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Riggs BJ, Carpenter JL. Pediatric Neurocritical Care: Maximizing Neurodevelopmental Outcomes Through Specialty Care. Pediatr Neurol 2023; 149:187-198. [PMID: 37748977 DOI: 10.1016/j.pediatrneurol.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/27/2023] [Accepted: 08/04/2023] [Indexed: 09/27/2023]
Abstract
The field of pediatric neurocritical care (PNCC) has expanded and evolved over the last three decades. As mortality from pediatric critical care illness has declined, morbidity from neurodevelopmental disorders has expanded. PNCC clinicians have adopted a multidisciplinary approach to rapidly identify neurological injury, implement neuroprotective therapies, minimize secondary neurological insults, and establish transitions of care, all with the goal of improving neurocognitive outcomes for their patients. Although there are many aspects of PNCC and adult neurocritical care (NCC) medicine that are similar, elemental difference between adult and pediatric medicine has contributed to a divergent evolution of the respective fields. The low incidence of pediatric critical care illness, the heterogeneity of neurological insults, and the limited availability of resources all shape the need for a PNCC clinical care model that is distinct from the established paradigm adopted by the adult neurocritical care community at large. Considerations of neurodevelopment are fundamental in pediatrics. When neurological injury occurs in a child, the neurodevelopmental stage at the time of insult alters the impact of the neurological disease. Developmental variables contribute to a range of outcomes for seemingly similar injuries. Despite the relative infancy of the field of PNCC, early reports have shown that implementation of a specialized PNCC service elevates the quality and safety of care, promotes education and communication, and improves outcomes for children with acute neurological injuries. The multidisciplinary approach of PNCC clinicians and researchers also promotes a culture that emphasizes the importance of quality improvement and education initiatives, as well as development of and adherence to evidence-based guidelines and family-focused care models.
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Affiliation(s)
- Becky J Riggs
- Division of Pediatric Critical Care Medicine, Oregon Health & Science University, Portland, Oregon.
| | - Jessica L Carpenter
- Division of Pediatric Neurology, University of Maryland Medical Center, Baltimore, Maryland
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Bolesta S, Burry L, Perreault MM, Gélinas C, Smith KE, Eadie R, Carini FC, Saltarelli K, Mitchell J, Harpel J, Stewart R, Riker RR, Fraser GL, Erstad BL. International Analgesia and Sedation Weaning and Withdrawal Practices in Critically Ill Adults: The Adult Iatrogenic Withdrawal Study in the ICU. Crit Care Med 2023; 51:1502-1514. [PMID: 37283558 DOI: 10.1097/ccm.0000000000005951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Iatrogenic withdrawal syndrome (IWS) associated with opioid and sedative use for medical purposes has a reported high prevalence and associated morbidity. This study aimed to determine the prevalence, utilization, and characteristics of opioid and sedative weaning and IWS policies/protocols in the adult ICU population. DESIGN International, multicenter, observational, point prevalence study. SETTING Adult ICUs. PATIENTS All patients aged 18 years and older in the ICU on the date of data collection who received parenteral opioids or sedatives in the previous 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS ICUs selected 1 day for data collection between June 1 and September 30, 2021. Patient demographic data, opioid and sedative medication use, and weaning and IWS assessment data were collected for the previous 24 hours. The primary outcome was the proportion of patients weaned from opioids and sedatives using an institutional policy/protocol on the data collection day. There were 2,402 patients in 229 ICUs from 11 countries screened for opioid and sedative use; 1,506 (63%) patients received parenteral opioids, and/or sedatives in the previous 24 hours. There were 90 (39%) ICUs with a weaning policy/protocol which was used in 176 (12%) patients, and 23 (10%) ICUs with an IWS policy/protocol which was used in 9 (0.6%) patients. The weaning policy/protocol for 47 (52%) ICUs did not define when to initiate weaning, and the policy/protocol for 24 (27%) ICUs did not specify the degree of weaning. A weaning policy/protocol was used in 34% (176/521) and IWS policy/protocol in 9% (9/97) of patients admitted to an ICU with such a policy/protocol. Among 485 patients eligible for weaning policy/protocol utilization based on duration of opioid/sedative use initiation criterion within individual ICU policies/protocols 176 (36%) had it used, and among 54 patients on opioids and/or sedatives ≥ 72 hours, 9 (17%) had an IWS policy/protocol used by the data collection day. CONCLUSIONS This international observational study found that a small proportion of ICUs use policies/protocols for opioid and sedative weaning or IWS, and even when these policies/protocols are in place, they are implemented in a small percentage of patients.
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Affiliation(s)
- Scott Bolesta
- Department of Pharmacy Practice, Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA
| | - Lisa Burry
- Departments of Pharmacy and Medicine, Sinai Health System, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Marc M Perreault
- Department of Pharmacy, McGill University Health Center and Faculty of Pharmacy, University of Montréal, Montréal, QC, Canada
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, and Centre for Nursing Research/Lady Davis Institute, Jewish General Hospital-CIUSSS West-Central-Montréal, Montréal, QC, Canada
| | | | - Rebekah Eadie
- Critical Care/Pharmacy, Ulster Hospital, Dundonald, United Kingdom
| | - Federico C Carini
- MS-ICU, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | - Jamie Harpel
- Department of Pharmacy Practice, Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA
| | - Ryan Stewart
- Department of Pharmacy Practice, Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA
| | - Richard R Riker
- Department of Critical Care/Pulmonary Medicine, Maine Medical Center, Portland, ME
| | | | - Brian L Erstad
- Department of Pharmacy Practice and Science, The University of Arizona, Tucson, AZ
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Lindberg HB, Steindal SA, Kvande ME. Critical care nurses' experiences of caring for patients with iatrogenic opioid withdrawal in the intensive care unit: A qualitative study. Intensive Crit Care Nurs 2023; 78:103452. [PMID: 37178587 DOI: 10.1016/j.iccn.2023.103452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/20/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVES To explore critical care nurses' experiences of caring for adult patients experiencing iatrogenic opioid withdrawal in the intensive care unit. RESEARCH METHODOLOGY/DESIGN A qualitative study with an explorative and descriptive design was conducted. Data were collected through semi-structured interviews and systematic text condensation was used to analyse the data. The study was reported according to the consolidated criteria for reporting qualitative research checklist. SETTING AND PARTICIPANTS Ten critical care nurses, working at three different intensive care units in two university hospitals in Norway. FINDINGS Three categories were identified in the data analysis. "Subtle signs and symptoms of opioid withdrawal", lack of a systematic approach to opioid withdrawal, and the prerequisites for appropriate management of opioid withdrawal. Critical care nurses experienced challenges in identifying opioid withdrawal due to subtle and vague signs and symptoms, especially when not knowing their patient or when difficulties were encountered with patient communication. A systematic approach to opioid withdrawal and increased knowledge, definitive plans for weaning, as well as interdisciplinary unity and collaboration, could improve the management of opioid withdrawal. CONCLUSION Validated assessment tools, systematic strategies, and guidelines are essential for the management of opioid withdrawal in opioid naïve patients in intensive care units. The prerequisites for an appropriate management of opioid withdrawal are an accurate and effective communication among critical care nurses and other healthcare professionals involved in patient care. IMPLICATIONS FOR CLINICAL PRACTICE There is a need for a validated assessment tool, systematic strategies, and guidelines for the management of opioid withdrawal in opioid naïve patients in intensive care units. Increased emphasis needs to be placed on the process of identifying iatrogenic opioid withdrawal and improving opioid withdrawal management in the education system and clinical practice.
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Affiliation(s)
- Hedda Bekken Lindberg
- Lovisenberg Diaconal University College, Lovisenberggata 15B, 0456 Oslo, Norway; Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway.
| | - Simen A Steindal
- Lovisenberg Diaconal University College, Lovisenberggata 15B, 0456 Oslo, Norway; Faculty of Health Studies, VID Specialized University, Oslo, Norway.
| | - Monica Evelyn Kvande
- Lovisenberg Diaconal University College, Lovisenberggata 15B, 0456 Oslo, Norway; Department of Anaesthesiology and Surgery, University Hospital of North Norway, Tromsø, Norway.
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Fox MA, Carothers C, Dircksen KK, Birrer KL, Choi MJ, Mukkera SR. Prevalence and Risk Factors for Iatrogenic Opioid Withdrawal in Medical Critical Care Patients. Crit Care Explor 2023; 5:e0904. [PMID: 37151892 PMCID: PMC10158916 DOI: 10.1097/cce.0000000000000904] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
Opioids are the mainstay of pain management and sedation in critically ill patients, which can lead to the development of physiologic tolerance and dependency. The prevalence of iatrogenic opioid withdrawal syndrome (IWS) is reported as 17-32% in the ICU; however, limited evidence exists for the medical ICU patient population. OBJECTIVES To identify the and risk factors for IWS in adult patients admitted to critical care medicine services who received greater than or equal to 24 hours of continuous opioid infusion therapy. DESIGN SETTING AND PARTICIPANTS A prospective, observational study was conducted in a tertiary care hospital in adult medical ICU patients. Ninety-two patients who received greater than or equal to 24 hours of continuous opioid infusions were included in the study. MAIN OUTCOMES AND MEASUREMENTS Patients were assessed daily after opioid infusion discontinuation using the Clinical Opiate Withdrawal Scale (COWS) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) opioid withdrawal criteria for a maximum of 5 days. The primary outcome was the prevalence of IWS of moderate severity or greater using COWS. Secondary outcomes included the prevalence of IWS diagnosis of any severity based on COWS, the prevalence of IWS diagnosis based on a positive DSM-V score, and the identification of potential risk factors for developing IWS of any severity. RESULTS Four hundred forty-seven patients received greater than or equal to 24 hours of continuous opioid therapy. Of these, 385 were excluded, leaving 92 patients included in the final analysis. Except for a higher prevalence of psychiatric history in the IWS-positive group, baseline characteristics were similar. Overall, 11 patients (12%) developed IWS of moderate severity or greater, based on COWS. The IWS-positive group also had longer durations of opioid infusions, higher cumulative opioid infusion doses, higher mean daily doses, and higher infusion rates at any given time. The concomitant use of dexmedetomidine (38.3 vs 15.6%, p = 0.014) and benzodiazepines (63.8 vs 37.8%, p = 0.021) during or after the opioid infusion were significantly higher in the IWS-positive group compared with the IWS-negative group. No significant differences were found between the two groups for scheduled or as needed opioids after cessation of the opioid infusion. Continuous opioid infusions greater than or equal to 72 hours and total daily dose greater than or equal to 1,200 μg were found to be independent predictors for the development of iatrogenic opioid withdrawal via logistic regression. CONCLUSIONS AND RELEVANCE Approximately one in every eight patients receiving continuous infusion opioid for greater than 24 hours while mechanically ventilated in the medical ICU will develop IWS of moderate severity or greater; this increases to one in three patients diagnosed with DSM-V criteria or any level of IWS severity. Patients receiving opioid infusions greater than or equal to 72 hours, or a total daily fentanyl dose of greater than or equal to 1,200 μg (~ 50 μg/hr) are at a higher risk for developing IWS and should be monitored as part of clinical practice when opioid infusions are discontinued.
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Affiliation(s)
- Marlena A Fox
- Department of Pharmacy, Orlando Health Orlando Regional Medical Center (OHORMC), Orlando, FL
| | - Chancey Carothers
- Department of Pharmacy, Orlando Health Orlando Regional Medical Center (OHORMC), Orlando, FL
| | - Katie K Dircksen
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | - Kara L Birrer
- Department of Pharmacy, Orlando Health Orlando Regional Medical Center (OHORMC), Orlando, FL
| | - Min J Choi
- Department of Pharmacy, Sarasota Memorial Hospital, Sarasota, FL
| | - Satyanarayana R Mukkera
- Department of Critical Care Medicine, Orlando Health Orlando Regional Medical Center (OHORMC), Orlando, FL
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McAlister S, Connor JA, Engstrand S, McLellan MC. Validation of the withdrawal assessment tool-1 (WAT-1) in pediatric cardiovascular patients on an inpatient unit. J SPEC PEDIATR NURS 2023; 28:e12404. [PMID: 36808815 DOI: 10.1111/jspn.12404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/21/2022] [Accepted: 02/06/2023] [Indexed: 02/22/2023]
Abstract
PURPOSE Sedation and analgesia are administered to critically ill patients, which may result in physical dependence and subsequent iatrogenic withdrawal. The Withdrawal Assessment Tool-1 (WAT-1) was developed and validated as an objective measurement of pediatric iatrogenic withdrawal in intensive care units (ICUs), with a WAT-1 score ≥ 3 indicative of withdrawal. This study's objectives were to test interrater reliability and validity of the WAT-1 in pediatric cardiovascular patients in a non-ICU setting. DESIGN AND METHODS This prospective observational cohort study was conducted on a pediatric cardiac inpatient unit. WAT-1 assessments were performed by the patient's nurse and a blinded expert nurse rater. Intra-class correlation coefficients were calculated, and Kappa statistics were estimated. A two-sample, one-sided test of proportions of weaning (n = 30) and nonweaning (n = 30) patients with a WAT-1 ≥3 were compared. RESULTS Interrater reliability was low (K = 0.132). The WAT-1 area under the receiver operating curve was 0.764 (95% confidence interval; ± 0.123). There was a significantly higher proportion (50%, p = 0.009) of weaning patients with WAT-1 scores ≥3 compared to the nonweaning patients (10%). The WAT-1 elements of moderate/severe uncoordinated/repetitive movement and loose, watery stools were significantly higher in the weaning population. PRACTICE IMPLICATIONS Methods to improve interrater reliability warrant further examination. The WAT-1 had good discrimination at identifying withdrawal in cardiovascular patients on an acute cardiac care unit. Frequent nurse re-education may increase accurate tool use. The WAT-1 tool may be used in the management of iatrogenic withdrawal in pediatric cardiovascular patients in a non-ICU setting.
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Affiliation(s)
- Sarah McAlister
- Advanced Practice Nurse, Acute Cardiac Care Unit, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jean A Connor
- Director Nursing Research Cardiovascular, Critical Care & Perioperative Patient Services, Boston Children's Hospital, Assistant Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Shannon Engstrand
- Senior Program Coordinator, Cardiovascular, Critical Care & Perioperative Patient Services, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mary C McLellan
- Clinical Inquiry Coordinator, Staff Nurse III, Acute Cardiac Care Unit, Boston Children's Hospital, Boston, Massachusetts, USA
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Decreases in Nephrotoxic Pain Medications Are Not Associated With Increased Opioid Utilization in Critically Ill Children. Pediatr Crit Care Med 2022; 23:e564-e573. [PMID: 36066647 DOI: 10.1097/pcc.0000000000003072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Quality improvement initiatives to decrease rates of nephrotoxic medication exposure have reduced rates of acute kidney injury (AKI) in noncritically ill children. The objective of our study was to analyze the implementation of a similar program in critically ill children and to measure important balancing measures including opioid and benzodiazepine exposure. DESIGN Prospective quality improvement study. SETTING PICU at Children's Hospital Colorado between 2018 and 2020. PATIENTS All children admitted to PICU. INTERVENTIONS Quality improvement initiative called Nephrotoxic Injury Negated by Just-In-Time Action (NINJA). MEASUREMENT AND MAIN RESULTS Eight thousand eight hundred thirty-three PICU patient admissions were included. Mean rates of nephrotoxic medication exposure/1,000 PICU patient days decreased from 46 to 26, whereas rates of nephrotoxic AKI/1,000 PICU patient days did not change. Nonsteroidal anti-inflammatory drug dispenses per 1,000 patient days were reduced from 521 to 456. Similarly, opioid and benzodiazepine exposures per 1,000 patient days were reduced from 812 to 524 and 441 to 227, respectively, during the study observation period. CONCLUSIONS The NINJA intervention was efficaciously implemented in our single-center PICU. Nephrotoxic exposure is a modifiable factor that did not inadvertently increase exposure to opioids and benzodiazepines.
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Silverman MJ. A recovery-oriented critical interpretive synthesis of withdrawal tools in the Journal of Substance Use. JOURNAL OF SUBSTANCE USE 2022. [DOI: 10.1080/14659891.2022.2091048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Lamey PS, Landis DM, Nugent KM. Iatrogenic opioid withdrawal syndromes in adults in intensive care units: a narrative review. J Thorac Dis 2022; 14:2297-2308. [PMID: 35813766 PMCID: PMC9264079 DOI: 10.21037/jtd-22-157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/12/2022] [Indexed: 11/08/2022]
Abstract
Background and Objective In hospitalized patients, opiates are essential analgesics and sedatives used in intensive care unit (ICU) patients. However, the iatrogenic opioid withdrawal syndrome (IOWS) in ICU patients has been poorly characterized, and there are no well accepted, standardized diagnostic tools for hospitalized adults. This review analyzed recent clinical studies to determine the frequency, characteristics, and treatment of IOWS in critically ill adults. Methods The initial literature search used the PubMed MeSH terms “Analgesics”, “Opioids”, “Iatrogenic Disease”, and “Neurobiology”. The main focus was on clinical studies describing IOWS in adults receiving intravenous opioids in ICUs. Key Content and Findings Review of 8 studies indicated that IOWS occurs in 15% to 40% of patients in intensive care units who required opioid infusions. These reports included patients in medical ICUs, trauma ICUs, surgical ICUs, and burn ICUs; many patients also received sedative drugs. Most of the studies used DSM-5 criteria to identify the syndrome. Factors which predicted the development of this syndrome varied from study to study; important considerations included the weaning rate for the opioid, the duration of opioid infusion, and the concomitant infusion of benzodiazepines. Treatment approaches included the reinstitution of the opioid infusion with slower reductions in the rate and the use of an alpha-2 agonist, such dexmedetomidine or clonidine. Many patients appeared to recover without specific treatment.
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Affiliation(s)
- Patrice S Lamey
- The Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Dylan M Landis
- The Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Kenneth M Nugent
- The Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Smith HAB, Besunder JB, Betters KA, Johnson PN, Srinivasan V, Stormorken A, Farrington E, Golianu B, Godshall AJ, Acinelli L, Almgren C, Bailey CH, Boyd JM, Cisco MJ, Damian M, deAlmeida ML, Fehr J, Fenton KE, Gilliland F, Grant MJC, Howell J, Ruggles CA, Simone S, Su F, Sullivan JE, Tegtmeyer K, Traube C, Williams S, Berkenbosch JW. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatr Crit Care Med 2022; 23:e74-e110. [PMID: 35119438 DOI: 10.1097/pcc.0000000000002873] [Citation(s) in RCA: 142] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
RATIONALE A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available. OBJECTIVE To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility. DESIGN The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to. METHODS Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence. RESULTS The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements. CONCLUSIONS The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.
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Affiliation(s)
- Heidi A B Smith
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
- Division of Pediatric Cardiac Anesthesiology, Vanderbilt University Medical Center, Department of Anesthesiology, Nashville, TN
| | - James B Besunder
- Division of Pediatric Critical Care, Akron Children's Hospital, Akron, OH
- Department of Pediatrics, Northeast Ohio Medical University, Akron, OH
| | - Kristina A Betters
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK
- The Children's Hospital at OU Medical Center, Oklahoma City, OK
| | - Vijay Srinivasan
- Departments of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Anne Stormorken
- Pediatric Critical Care, Rainbow Babies Children's Hospital, Cleveland, OH
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH
| | - Elizabeth Farrington
- Betty H. Cameron Women's and Children's Hospital at New Hanover Regional Medical Center, Wilmington, NC
| | - Brenda Golianu
- Division of Pediatric Anesthesia and Pain Management, Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
| | - Aaron J Godshall
- Department of Pediatrics, AdventHealth For Children, Orlando, FL
| | - Larkin Acinelli
- Division of Critical Care Medicine, Johns Hopkins All Children's Hospital, St Petersburg, FL
| | - Christina Almgren
- Lucile Packard Children's Hospital Stanford Pain Management, Palo Alto, CA
| | | | - Jenny M Boyd
- Division of Pediatric Critical Care, N.C. Children's Hospital, Chapel Hill, NC
- Division of Pediatric Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael J Cisco
- Division of Pediatric Critical Care Medicine, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA
| | - Mihaela Damian
- Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA
- Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Mary L deAlmeida
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA
- Division of Pediatric Critical Care, Emory University School of Medicine, Atlanta, GA
| | - James Fehr
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
- Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA
| | | | - Frances Gilliland
- Division of Cardiac Critical Care, Johns Hopkins All Children's Hospital, St Petersburg, FL
- College of Nursing, University of South Florida, Tampa, FL
| | - Mary Jo C Grant
- Primary Children's Hospital, Pediatric Critical Care Services, Salt Lake City, UT
| | - Joy Howell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | | | - Shari Simone
- University of Maryland School of Nursing, Baltimore, MD
- Pediatric Intensive Care Unit, University of Maryland Medical Center, Baltimore, MD
| | - Felice Su
- Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA
- Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Janice E Sullivan
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Chani Traube
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - Stacey Williams
- Division of Pediatric Critical Care, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - John W Berkenbosch
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY
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Mattsson J, Meijers J, Björling G. Challenges in Nursing Care of Children With Substance Withdrawal Syndrome in the PICU. SAGE Open Nurs 2022; 8:23779608221117382. [PMID: 35959413 PMCID: PMC9358588 DOI: 10.1177/23779608221117382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/27/2022] [Accepted: 07/16/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction Substance withdrawal is one of the most common advert events in the Pediatric Intensive Care Unit (PICU), as the administration of potent opiates and sedative drugs is frequently performed several times each day. Objectives The present study explored the challenges in nursing care of children with substance withdrawal syndrome in the PICU. Method The study has an explorative and descriptive semi-structured qualitative interview design, with a strategic selection of informants. It was conducted at one out of three pediatric intensive care units in Sweden. Results Three different main themes were identified describing the different challenges regarding withdrawal symptoms: monitor the child’s interest, work with structured support, and understand the observation. Conclusions There is a discrepancy between the medical perspective and the nursing care perspective regarding children in PICU suffering from withdrawal syndrome. The lack of joint guidelines, language, and nursing diagnoses may lead to subjective evaluations and increase suffering for these children.
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Affiliation(s)
- Janet Mattsson
- Department of Learning, Informatics, Management and Ethics, LIME, Karolinska Institutet, Stockholm, Sweden
- Children’s Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Johannes Meijers
- Children’s Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Gunilla Björling
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Faculty of Nursing, Kilimanjaro Christian Medical University College, Moshi, Tanzania
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Taesotikul S, Dilokpattanamongkol P, Tangsujaritvijit V, Suthisisang C. Incidence and clinical manifestation of iatrogenic opioid withdrawal syndrome in mechanically ventilated patients. Curr Med Res Opin 2021; 37:1213-1219. [PMID: 33966568 DOI: 10.1080/03007995.2021.1928616] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The incidence of iatrogenic opioid withdrawal syndrome (IOWS) in mechanically ventilated adults has been questioned in settings driven by analgosedation strategies. This study aimed to describe the incidence, risk factors and clinical impact of IOWS in mechanically ventilated adults. METHODS This prospective, observational study was performed between 1 January and 31 August 2018. IOWS was identified based on the presence of at least three signs or symptoms according to the Diagnostic and Statistical Manual 5th edition (DSM-5) criteria after opioid discontinuation or rate reduction. Incidence of IOWS, patient characteristics, opioid administration, and the impact of IOWS on the duration of mechanical ventilator and length of stay in the intensive care unit (ICU) were collected. RESULTS Thirteen out of 55 patients (23.6%) manifested withdrawal symptoms. Two patients in the non-withdrawal group also developed hypertensive urgency after opioid discontinuation. Patients who received rapid once-daily weaning, especially rate reduction more than 50 µg as fentanyl equivalent per hour, were associated with IOWS. However, there was no statistically significant difference in ventilator-free days and ICU-free days. CONCLUSIONS These findings showed that approximately one-fourth of mechanically ventilated patients who received opioid infusion experienced IOWS. Monitoring for IOWS is recommended especially in patients who received rapid weaning rate of opioids. Future studies to develop IOWS assessment tools with the change of hemodynamic parameters should be performed. TRIAL REGISTRATION This trial was registered in ClinicalTrials.gov: identifier NCT03374722, date of registration 15 December 2018.
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Affiliation(s)
- Suthinee Taesotikul
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | | | - Viratch Tangsujaritvijit
- Department of Critical Care Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Piyavate Hospital, Bangkok, Thailand
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Isaac L, van den Hoogen NJ, Habib S, Trang T. Maternal and iatrogenic neonatal opioid withdrawal syndrome: Differences and similarities in recognition, management, and consequences. J Neurosci Res 2021; 100:373-395. [PMID: 33675100 DOI: 10.1002/jnr.24811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/01/2021] [Indexed: 11/12/2022]
Abstract
Opioids are potent analgesics used to manage pain in both young and old, but the increased use in the pregnant population has significant individual and societal implications. Infants dependent on opioids, either through maternal or iatrogenic exposure, undergo neonatal opioid withdrawal syndrome (NOWS), where they may experience withdrawal symptoms ranging from mild to severe. We present a detailed and original review of NOWS caused by maternal opioid exposure (mNOWS) and iatrogenic opioid intake (iNOWS). While these two entities have been assessed entirely separately, recognition and treatment of the clinical manifestations of NOWS overlap. Neonatal risk factors such as age, genetic predisposition, drug type, and clinical factors like type of opioid, cumulative dose of opioid exposure, and disease status affect the incidence of both mNOWS and iNOWS, as well as their severity. Recognition of withdrawal is dependent on clinical assessment of symptoms, and the use of clinical assessment tools designed to determine the need for pharmacotherapy. Treatment of NOWS relies on a combination of non-pharmacological therapies and pharmacological options. Long-term consequences of opioids and NOWS continue to generate controversy, with some evidence of anatomic brain changes, but conflicting animal and human clinical evidence of significant cognitive or behavioral impacts on school-age children. We highlight the current knowledge on clinically relevant recognition, treatment, and consequences of NOWS, and identify new advances in clinical management of the neonate. This review brings a unique clinical perspective and critically analyzes gaps between the clinical problem and our preclinical understanding of NOWS.
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Affiliation(s)
- Lisa Isaac
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nynke J van den Hoogen
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
| | - Sharifa Habib
- Department of Neonatology, Hospital for Sick Children, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Tuan Trang
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
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Skrobik Y. Insights into Critical Care and Post-ICU Opiate Administration. Am J Respir Crit Care Med 2020; 202:484-486. [PMID: 32464072 PMCID: PMC7427376 DOI: 10.1164/rccm.202005-1815ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- Yoanna Skrobik
- McGill University Department of MedicineMcGill University Research InstituteMontreal, Quebec, Canada
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14
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Caldwell D, Wong J, Duffett M. Sedative Medications for Critically Ill Children during and after Mechanical Ventilation: A Retrospective Observational Study. Can J Hosp Pharm 2020; 73:125-132. [PMID: 32362669 PMCID: PMC7182370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Providing safe and effective sedation to critically ill children is challenging. The assessment, prevention, and treatment of symptoms of iatrogenic withdrawal are critical aspects of sedation practice. OBJECTIVE To describe the use of sedative medications in critically ill children at McMaster Children's Hospital. METHODS This retrospective observational study included children admitted over a 12-month period who survived their illness and who received sedation and at least 48 h of invasive ventilation. We collected data from the time of admission to the pediatric intensive care unit to 3 days after discontinuation of sedation. RESULTS We included 67 children. The median age was 1.6 (interquartile range [IQR] 0.2-6.2) years, and respiratory illnesses were the most common reason for admission (41 [61%]). The children received invasive ventilation for a median of 7 (IQR 4-11) days and sedation for a median of 12 (IQR 6-20) days. Sixty-six children (99%) received an opioid, and all received a benzodiazepine, with median cumulative doses of 14 (IQR 5-27) mg/kg morphine equivalents and 15 (IQR 6-32) mg/kg midazolam equivalents. Dexmedetomidine was given to 31 children (46%), for a median of 8 (IQR 4-12) days. Most children (67%) received sedation after extubation (median duration 7 [IQR 4-14] days). In addition, 32 children (48%) continued to receive sedative medications after transfer to the ward, for a median of 6 (IQR 4-13) days. Forty-two children (63%) had at least one Withdrawal Assessment Tool-1 (WAT-1) score indicative of iatrogenic withdrawal. Children who experienced withdrawal were exposed to more opioids and more benzodiazepines, both per day and overall, and for longer periods. CONCLUSIONS The children in this study were exposed to multiple sedatives, and many continued to receive these medications for an extended period after discontinuation of mechanical ventilation. Iatrogenic withdrawal was common and represents an important opportunity to improve children's recovery after critical illness.
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Affiliation(s)
- Deanna Caldwell
- , PharmD, ACPR, RPh, was, at the time of this study, a pharmacy resident at McMaster Children's Hospital, Hamilton, Ontario. She is now with the Department of Pharmacy, London Health Sciences, London, Ontario, BScPharm, PharmD, ACPR, RPh, is with the Department of Pharmacy, McMaster Children's Hospital, Hamilton, Ontario, BSc(Pharm), MSc, PhD, ACPR, RPh, is with the Department of Pediatrics, McMaster University, and the Department of Pediatrics, McMaster Children's Hospital, Hamilton, Ontario
| | - Jonathan Wong
- , PharmD, ACPR, RPh, was, at the time of this study, a pharmacy resident at McMaster Children's Hospital, Hamilton, Ontario. She is now with the Department of Pharmacy, London Health Sciences, London, Ontario, BScPharm, PharmD, ACPR, RPh, is with the Department of Pharmacy, McMaster Children's Hospital, Hamilton, Ontario, BSc(Pharm), MSc, PhD, ACPR, RPh, is with the Department of Pediatrics, McMaster University, and the Department of Pediatrics, McMaster Children's Hospital, Hamilton, Ontario
| | - Mark Duffett
- , PharmD, ACPR, RPh, was, at the time of this study, a pharmacy resident at McMaster Children's Hospital, Hamilton, Ontario. She is now with the Department of Pharmacy, London Health Sciences, London, Ontario, BScPharm, PharmD, ACPR, RPh, is with the Department of Pharmacy, McMaster Children's Hospital, Hamilton, Ontario, BSc(Pharm), MSc, PhD, ACPR, RPh, is with the Department of Pediatrics, McMaster University, and the Department of Pediatrics, McMaster Children's Hospital, Hamilton, Ontario
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Arroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA. Opioid and Benzodiazepine Iatrogenic Withdrawal Syndrome in Patients in the Intensive Care Unit. AACN Adv Crit Care 2019; 30:353-364. [PMID: 31951658 PMCID: PMC7017678 DOI: 10.4037/aacnacc2019267] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Iatrogenic withdrawal syndrome is an increasingly recognized issue among adult patients in the intensive care unit. The prolonged use of opioids and benzodiazepines during the intensive care unit stay and preexisting disorders associated with their use put patients at risk of developing iatrogenic withdrawal syndrome. Although research to date is scant regarding iatrogenic withdrawal syndrome in adult patients in the intensive care unit, it is important to recognize and adequately manage iatrogenic withdrawal syndrome in order to prevent possible negative outcomes during and after a patient's intensive care unit stay. This article discusses in depth 8 studies of iatrogenic withdrawal syndrome among adult patients in the intensive care unit. It also addresses important aspects of opioid and benzodiazepine iatrogenic withdrawal syndrome, including prevalence, risk factors, and assessment and considers its prevention and management.
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Affiliation(s)
- Carmen Mabel Arroyo-Novoa
- Carmen Mabel Arroyo-Novoa is Associate Professor, Graduate Department, University of Puerto Rico School of Nursing, Medical Sciences Campus, PO Box 365067, San Juan, PR 00936-5067 . Milagros I. Figueroa-Ramos is Associate Professor, Graduate Department, University of Puerto Rico School of Nursing, San Juan, Puerto Rico. Kathleen A. Puntillo is Professor Emeritus, Physiological Nursing Department, University of California, San Francisco, School of Nursing, San Francisco, California
| | - Milagros I Figueroa-Ramos
- Carmen Mabel Arroyo-Novoa is Associate Professor, Graduate Department, University of Puerto Rico School of Nursing, Medical Sciences Campus, PO Box 365067, San Juan, PR 00936-5067 . Milagros I. Figueroa-Ramos is Associate Professor, Graduate Department, University of Puerto Rico School of Nursing, San Juan, Puerto Rico. Kathleen A. Puntillo is Professor Emeritus, Physiological Nursing Department, University of California, San Francisco, School of Nursing, San Francisco, California
| | - Kathleen A Puntillo
- Carmen Mabel Arroyo-Novoa is Associate Professor, Graduate Department, University of Puerto Rico School of Nursing, Medical Sciences Campus, PO Box 365067, San Juan, PR 00936-5067 . Milagros I. Figueroa-Ramos is Associate Professor, Graduate Department, University of Puerto Rico School of Nursing, San Juan, Puerto Rico. Kathleen A. Puntillo is Professor Emeritus, Physiological Nursing Department, University of California, San Francisco, School of Nursing, San Francisco, California
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Thompson-Brazill KA. Pain Control in the Cardiothoracic Surgery Patient. Crit Care Nurs Clin North Am 2019; 31:389-405. [DOI: 10.1016/j.cnc.2019.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Duceppe MA, Perreault MM, Frenette AJ, Burry LD, Rico P, Lavoie A, Gélinas C, Mehta S, Dagenais M, Williamson DR. Frequency, risk factors and symptomatology of iatrogenic withdrawal from opioids and benzodiazepines in critically Ill neonates, children and adults: A systematic review of clinical studies. J Clin Pharm Ther 2018; 44:148-156. [DOI: 10.1111/jcpt.12787] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/19/2018] [Indexed: 12/01/2022]
Affiliation(s)
| | - Marc M. Perreault
- Pharmacy Department; McGill University Health Centre; Montreal Quebec Canada
- Faculté de Pharmacie; Université de Montréal; Montreal Quebec Canada
| | - Anne Julie Frenette
- Faculté de Pharmacie; Université de Montréal; Montreal Quebec Canada
- Pharmacy Department; Hôpital du Sacré-Coeur de Montréal; Montreal Quebec Canada
| | - Lisa D. Burry
- Pharmacy Department, Mount Sinai Hospital; Sinai Health System; Toronto Ontario Canada
- Leslie Dan Faculty of Pharmacy; University of Toronto; Toronto Ontario Canada
| | - Philippe Rico
- Faculté de Médicine; Université de Montréal; Montreal Quebec Canada
- Department of Critical Care; Hôpital du Sacré-Coeur de Montréal; Montreal Quebec Canada
| | - Annie Lavoie
- Faculté de Pharmacie; Université de Montréal; Montreal Quebec Canada
- Pharmacy Department; Centre Hospitalier Universitaire Sainte-Justine; Montreal Quebec Canada
| | - Céline Gélinas
- Ingram School of Nursing; McGill University; Montreal Quebec Canada
- Centre for Nursing Research/Lady Davis Institute; Jewish General Hospital; Montreal Quebec Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, and Interdepartmental Division of Critical Care Medicine; University of Toronto; Toronto Ontario Canada
| | - Maryse Dagenais
- Pediatric Intensive Care Unit; McGill University Health Centre; Montreal Quebec Canada
| | - David R. Williamson
- Faculté de Pharmacie; Université de Montréal; Montreal Quebec Canada
- Pharmacy Department; Hôpital du Sacré-Coeur de Montréal; Montreal Quebec Canada
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D'Souza G, Wren AA, Almgren C, Ross AC, Marshall A, Golianu B. Pharmacological Strategies for Decreasing Opioid Therapy and Management of Side Effects from Chronic Use. CHILDREN 2018; 5:children5120163. [PMID: 30563157 PMCID: PMC6306833 DOI: 10.3390/children5120163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/27/2018] [Accepted: 12/03/2018] [Indexed: 12/04/2022]
Abstract
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.
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Affiliation(s)
- Genevieve D'Souza
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA 94304, USA.
| | - Anava A Wren
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Stanford University, Palo Alto, CA 94304, USA.
| | - Christina Almgren
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA 94304, USA.
| | - Alexandra C Ross
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA 94304, USA.
| | - Amanda Marshall
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA 94304, USA.
| | - Brenda Golianu
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA 94304, USA.
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Erstad BL. Implications of the opioid epidemic for critical care practice. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2018. [DOI: 10.1002/jac5.1052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Brian L. Erstad
- Department of Pharmacy Practice and Science, College of Pharmacy; University of Arizona; Tucson Arizona
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