

There was no significant difference in length of PICU or hospital stay between the groups. The noDex group trended toward a higher re-intubation rate of 25%, as compared with 11% of DexWOM and 5.6% of DexWM (p = 0.21). There was no significant difference in days of oral sedation taper required or Withdrawal Assessment Tool (WAT-1) score for post-extubation days 1 and 3. By post-extubation day 5, 100% of the DexWM group had WAT-1 scores <3 as compared with 71.4% of the noDex group (p = 0.037). Notably, lower average daily doses of dexmedetomidine and midazolam were used in the DexWM group, as compared with the DexWOM and noDex groups, respectively.

CONCLUSION

Dexmedetomidine as a primary sedation agent with midazolam allows for adequate sedation following SS-LTR. The combination of the two drugs in the DexWM group not only reduced the dosage of each drug needed, but also significantly improved WAT-1 scores by post-extubation day 5, as compared with the alternative sedation regimens.

Evaluation of an updated sedation protocol to reduce benzodiazepines in a pediatric intensive care unit

Aim: Midazolam like other benzodiazepines is supposed to be neurotoxic in small children and to represent a risk factor for the development of delirium. The aim of this study was to evaluate whether a modified analgesia and sedation protocol is feasible and effective to reduce the requirement of midazolam in neonates and young infants after cardiac surgery.Methods: Patients aged 6 months or younger who underwent surgery for congenital heart disease with cardiopulmonary bypass were enrolled and divided into a pre-modification group (January-December 2016) and after adjusting our sedation protocol into a post-modification group (January-December 2018). We assessed the doses of midazolam, morphine and clonidine as well as sedation scores according to our nurse-driven sedation protocol every 8 h until 120 h after cardiac surgery. During weaning from analgesia and sedation, children were monitored regarding withdrawal symptoms and pediatric delirium.Results: Sixty-five patients were included (33 patients in the pre-modification group, 32 patients in the post-modification group). The number of patients receiving midazolam and the cumulative dose of midazolam could be successfully reduced. The sedation scores were still within the desired target range for adequate sedation without any negative side effects.Conclusions: It is feasible and safe to reduce the use of midazolam in infants after cardiac surgery maintaining sedation goals based on a modified nurse-driven analgesia and sedation protocol.

Protocolized Sedative Weaning vs Usual Care in Pediatric Critically Ill Patients: A Pilot Randomized Controlled Trial

Aims

The prolonged use of benzodiazepines and opioids can lead to an increase in the incidence of withdrawal syndrome. One of the known risk factors is the lack of a sedative-weaning protocol. This study established a sedative-weaning protocol and compared this protocol with the usual care of weaning in high-risk critically ill children.

Materials and methods

This was an open-label, randomized controlled trial in a tertiary-care hospital. We recruited children aged 1 month to 18 years who had received intravenous sedative or analgesic drugs for at least 5 days. The exclusion criteria were patients who had already experienced the withdrawal syndrome. We established a weaning protocol. Eligible patients were randomly divided into the protocolized (intervention) and usual care (control) groups. The primary objective was to determine the prevalence of the withdrawal syndrome compared between two groups.

Results

Thirty eligible patients were enrolled (19 in the intervention and 11 in the control group). Baseline characteristics were not significantly different between both the groups. The prevalence of the withdrawal syndrome was 84% and 81% of patients in the intervention and control group, respectively. The duration of the initial weaning phase was shorter in the intervention group than in the control group (p value = 0.026). The cumulative dose of morphine solution for rescue therapy in the intervention group was statistically lower than that in the control group (p value = 0.016).

Conclusion

The implementation of the sedative-weaning protocol led to a significant reduction in the percentage of withdrawal days and length of intensive care unit stay without any adverse drug reactions. External validation would be needed to validate this protocol.

ClinicalTrials.gov identifier

NCT03018977

How to cite this article

Tiacharoen D, Lertbunrian R, Veawpanich J, Suppalarkbunlue N, Anantasit N. Protocolized Sedative Weaning vs Usual Care in Pediatric Critically Ill Patients: A Pilot Randomized Controlled Trial. Indian J Crit Care Med 2020;24(6):451–458.

Assessment and treatment of the withdrawal syndrome in paediatric intensive care units: Systematic review

BACKGROUND

Sedoanalgesia secondary iatrogenic withdrawal syndrome (IWS) in paediatric intensive units is frequent and its assessment is complex. Therapies are heterogeneous, and there is currently no gold standard method for diagnosis. In addition, the assessment scales validated in children are scarce. This paper aims to identify and describe both the paediatric diagnostic and assessment tools for the IWS and the treatments for the IWS in critically ill paediatric patients.

METHODS

A systematic review was conducted according to the PRISMA guidelines. This review included descriptive and observational studies published since 2000 that analyzed paediatric scales for the evaluation of the iatrogenic withdrawal syndrome and its treatments. The eligibility criteria included neonates, newborns, infants, pre-schoolers, and adolescents, up to age 18, who were admitted to the paediatric intensive care units with continuous infusion of hypnotics and/or opioid analgesics, and who presented signs or symptoms of deprivation related to withdrawal and prolonged infusion of sedoanalgesia.

RESULTS

Three assessment scales were identified: Withdrawal Assessment Tool-1, Sophia Observation Withdrawal Symptoms, and Opioid and Benzodiazepine Withdrawal Score. Dexmedetomidine, methadone and clonidine were revealed as options for the treatment and prevention of the iatrogenic withdrawal syndrome. Finally, the use of phenobarbital suppressed symptoms of deprivation that are resistant to other drugs.

CONCLUSIONS

The reviewed scales facilitate the assessment of the iatrogenic withdrawal syndrome and have a high diagnostic quality. However, its clinical use is very rare. The treatments identified in this review prevent and effectively treat this syndrome. The use of validated iatrogenic withdrawal syndrome assessment scales in paediatrics clinical practice facilitates assessment, have a high diagnostic quality, and should be encouraged, also ensuring nurses' training in their usage.

Effect of a Sedation Weaning Protocol on Safety and Medication Use among Hospitalized Children Post Critical Illness

BACKGROUND

Best practice guidelines for the safe and compassionate care of critically ill children necessitates the use of sedation to ensure adequate ventilation, patient safety and comfort. Prolonged use of sedation can result in tolerance, physical dependence and iatrogenic withdrawal syndrome if medications are weaned too quickly.

PROBLEM

In the context of medication errors related to parent administration of outpatient sedation weans, we set out to improve the safety of children weaning from sedatives.

METHODS

A retrospective analysis was completed. Quality improvement was guided by using Plan-Do-Study-Act cycles.

INTERVENTIONS

An evidence-based post PICU sedation weaning guideline was created and implemented over time with ongoing education, and review of progress with staff members with pre-post evaluation.

RESULTS

Post intervention, there were significant differences in the numbers of patients discharged on home weaning from both opioids and benzodiazepines (11%, n = 24/219 pre; 3%, n = 7/233 post; p < 0.005). The number of patients discharged with a methadone wean decreased (7%, n = 16/219 pre; 0%, 0/233 post; p = 0.03). Despite these differences, there were no significant differences in the median hospital length of stay (42 pre; 39 post; p = 0.35). Post implementation more children had mild to moderate symptoms of withdrawal (11% pre; 21% post; p < 0.005) as compared to pre-implementation, however, the percentage of severe symptoms remained consistently low (0.6% pre; 1% post; p = 0.11).

CONCLUSIONS

Implementation of an evidence-based post PICU weaning guideline significantly reduced the number of patients discharged on potentially dangerous medications with modest increases in mild-moderate symptoms of withdrawal and no significant change in length of stay or the incidence of severe symptoms of withdrawal.

A Standardized Care Pathway following Mandibular Distraction in Infants Less Than 3 Months of Age

OBJECTIVES

To assess for differences in postoperative care following mandibular distraction osteogenesis (MDO) in infants before and after implementation of a standardized protocol.

STUDY DESIGN

Retrospective chart review.

SETTING

Urban tertiary pediatric hospital.

SUBJECTS AND METHODS

The inpatient charts of infants who underwent MDO before 90 days of age were assessed for metrics such as postoperative length of stay (LOS), duration of mechanical ventilation, and the choice and duration of sedating medications.

RESULTS

Over a 6-year period, 16 patients met inclusion criteria. The first 4 consecutive patients were managed at the discretion of the critical care staff. The remaining 12 infants were managed with a planned 4- to 6-day period of postoperative intubation, during which a standard protocol determined the choice, dosage, and duration of sedating medications. The mean age was similar between groups (preprotocol: mean, 26.5 days; protocol: mean, 20.3 days; P = .51). The mean postoperative LOS was 13.3 days less among infants managed with the protocol (P = .06), and the mean number of midazolam boluses was fewer among protocol patients (P < .01). A more consistent postoperative LOS, duration of mechanical ventilation, and exposure to sedating medications was observed among protocol subjects (P < .01). The LOS for 2 patients in the preprotocol group was extended due to iatrogenic withdrawal syndrome. There were no instances of accidental extubation or anoxia in either group.

CONCLUSIONS

Among infants undergoing MDO, standardizing postoperative airway and sedation practices may offer a more predictable postoperative course as compared with a case-by-case management philosophy.

Reevaluating a Standardized Sedation Weaning Protocol for Pediatric Laryngotracheal Reconstruction for Continuous Quality Improvement

Importance

Health care organizations are complex and evolving systems. To date, longitudinal evaluation to ensure the sustainability of quality improvement (QI) initiatives has been missing from the otolaryngology literature. We sought to reassess perioperative management of laryngotracheal reconstruction, which requires adequate sedation.

Objective

Using principles of continuous QI, the objectives of this study were to (1) describe step-by-step methods to sustain QI efforts and (2) revisit a series of process, outcome, and balance measures for sedation weaning management following implementation of a new electronic health record (EHR).

Design, Setting, and Participants

A standardized sedation weaning protocol was previously developed and instituted in February 2013. To address healthcare system-wide changes, a 7-step, Institute for Healthcare Improvement methodology was used to reevaluate a series of measures comparing a previous postweaning group (2013-2014; 13 patients) and current post-EHR group (2016; 11 patients). We conducted a focus group review of these 24 patients.

Main Outcomes and Measures

The primary outcome measure was length of sedation weaning. Secondary outcome, process, and balance measures included total length of sedation, absence of standardized wean document, absence of specific recommendations on weaning regimen, length of stay, continued weaning at discharge, discharge location, absence of discharge instructions on weaning regimen or iatrogenic withdrawal syndrome (IWS), discharge within 72 hours of stopping weaning, and readmission.

Results

The postweaning and post-EHR groups were similar in age (20.5 months [95% CI, 11.92-29.15] vs 26.5 months [95% CI, 17.68-35.40]), as well as male sex (11 of 13 [85%] vs 10 of 11 [91%]), respectively. In the post-EHR group, the standardized sedation wean document was missing from 9 of 11 (82%) medical records. However, the primary outcome measure, length of sedation weaning, remained stable at 9.45 (95% CI, 7.62-11.29) days in the post-EHR group compared with 9.08 (95% CI, 7.00-11.18) days in the postweaning group. In addition, only 5 of 11 (46%) of discharges in the post-EHR group had specific guidance on weaning since the standardized template was no longer in use. As a result, in the post-EHR group, patients were 15.2 (95% CI, 0.46-242.34) times as likely to lack discharge instructions on weaning or IWS.

Conclusions and Relevance

Quality improvement is meant to be a continuous process in which reevaluation of care practices are regularly performed. System-wide redesign can be achieved using a formal methodological approach. Moving forward, notable QI opportunities for our institution included the development of a flexible sedation weaning template, as well as enhancements to discharge instructions to include IWS diagnosis and treatment.

Sedation Management for Critically Ill Children with Pre-Existing Cognitive Impairment

OBJECTIVE

To compare current analgesia and sedation management practices between critically ill children with pre-existing cognitive impairment and critically ill neurotypical children, including possible indicators of therapeutic efficacy.

STUDY DESIGN

This study used secondary analysis of prospective data from the RESTORE clinical trial, with 2449 children admitted to the pediatric intensive care unit and receiving mechanical ventilation for acute respiratory failure. Subjects with a baseline Pediatric Cerebral Performance Category ≥3 were defined as subjects with cognitive impairment, and differences between groups were explored using regression methods accounting for pediatric intensive care unit as a cluster variable.

RESULTS

This study identified 412 subjects (17%) with cognitive impairment. Compared with neurotypical subjects, subjects with cognitive impairment were older (median, years, 6.2 vs 1.4; P < .001) with more severe pediatric acute respiratory distress syndrome (40% vs 33%; P = .009). They received significantly lower cumulative doses of opioids (median, mg/kg, 14.2 vs 16.2; P < .001) and benzodiazepines (10.6 vs 14.4; P < .001). Three nonverbal subjects with cognitive impairment received no analgesia or sedation. Subjects with cognitive impairment were assessed as having more study days awake and calm and fewer study days with an episode of pain. They were less likely to be assessed as having inadequate pain/sedation management or unplanned endotracheal/invasive tube removal. Subjects with cognitive impairment had more documented iatrogenic withdrawal symptoms than neurotypical subjects.

CONCLUSIONS

Subjects with cognitive impairment in this study received less medication, but it is unclear whether they have authentically lower analgesic and/or sedative requirements or are vulnerable to inadequate assessment of discomfort because of the lack of validated assessment tools. We recommend the development of pain and sedation assessment tools specific to this patient population.

Survey of the Current Use of Dexmedetomidine and Management of Withdrawal Symptoms in Critically Ill Children

OBJECTIVES

Dexmedetomidine use for sedation in the pediatric intensive care units (PICUs) has increased since its initial US Food and Drug Administration (FDA) approval in adults. However, there is limited evidence to direct providers regarding current usage, dosing, and monitoring for withdrawal symptoms in pediatric patients. This study sought to determine the utilization of dexmedetomidine and management of dexmedetomidine withdrawal symptoms among PICU physicians.

METHODS

A questionnaire survey was distributed to all members of the American Academy of Pediatrics Section on Critical Care. It assessed the practice site demographics, indication, dosing, and duration of dexmedetomidine infusion, unit protocol, and strategies for management of dexmedetomidine withdrawal.

RESULTS

A total of 147 surveys (21.1%) were returned and analyzed. The reported uses for dexmedetomidine were as a primary sedative (59.9%), adjunctive agent for sedation (82.3%), and adjunctive agent to assist weaning sedation (62.6%) or from mechanical ventilation (70.1%). One hundred twenty-nine respondents (87.8%) had concerns over dexmedetomidine withdrawal, with 59 respondents becoming concerned after 120 hours of infusion (45.7%). Most respondents reported managing dexmedetomidine withdrawal symptoms via a regimented wean and initiation of clonidine (81%). Units with >1000 admissions per year were more likely to have a protocol related to dexmedetomidine use (p = 0.021). Units with >1000 admissions per year reported using clonidine for withdrawal at a higher rate, whereas units with ≤1000 admissions per year used a systematic wean of dexmedetomidine (p = 0.014).

CONCLUSIONS

Dexmedetomidine use in the PICU is varied among pediatric intensive care physicians. Intensivists have withdrawal concerns after dexmedetomidine discontinuation, and the primary management of this withdrawal phenomenon is the initiation of clonidine with a regimented dexmedetomidine wean.

Pharmacological Strategies for Decreasing Opioid Therapy and Management of Side Effects from Chronic Use

As awareness increases about the side effects of opioids and risks of misuse, opioid use and appropriate weaning of opioid therapies have become topics of significant clinical relevance among pediatric populations. Critically ill hospitalized neonates, children, and adolescents routinely receive opioids for analgesia and sedation as part of their hospitalization, for both acute and chronic illnesses. Opioids are frequently administered to manage pain symptoms, reduce anxiety and agitation, and diminish physiological stress responses. Opioids are also regularly prescribed to youth with chronic pain. These medications may be prescribed during the initial phase of a diagnostic workup, during an emergency room visit; as an inpatient, or on an outpatient basis. Following treatment for underlying pain conditions, it can be challenging to appropriately wean and discontinue opioid therapies. Weaning opioid therapy requires special expertise and care to avoid symptoms of increased pain, withdrawal, and agitation. To address this challenge, there have been enhanced efforts to implement opioid-reduction during pharmacological therapies for pediatric pain management. Effective pain management therapies and their outcomes in pediatrics are outside the scope of this paper. The aims of this paper were to: (1) Review the current practice of opioid-reduction during pharmacological therapies; and (2) highlight concrete opioid weaning strategies and management of opioid withdrawal.

Evaluation of IV to Enteral Benzodiazepine Conversion Calculations in a Pediatric Intensive Care Setting

OBJECTIVES

To evaluate if institutionally established calculations for transitioning continuous IV midazolam to enteral benzodiazepines maintain Withdrawal Assessment Tool-Version 1 scores equal to or less than preconversion values.

DESIGN

Retrospective cohort study evaluating the effectiveness and safety of benzodiazepine conversion calculations embedded within an institution-specific clinical pathway for sedation and weaning of mechanically ventilated pediatric patients.

SETTING

A 55-bed, mixed-medical, noncardiac surgical PICU in a tertiary care children's hospital.

PATIENTS

All patients age 6 months to 18 years who received continuous midazolam for 5 days or longer while mechanically ventilated for 5-21 days and were then converted to either enteral diazepam or lorazepam following extubation (or return to baseline ventilator settings in tracheostomy-dependent patients) between January 1, 2015, and June 30, 2016.

INTERVENTIONS

Benzodiazepine conversion calculations were applied according to institutional clinical pathway guidance.

MEASUREMENTS AND MAIN RESULTS

Withdrawal Assessment Tool-Version 1 scores were compared pre and post benzodiazepine conversion. Patient demographics, benzodiazepine dose escalations, as needed benzodiazepine requirements, and severe adverse events within 48 hours of conversion were assessed. Seventy-one patient encounters were analyzed (median age, 2.5 yr; interquartile range, 1.2-5.3). The median Withdrawal Assessment Tool-Version 1 scores pre conversion and post conversion were not significantly different (1 [interquartile range, 0.75-2] and 1 [interquartile range, 0.25-2], respectively, p = 0.1). As needed benzodiazepine doses were administered in 38% of encounters post conversion, but escalation of a scheduled enteral benzodiazepine regimen was only required in 2.8% of encounters. Post conversion, one patient (1.4%) had increased seizure activity, and four patients (5.6%) required fluid boluses secondary to tachycardia or dehydration, but not hypotension.

CONCLUSIONS

These findings suggest that standardized benzodiazepine conversions successfully achieved consistent Withdrawal Assessment Tool-Version 1 scores compared with preconversion values. Severe adverse events associated with oversedation and/or withdrawal were minimal and confounded by underlying disease states.

Delirium in Pediatric Critical Care

Delirium occurs frequently in the critically ill child. It is a syndrome characterized by an acute onset and fluctuating course, with behaviors that reflect a disturbance in awareness and cognition. Delirium represents global cerebral dysfunction due to the direct physiologic effects of an underlying medical illness or its treatment. Pediatric delirium is strongly associated with poor outcomes, including increased mortality, prolonged intensive care unit length of stay, longer time on mechanical ventilation, and increased cost of care. With heightened awareness, the pediatric intensivist can detect, treat, and prevent delirium in at-risk children.

Sophia Observation withdrawal Symptoms-Paediatric Delirium scale: A tool for early screening of delirium in the PICU

BACKGROUND

Delirium in critically ill children is a severe neuropsychiatric disorder which has gained increased attention from clinicians. Early identification of delirium is essential for successful management. The Sophia Observation withdrawal Symptoms-Paediatric Delirium (SOS-PD) scale was developed to detect Paediatric Delirium (PD) at an early stage.

OBJECTIVE

The aim of this study was to determine the measurement properties of the PD component of the SOS-PD scale in critically ill children.

METHODS

A prospective, observational study was performed in patients aged 3 months or older and admitted for more than 48h. These patients were assessed with the SOS-PD scale three times a day. If the SOS-PD total score was 4 or higher in two consecutive observations, the child psychiatrist was consulted to assess the diagnosis of PD using the Diagnostic and Statistical Manual-IV criteria as the "gold standard". The child psychiatrist was blinded to outcomes of the SOS-PD. The interrater reliability of the SOS-PD between the care-giving nurse and a researcher was calculated with the intraclass correlation coefficient (ICC).

RESULTS

A total of 2088 assessments were performed in 146 children (median age 49 months; IQR 13-140). The ICC of 16 paired nurse-researcher observations was 0.90 (95% CI 0.70-0.96). We compared 63 diagnoses of the child psychiatrist versus SOS-PD assessments in 14 patients, in 13 of whom the diagnosis of PD was confirmed. The sensitivity was 96.8% (95% CI 80.4-99.5%) and the specificity was 92.0% (95% CI 59.7-98.9%).

CONCLUSIONS

The SOS-PD scale shows promising validity for early screening of PD. Further evidence should be obtained from an international multicentre study.

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.