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Leszczyński PK, Sholokhova D, Wejnarski A. The use of analgesics in pediatric patients with body injuries in pre-hospital conditions. Minerva Pediatr (Torino) 2024; 76:357-362. [PMID: 33107279 DOI: 10.23736/s2724-5276.20.06094-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND Despite the positive dynamic changes in medicine and science, injuries continue to be the dominant cause of death among people under 45 years of age. Children's injuries are particularly dangerous as they can lead to hypovolemic shock, disability or even death. EMS uses opioid and non-opioid analgesics in order to provide relief to patients suffering from pain. The aim of this work is to analyze the types of pharmacological substances used in children in pre-hospital conditions. METHODS The research tools included medical documentation of the emergency medical services in Poland. The analysis included 68,441 medical emergency treatment forms from 2016-2017, from which 464 interventions for children after trauma were selected. The general patient profile, characteristics of the event site, type of injuries suffered, type of intervening EMS, pharmacotherapy being used, as well as vital signs (GCS, RTS, HR, NiBP) were subject to assessment. The χ2 independence tests were performed, considering the results as statistically significant for P<0.05. RESULTS There were 354 instances of BEMS (Basic Emergency Medical Services - without a doctor) and 110 instances of SEMS (Specialist Emergency Medical Services - with a doctor) sent to the emergency site. The mean age was 10.8±4.84 years. Boys were subject to intervention more often than girls (N.=283 vs. N.=181). Analgesics were administered in case of 49 (10.56%) patients only. Nonsteroidal anti-inflammatory drugs (NSAIDs) were the analgesics of choice, which were used in 25 patients (50%), while opioid analgesics were used in 10 patients (20.40%). Analgesia was mostly used in patients with lower limb (34.69%) and upper limb (30.61%) injuries. The lowest percentage of analgesic use was observed in patients with head and neck injuries (3.06%). There was a significant relationship demonstrated between the type of EMS and the use of analgesics (χ2=6.330; P=0.012). CONCLUSIONS Analgesia with EMS in children with injuries is critically insufficient. NSAIDs are the most commonly administered drugs in pre-hospital conditions. Head and torso injuries reduce the percentage of drugs administered by EMS. The EMS teams with no doctors (BEMS) are significantly more likely to use anesthetics, compared to SEMS.
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Affiliation(s)
- Piotr K Leszczyński
- Faculty of Medical and Health Sciences, Siedlce University of Natural Sciences and Humanities, Siedlce, Poland -
| | - Daryna Sholokhova
- Voivodship Ambulance Station and Sanitary Transport "Meditrans", Warsaw, Poland
| | - Arkadiusz Wejnarski
- Faculty of Medical and Health Sciences, Siedlce University of Natural Sciences and Humanities, Siedlce, Poland
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Groman A, Spyhalsky A, Michienzi K, Breuer R. Impact of Intravenous Methadone Dosing Schedule on Iatrogenic Withdrawal Syndrome in a Pediatric Intensive Care Unit. J Pediatr Pharmacol Ther 2024; 29:266-272. [PMID: 38863852 PMCID: PMC11163900 DOI: 10.5863/1551-6776-29.3.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/14/2023] [Indexed: 06/13/2024]
Abstract
OBJECTIVE To compare median Sophia Observation withdrawal Symptoms scale (SOS) scores between -intravenous methadone dosing scheduled every 6 hours or every 8 hours for iatrogenic withdrawal -syndrome (IWS). METHODS This single-center, retrospective chart review evaluated patients aged 4 weeks through 18 years treated with intravenous methadone for IWS. Children admitted to the pediatric intensive care unit (PICU) of a tertiary care children's hospital between August 2017 and July 2021 and treated for IWS for at least 48 hours were eligible for inclusion. Methadone dosing schedules were compared, with a primary outcome of median Sophia Observation withdrawal Symptoms (SOS) score during the first 24 hours after cessation of continuous fentanyl infusion. Secondary outcomes included PICU and general pediatric unit lengths of stay, extubation failure rates, and mortality. RESULTS Twenty patients met inclusion criteria, with 9 in the 6-hour dosing group. There was no difference in median SOS score, extubation failure, length of stay, or mortality between the 2 groups. CONCLUSIONS During the first 24 hours after cessation of continuous fentanyl, there appears to be no -difference in IWS severity, as determined by bedside nurse scoring, between patients treated with -intravenous methadone every 6 hours compared with every 8 hours.
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Affiliation(s)
- Aleah Groman
- Department of Pharmacy (AG, AS, KM), Kaleida Health John R. Oishei Children’s Hospital, Buffalo, NY
| | - Autumn Spyhalsky
- Department of Pharmacy (AG, AS, KM), Kaleida Health John R. Oishei Children’s Hospital, Buffalo, NY
- PharmD Candidate (AS), State University of New York at Buffalo, School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, anticipated graduation 2024
| | - Kelly Michienzi
- Department of Pharmacy (AG, AS, KM), Kaleida Health John R. Oishei Children’s Hospital, Buffalo, NY
| | - Ryan Breuer
- Department of Pediatrics (RB), UBMD Physicians Group, Buffalo, NY
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Wang Y, Zheng Y, Chen L, Lin L, Chen B, Lin Z, Bao S. Study on Risk Factors and Receiver Operator Characteristic Curve of Iatrogenic Withdrawal Syndrome in Pediatric Intensive Care Units: A Retrospective Study. Pharmacology 2024; 109:237-242. [PMID: 38631312 DOI: 10.1159/000538861] [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: 01/05/2024] [Accepted: 04/08/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION The aims of this study were to investigate the independent risk factors associated with iatrogenic withdrawal syndrome in pediatric intensive care units (PICUs) and to establish receiver operator characteristic (ROC) curve to facilitate the diagnosis of iatrogenic withdrawal syndrome in clinical settings. METHODS Pediatric patients who received analgesic and sedative medication at a tertiary hospital in the southern Zhejiang region of China between January 2016 and December 2022 were selected for the study. Clinical case data were retrospectively analyzed to gather information including age, gender, weight, total dose of analgesic and sedative medication, total treatment duration, average maintenance dose, and other relevant parameters. Medically induced withdrawal symptom scores were assessed using the Sophia Observation Scale for Withdrawal Symptoms (SOS). Univariate and multivariate logistic regression analyses were conducted on the above indicators to identify the risk factors for iatrogenic withdrawal, and an ROC curve was constructed. RESULTS The study encompassed a total of 104 pediatric patients, comprising 47 patients in the SOS score ≥4 group and 57 patients in the SOS score ≤3 group. The incidence of iatrogenic withdrawal was 45.19%. Univariate analysis identified cumulative total dose of fentanyl, average daily dose of fentanyl, average daily dose of midazolam, and patient weight (p < 0.05) as factors associated with iatrogenic withdrawal syndrome. The logistic multiple regression analysis revealed that the average daily dose of fentanyl was an independent risk factor for the occurrence of iatrogenic withdrawal syndrome in critically ill children (p < 0.05). ROC curve analysis indicated an area under the curve of 0.711 (95% CI: 0.610-0.811) with sensitivity and specificity of 73.7% and 61.7%, respectively. CONCLUSION The average daily maintenance dose of fentanyl holds significant clinical value in diagnosing and evaluating the prognosis of iatrogenic withdrawal syndrome and can provide a scientific foundation for enhancing sedative and analgesic management in clinical practice.
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Affiliation(s)
- Yi Wang
- Department of Pharmacy, Taizhou Women and Children's Hospital of Wenzhou Medical University, Taizhou, China,
| | - Ying Zheng
- Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of WMU, Wenzhou, China
| | - Lijia Chen
- Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of WMU, Wenzhou, China
| | - Lingjie Lin
- PICU of the Second Affiliated Hospital and Yuying Children's Hospital of WMU, Wenzhou, China
| | - Binwu Chen
- Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of WMU, Wenzhou, China
| | - Zhengfeng Lin
- Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of WMU, Wenzhou, China
| | - Shihui Bao
- Department of Pharmacy, Taizhou Women and Children's Hospital of Wenzhou Medical University, Taizhou, China
- Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of WMU, Wenzhou, China
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4
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Bakshi SG, Amin N, Bhosale S, Qureshi SS. An interesting case of opioid-induced hyperalgesia and acute abdomen in the postoperative period. J Anaesthesiol Clin Pharmacol 2024; 40:353-354. [PMID: 38919440 PMCID: PMC11196059 DOI: 10.4103/joacp.joacp_393_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/22/2022] [Accepted: 12/22/2022] [Indexed: 06/27/2024] Open
Affiliation(s)
- Sumitra G. Bakshi
- Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, India
| | - Nayana Amin
- Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, India
| | - Shilpushp Bhosale
- Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, India
| | - Sajid S. Qureshi
- Department of Paediatric Surgery, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, India
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5
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Fundora MP, Kalicheti M, Zhao G, Maher KO, Serban N. Opioid Utilization after Cardiac Surgery in the Pediatric Medicaid-Insured Population. J Pediatr 2024; 265:113809. [PMID: 37918516 DOI: 10.1016/j.jpeds.2023.113809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/25/2023] [Accepted: 10/29/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE To determine the variation of outpatient opioid prescribing across the US in postoperative pediatric cardiac patients. STUDY DESIGN Retrospective, cross-sectional study using a concatenated database of Medicaid claims between from 2016 through 2018 of children 0-17 years, discharged after cardiac surgery and receiving an opioid prescription within 30 days. Filled prescriptions were identified and converted to morphine milligram equivalents (MME). Use, duration, and dose were analyzed by sex, race, ethnicity, residence urbanicity, and region. RESULTS Among 17 186 Medicaid-enrolled children after cardiac surgery, 2129 received opioids within 30 days of discharge. Females received lower doses than males (coefficient -0.17, P = .022). Hispanic individuals were less likely to receive opioids (coefficient 0.53, P < .05, 95% CI: 0.38-0.71) and for shorter periods (coefficient 0.83, P < .001). Midwest (MW) (OR 0.61, 95% P-values < 0.05, 95% CI: 0.46-0.80) and Northeast (NE) (OR 0.43, 95% P-values < 0.05, 95% CI: 0.30-0.61) regions were less likely to receive opioids but used higher doses compared with the Southeast (SE) (MW coefficient 0.41, Southwest (SW) coefficient 0.18, NE coefficient 0.32, West (W) coefficient 0.19, P < .05). CONCLUSIONS There were significant variations in opioid prescribing after cardiac surgery by race, ethnicity, sex, and region. National guidelines for outpatient use of opioids in children after cardiac surgery may help limit practice variation and reduce potential harms in outpatient opioid usage.
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Affiliation(s)
- Michael P Fundora
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA.
| | - Manvitha Kalicheti
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Guantao Zhao
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Kevin O Maher
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Nicoleta Serban
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA
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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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Zimmerman KO, Westreich D, Funk MJ, Benjamin DK, Turner D, Stürmer, T. Comparative Effectiveness of Dual- Versus Mono-Sedative Therapy on Opioid Administration, Sedative Administration, and Sedation Level in Mechanically Ventilated, Critically Ill Children. J Pediatr Pharmacol Ther 2023; 28:409-416. [PMID: 38130497 PMCID: PMC10731925 DOI: 10.5863/1551-6776-28.5.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2023]
Abstract
OBJECTIVE We estimated the effect of early initiation of dual therapy vs monotherapy on drug administration and related outcomes in mechanically ventilated, critically ill children. METHODS We used the electronic medical record at a single tertiary medical center to conduct an active comparator, new user cohort study. We included children <18 years of age who were exposed to a sedative or analgesic within 6 hours of intubation. We used stabilized inverse probability of treatment weighting to account for confounding at baseline. We estimated the average effect of initial dual therapy vs monotherapy on outcomes including cumulative opioid, benzodiazepine, and dexmedetomidine dosing; sedation scores; time to double the opioid or benzodiazepine infusion rate; initiation of neuromuscular blockade within the first 7 days of follow-up; time to extubation; and 7-day all-cause in-hospital death. RESULTS The cohort included 640 patients. Children receiving dual therapy received 0.03 mg/kg (95% CI, 0.02-0.04) more dexmedetomidine over the first 7 days after initiation of mechanical ventilation than did monotherapy patients. Dual therapy patients had similar sedation scores, time to double therapy, initiation of neuromuscular blockade, and time to extubation as monotherapy patients. Dual therapy patients had a lower incidence of death. CONCLUSIONS In this study, initial dual therapy compared with monotherapy does not reduce overall drug administration during mechanical ventilation. The identified effect of dual therapy on mortality deserves further investigation.
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Affiliation(s)
- Kanecia O. Zimmerman
- Duke Clinical Research Institute (KOZ, DKB), Duke University School of Medicine, Durham, NC
- Department of Pediatrics (KOZ, DKB, DT), Duke University School of Medicine, Durham, NC
- Department of Epidemiology (KOZ, DW, MJF, TS), Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Daniel Westreich
- Department of Epidemiology (KOZ, DW, MJF, TS), Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michele Jonsson Funk
- Department of Epidemiology (KOZ, DW, MJF, TS), Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Daniel K. Benjamin
- Duke Clinical Research Institute (KOZ, DKB), Duke University School of Medicine, Durham, NC
- Department of Pediatrics (KOZ, DKB, DT), Duke University School of Medicine, Durham, NC
| | - David Turner
- Department of Pediatrics (KOZ, DKB, DT), Duke University School of Medicine, Durham, NC
| | - Til Stürmer,
- Department of Epidemiology (KOZ, DW, MJF, TS), Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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Dokken M, Rustøen T, Diep LM, Fagermoen FE, Huse RI, Egerod I, Bentsen GK. Implementation of an algorithm for tapering analgosedation reduces iatrogenic withdrawal syndrome in pediatric intensive care. Acta Anaesthesiol Scand 2023; 67:1229-1238. [PMID: 37287092 DOI: 10.1111/aas.14288] [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: 03/11/2023] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 06/09/2023]
Abstract
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.
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Affiliation(s)
- Mette Dokken
- Division of Emergencies and Critical Care, Paediatric Intensive Care Section, Oslo University Hospital-Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tone Rustøen
- Division of Emergencies and Critical Care, Department of Research and Development, Oslo University Hospital, Oslo, Norway
- Institute of Health Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lien My Diep
- Oslo Center for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Frode Even Fagermoen
- Division of Emergencies and Critical Care, Department of Anesthesia and Intensive Care medicine, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Rakel Iren Huse
- Division of Emergencies and Critical Care, Paediatric Intensive Care Section, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | - Ingrid Egerod
- Department of Intensive Care, University of Copenhagen, Rigshospitalet, Denmark
| | - Gunnar Kristoffer Bentsen
- Division of Emergencies and Critical Care, Department of Anesthesia and Intensive Care medicine, Oslo University Hospital-Rikshospitalet, Oslo, Norway
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10
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Feeney ME, Steiling K. Successful management of suspected propofol dependence with phenobarbital in an adult patient with COVID-19. Am J Health Syst Pharm 2023; 80:1309-1314. [PMID: 37368792 DOI: 10.1093/ajhp/zxad151] [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: 06/25/2023] [Indexed: 06/29/2023] Open
Abstract
PURPOSE In critically ill patients, high sedation requirements for prolonged durations are often needed to achieve ventilator synchrony, a practice that was particularly common during the early stages of the coronavirus disease 2019 (COVID-19) pandemic. We report the successful use of phenobarbital to facilitate propofol weaning after prolonged medication exposure. SUMMARY A 64-year-old male with hypertension was admitted for the management of acute respiratory distress syndrome due to COVID-19 pneumonia. The patient received high doses of fentanyl and propofol with periods of concomitant midazolam and dexmedetomidine throughout his prolonged time on mechanical ventilation. Total days of exposure were 19 for fentanyl, 17 for propofol, 12 for midazolam, and 15 for dexmedetomidine. Upon improvement in lung function, attempts to wean the patient from propofol all failed due to symptoms such as tachypnea, tachycardia, and hypertension, with symptom resolution only upon return to the previous dose. Phenobarbital was trialed for possible propofol withdrawal syndrome, allowing for a dose reduction of 10 μg/kg/min within 2 hours of the first dose without any corresponding symptoms. The patient continued to receive intermittent doses of phenobarbital for another 36 hours until propofol was discontinued. He underwent tracheostomy shortly after weaning off all sedation and was discharged to rehab 34 days after his initial admission. CONCLUSION Information concerning propofol withdrawal syndrome in the literature is limited. Our experience demonstrates the successful use of phenobarbital to facilitate propofol weaning after prolonged exposure.
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Affiliation(s)
- Megan E Feeney
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA
| | - Katrina Steiling
- Department of Pulmonology and Critical Care Medicine, Boston Medical Center, Boston, MA, USA
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11
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Deptola S, Hemmann B, Hemmelgarn T, DiPaola K, Cortezzo DE. Propofol Sedation Washouts in Critically Ill Infants: A Case Series. J Pediatr Pharmacol Ther 2023; 28:354-364. [PMID: 37795284 PMCID: PMC10547045 DOI: 10.5863/1551-6776-28.4.354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/29/2022] [Indexed: 10/06/2023]
Abstract
Medically complex infants are experiencing longer hospital stays, more invasive procedures, and increasingly involved therapeutic interventions that often require long-term analgesia and sedation. This is most commonly achieved with continuous intravenous infusions of opioids and benzodiazepines. There are times when patients develop a tolerance for these medications or the clinical scenario necessitates a rapid wean of them. A rapid wean of either class of medication can lead to increased signs of pain and agitation or withdrawal symptoms. As a result, when a rapid wean is needed or there has been a failure to control symptoms with conventional measures, alternative therapies are considered. Propofol, a sedative hypnotic typically used for general anesthesia and procedural sedation, is one such medication. It has effectively been used for short-term sedation in adults and children to facilitate weaning benzodiazepines and opioids. There is a paucity of data on the use of propofol in infants for this purpose. Here we describe the use of propofol to rapidly wean high-dose sedation and analgesia medications, a propofol sedation washout, in 3 infants. The washouts proved to be safe and efficacious. Based on institutional experience and a literature review, considerations and recommendations are made for propofol sedation washouts in infants.
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Affiliation(s)
- Stephen Deptola
- Division of Pharmacy (SD, BH, TH, KD), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Brianna Hemmann
- Division of Pharmacy (SD, BH, TH, KD), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Trina Hemmelgarn
- Division of Pharmacy (SD, BH, TH, KD), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Kyle DiPaola
- Division of Pharmacy (SD, BH, TH, KD), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - DonnaMaria E. Cortezzo
- Division of Neonatology and Pulmonary Biology (DEC), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Pain and Palliative Medicine (DEC), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics (DEC), University of Cincinnati College of Medicine, Cincinnati, Ohio
- Department of Anesthesiology (DEC), University of Cincinnati College of Medicine, Cincinnati, Ohio
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12
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King CE, Wood DN, Koo J, Cutler AB, Vesel TP. Sedation Weaning Initiative Targeting Methadone Exposure: Single Center Improvements in Withdrawal Symptoms and Hospital Length of Stay for Pediatric Cardiac Critical Care. Pediatr Crit Care Med 2023; 24:e332-e341. [PMID: 37409901 DOI: 10.1097/pcc.0000000000003233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
OBJECTIVES Sedation and pain medications are necessary in the management of postoperative pediatric cardiac patients. Prolonged exposure to these medications can lead to negative side effects including withdrawal. We hypothesized that standardized weaning guidelines would decrease exposure to sedation medications and decrease withdrawal symptoms. The primary aim was to decrease average days of methadone exposure to within goal for moderate- and high-risk patients within 6 months. DESIGN Quality improvement methods were used to standardize sedation medication weaning in a pediatric cardiac ICU. SETTING This study took place at Duke Children's Hospital Pediatric Cardiac ICU in Durham, North Carolina from January 1, 2020, to December 31, 2021. PATIENTS Children less than 12 months old admitted to the pediatric cardiac ICU who underwent cardiac surgery. INTERVENTIONS Sedation weaning guidelines were implemented over the course of 12 months. Data were tracked every 6 months and compared with the 12 months pre-intervention. Patients were stratified into low, moderate, and high risk withdrawal categories based on duration of opioid infusion exposure. MEASUREMENTS AND MAIN RESULTS Total sample size was 94 patients in the moderate and high risk categories. Process measures included documentation of Withdrawal Assessment Tool scores and appropriate methadone prescription in patients which increased to 100% post-intervention. For outcome measures, we observed decreased dexmedetomidine infusion duration, decreased methadone wean duration, decreased frequency of elevated Withdrawal Assessment Tool scores, and decreased hospital length of stay post-intervention. For the primary aim, methadone wean duration consistently decreased after each study period. Our intervention did not adversely impact balancing measures. CONCLUSIONS A quality improvement initiative to standardize sedation weaning in a Pediatric Cardiac ICU was successfully implemented and was correlated with decreased duration of sedation medications, decreased withdrawal scores, and decreased length of stay.
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Affiliation(s)
- Caitlin E King
- Department of Pediatrics, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | | | - Jeannie Koo
- Department of Pediatrics, Duke University, Durham, NC
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13
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Azamfirei R, Mennie C, Dinglas VD, Fatima A, Colantuoni E, Gurses AP, Balas MC, Needham DM, Kudchadkar SR. Impact of a multifaceted early mobility intervention for critically ill children - the PICU Up! trial: study protocol for a multicenter stepped-wedge cluster randomized controlled trial. Trials 2023; 24:191. [PMID: 36918956 PMCID: PMC10015670 DOI: 10.1186/s13063-023-07206-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/28/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Over 50% of all critically ill children develop preventable intensive care unit-acquired morbidity. Early and progressive mobility is associated with improved outcomes in critically ill adults including shortened duration of mechanical ventilation and improved muscle strength. However, the clinical effectiveness of early and progressive mobility in the pediatric intensive care unit has never been rigorously studied. The objective of the study is to evaluate if the PICU Up! intervention, delivered in real-world conditions, decreases mechanical ventilation duration (primary outcome) and improves delirium and functional status compared to usual care in critically ill children. Additionally, the study aims to identify factors associated with reliable PICU Up! delivery. METHODS The PICU Up! trial is a stepped-wedge, cluster-randomized trial of a pragmatic, interprofessional, and multifaceted early mobility intervention (PICU Up!) conducted in 10 pediatric intensive care units (PICUs). The trial's primary outcome is days alive free of mechanical ventilation (through day 21). Secondary outcomes include days alive and delirium- and coma-free (ADCF), days alive and coma-free (ACF), days alive, as well as functional status at the earlier of PICU discharge or day 21. Over a 2-year period, data will be collected on 1,440 PICU patients. The study includes an embedded process evaluation to identify factors associated with reliable PICU Up! delivery. DISCUSSION This study will examine whether a multifaceted strategy to optimize early mobility affects the duration of mechanical ventilation, delirium incidence, and functional outcomes in critically ill children. This study will provide new and important evidence on ways to optimize short and long-term outcomes for pediatric patients. TRIAL REGISTRATION ClinicalTrials.gov NCT04989790. Registered on August 4, 2021.
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Affiliation(s)
- Razvan Azamfirei
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- "George Emil Palade" University of Medicine, Pharmacy, Science, and Technology, Targu Mures, Romania
| | - Colleen Mennie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Victor D Dinglas
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Outcomes after Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
| | - Arooj Fatima
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Outcomes after Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth Colantuoni
- Outcomes after Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Ayse P Gurses
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Health Care Human Factors, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Michele C Balas
- College of Nursing, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Outcomes after Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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14
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Mondardini MC, Sperotto F, Daverio M, Amigoni A. Analgesia and sedation in critically ill pediatric patients: an update from the recent guidelines and point of view. Eur J Pediatr 2023; 182:2013-2026. [PMID: 36892607 DOI: 10.1007/s00431-023-04905-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/14/2023] [Accepted: 02/26/2023] [Indexed: 03/10/2023]
Abstract
In the last decades, the advancement of knowledge in analgesia and sedation for critically ill pediatric patients has been conspicuous and relevant. Many recommendations have changed to ensure patients' comfort during their intensive care unit (ICU) stay and prevent and treat sedation-related complications, as well as improve functional recovery and clinical outcomes. The key aspects of the analgosedation management in pediatrics have been recently reviewed in two consensus-based documents. However, there remains a lot to be researched and understood. With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field. Conclusion: With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field. What is Known: • Critically ill pediatric patients receiving intensive care required analgesia and sedation to attenuate painful and stressful stimuli. •Optimal management of analgosedation is a challenge often burdened with complications such as tolerance, iatrogenic withdrawal syndrome, delirium, and possible adverse outcomes. What is New: •The new insights on the analgosedation treatment for critically ill pediatric patients delineated in the recent guidelines are summarized to identify strategies for changes in clinical practice. •Research gaps and potential for quality improvement projects are also highlighted.
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Affiliation(s)
- Maria Cristina Mondardini
- Pediatric Anesthesia and Intensive Care Unit, Department of Woman's and Child's Health, IRCCS University Hospital of Bologna Policlinico S. Orsola, Bologna, Italy
| | - Francesca Sperotto
- Cardiovascular Critical Care Unit, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy.
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15
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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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16
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Cuitavi J, Torres-Pérez JV, Lorente JD, Campos-Jurado Y, Andrés-Herrera P, Polache A, Agustín-Pavón C, Hipólito L. Crosstalk between Mu-Opioid receptors and neuroinflammation: Consequences for drug addiction and pain. Neurosci Biobehav Rev 2023; 145:105011. [PMID: 36565942 DOI: 10.1016/j.neubiorev.2022.105011] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 11/29/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
Mu-Opioid Receptors (MORs) are well-known for participating in analgesia, sedation, drug addiction, and other physiological functions. Although MORs have been related to neuroinflammation their biological mechanism remains unclear. It is suggested that MORs work alongside Toll-Like Receptors to enhance the release of pro-inflammatory mediators and cytokines during pathological conditions. Some cytokines, including TNF-α, IL-1β and IL-6, have been postulated to regulate MORs levels by both avoiding MOR recycling and enhancing its production. In addition, Neurokinin-1 Receptor, also affected during neuroinflammation, could be regulating MOR trafficking. Therefore, inflammation in the central nervous system seems to be associated with altered/increased MORs expression, which might regulate harmful processes, such as drug addiction and pain. Here, we provide a critical evaluation on MORs' role during neuroinflammation and its implication for these conditions. Understanding MORs' functioning, their regulation and implications on drug addiction and pain may help elucidate their potential therapeutic use against these pathological conditions and associated disorders.
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Affiliation(s)
- Javier Cuitavi
- Department of Pharmacy and Pharmaceutical Technology and Parasitology, University of Valencia, Avda. Vicent Andrés Estellés s/n., 46100 Burjassot, Spain.
| | - Jose Vicente Torres-Pérez
- Department of Cellular Biology, Functional Biology and Physical Anthropology, University of Valencia, Avda. Vicent Andrés Estellés s/n., 46100 Burjassot, Spain
| | - Jesús David Lorente
- Department of Pharmacy and Pharmaceutical Technology and Parasitology, University of Valencia, Avda. Vicent Andrés Estellés s/n., 46100 Burjassot, Spain
| | - Yolanda Campos-Jurado
- Department of Pharmacy and Pharmaceutical Technology and Parasitology, University of Valencia, Avda. Vicent Andrés Estellés s/n., 46100 Burjassot, Spain
| | - Paula Andrés-Herrera
- Department of Pharmacy and Pharmaceutical Technology and Parasitology, University of Valencia, Avda. Vicent Andrés Estellés s/n., 46100 Burjassot, Spain
| | - Ana Polache
- Department of Pharmacy and Pharmaceutical Technology and Parasitology, University of Valencia, Avda. Vicent Andrés Estellés s/n., 46100 Burjassot, Spain
| | - Carmen Agustín-Pavón
- Department of Cellular Biology, Functional Biology and Physical Anthropology, University of Valencia, Avda. Vicent Andrés Estellés s/n., 46100 Burjassot, Spain
| | - Lucía Hipólito
- Department of Pharmacy and Pharmaceutical Technology and Parasitology, University of Valencia, Avda. Vicent Andrés Estellés s/n., 46100 Burjassot, Spain.
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17
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Geslain G, Ponsin P, Lãzãrescu AM, Tridon C, Robin N, Riaud C, Orliaguet G. Incidence of iatrogenic withdrawal syndrome and associated factors in surgical pediatric intensive care. Arch Pediatr 2023; 30:14-19. [PMID: 36481162 DOI: 10.1016/j.arcped.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/24/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Iatrogenic withdrawal syndrome (IWS) is a complication of prolonged sedation/analgesia in pediatric intensive care unit (PICU) patients. The epidemiology of IWS is poorly understood, as validated diagnostic tools are rarely used. The main objective of our study was to use the WAT-1 score to assess the incidence of IWS in our unit. The secondary objectives were to evaluate the consequences of IWS, associated factors, and management modalities. MATERIAL AND METHODS From July 2018 to January 2019, 48 children receiving endotracheal ventilation and sedation/analgesia by continuous infusion (>48 h) of benzodiazepines and/or opioids were included. As soon as sedation/analgesia was decreased and until 72 h after its complete discontinuation, the WAT-1 score was determined every 12 h. Substitution therapy was used for 98% of patients upon opioid and/or benzodiazepine withdrawal. IWS was defined as a WAT-1 score ≥3. Factors associated with IWS were assessed by univariate analysis. RESULTS IWS occurred in 25 (52%) patients. IWS was associated with a higher number of ventilator-associated pneumonia episodes (17 [68%] vs. one [4%]) and a longer PICU stay (13 [7; 25] vs. 9.0 [5.0; 10.5]) (p<0.001). Overall, 11 patients developed IWS after less than 5 days of sedation/analgesia. Severe head injury was associated with IWS (p = 0.03). Neither sedation discontinuation nor IWS prevention was standardized. CONCLUSION The high incidence and adverse consequences of IWS require improved prevention. Risk groups should be defined and a standardized withdrawal protocol established. The occurrence of IWS should be monitored routinely using a validated score.
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Affiliation(s)
- G Geslain
- Pediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; University of Paris, Paris, France.
| | - P Ponsin
- Department of Pediatric Anesthesia and Intensive Care, University Hospital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - A M Lãzãrescu
- Department of Pediatric Anesthesia and Intensive Care, University Hospital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - C Tridon
- Department of Pediatric Anesthesia and Intensive Care, University Hospital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - N Robin
- Department of Pediatric Anesthesia and Intensive Care, University Hospital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - C Riaud
- Department of Pediatric Anesthesia and Intensive Care, University Hospital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - G Orliaguet
- University of Paris, Paris, France; Department of Pediatric Anesthesia and Intensive Care, University Hospital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France; EA7323: Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, Hôpitaux Universitaires Paris Centre, University of Paris, Paris, France
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18
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Tessari A, Sperotto F, Pece F, Pettenuzzo G, Porcellato N, Poletto E, Mondardini MC, Pettenazzo A, Daverio M, Amigoni A. Is ketamine infusion effective and safe as an adjuvant of sedation in the PICU? Results from the Ketamine Infusion Sedation Study (KISS). Pharmacotherapy 2022. [PMID: 36567489 DOI: 10.1002/phar.2754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/08/2022] [Accepted: 10/11/2022] [Indexed: 12/27/2022]
Abstract
STUDY OBJECTIVE We aimed to evaluate the efficacy and safety of ketamine in ensuring comfort and sparing conventional drugs when used as an adjuvant for analgesia and sedation in the Pediatric Intensive Care Unit (PICU) as a continuous infusion (≥12 h). DESIGN Observational prospective study. SETTING Tertiary-care-center PICU. PATIENTS All consecutive patients <18 years who received ketamine for ≥12 h between January 2019 and July 2021. INTERVENTIONS ketamine infusion for ≥12 h. MEASUREMENTS AND MAIN RESULTS Seventy-seven patients (median age 16 months, Interquartile Range (IQR) 7-43) were enrolled. Twenty-six percent of patients (n = 20) were paralyzed, while 74% (n = 57) were not. The median infusion duration was 90 h (IQR 39-193), with doses between 15 (IQR 15-20) and 30 μg/kg/min (IQR 20-50). At 24 h of ketamine infusion, values of COMFORT-B-Scale (CBS) were significantly lower compared with values pre-ketamine (p < 0.001). Simultaneously, doses/kg/h of opioids and benzodiazepines significantly decreased at 24 h (p < 0.001 and p = 0.002, respectively), while doses/kg/h of propofol (p = 0.500) and dexmedetomidine (p = 0.072) did not significantly change. Seventy-four percent of non-paralyzed patients (42/57) had a decrease in CBS ≥2 points with no increase of concomitant analgosedation drugs. Among paralyzed patients (n = 20), 13 (65%) had no increase of concomitant analgosedation within 24 h after ketamine initiation. Overall, 55/77 (71%) of patients responded to ketamine. The mean and maximum ketamine infusion dosages were significantly higher in the non-responders (p = 0.021 and 0.028, respectively). Eleven patients had adverse events potentially related to ketamine (hypersalivation, systemic hypertension, dystonia/dyskinesia, tachycardia, and agitation) and six patients required intervention (dose reduction, suspension, or pharmacologic therapy). None of the patients developed delirium during ketamine infusion. CONCLUSIONS Ketamine used as a continuous infusion in the PICU might represent a valid strategy to ensure comfort and spare opioids and benzodiazepines in difficult-to-sedate PICU patients. Adverse events are minor and easily reversible. Future study will be needed to investigate long-term outcomes.
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Affiliation(s)
- Anna Tessari
- Pediatric Intensive Care Unit, Department of Women and Children's Health, University Hospital of Padua, Padua, Italy
| | - Francesca Sperotto
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Federico Pece
- Pediatric Intensive Care Unit, San Bortolo Hospital, Vicenza, Italy
| | - Giulia Pettenuzzo
- Pediatric Intensive Care Unit, Department of Women and Children's Health, University Hospital of Padua, Padua, Italy
| | - Nicola Porcellato
- Pediatric Intensive Care Unit, Department of Women and Children's Health, University Hospital of Padua, Padua, Italy
| | - Elisa Poletto
- Pediatric Intensive Care Unit, San Bortolo Hospital, Vicenza, Italy
| | | | - Andrea Pettenazzo
- Pediatric Intensive Care Unit, Department of Women and Children's Health, University Hospital of Padua, Padua, Italy
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Women and Children's Health, University Hospital of Padua, Padua, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women and Children's Health, University Hospital of Padua, Padua, Italy
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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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20
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Smith-Parrish M, Vargas Chaves DP, Taylor K, Achuff BJ, Lasa JJ, Hopper A, Ramamoorthy C. Analgesia, Sedation, and Anesthesia for Neonates With Cardiac Disease. Pediatrics 2022; 150:189889. [PMID: 36317978 DOI: 10.1542/peds.2022-056415k] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Abstract
Analgesia, sedation, and anesthesia are a continuum. Diagnostic and/or therapeutic procedures in newborns often require analgesia, sedation, and/or anesthesia. Newborns, in general, and, particularly, those with heart disease, have an increased risk of serious adverse events, including mortality under anesthesia. In this section, we discuss the assessment and management of pain and discomfort during interventions, review the doses and side effects of commonly used medications, and provide recommendations for their use in newborns with heart disease. For procedures requiring deeper levels of sedation and anesthesia, airway and hemodynamic support might be necessary. Although associations of long-term deleterious neurocognitive effects of anesthetic agents have received considerable attention in both scientific and lay press, causality is not established. Nonetheless, an early multimodal, multidisciplinary approach is beneficial for safe management before, during, and after interventional procedures and surgery to avoid problems of tolerance and delirium, which can contribute to long-term cognitive dysfunction.
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Affiliation(s)
- Melissa Smith-Parrish
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | | | - Barbara-Jo Achuff
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Javier J Lasa
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Andrew Hopper
- Loma Linda University Children's Hospital, Loma Linda, California
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21
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Klein K, Pereira JS, Curtinaz KALJ, Jantsch LB, de Souza NS, Carvalho PRA. Strategies for the management and prevention of withdrawal syndrome in critically ill pediatric patients: a systematic review. Rev Bras Ter Intensiva 2022; 34:507-518. [PMID: 36888832 PMCID: PMC9987009 DOI: 10.5935/0103-507x.20220145-en] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 09/21/2022] [Indexed: 10/24/2023] Open
Abstract
OBJECTIVE To verify strategies for the prevention and treatment of abstinence syndrome in a pediatric intensive care unit. METHODS This is a systematic review in the PubMed database®, Lilacs, Embase, Web of Science, Cochrane, Cinahl, Cochrane Database Systematic Review and CENTRAL. A three-step search strategy was used for this review, and the protocol was approved in PROSPERO (CRD42021274670). RESULTS Twelve articles were included in the analysis. There was great heterogeneity among the studies included, especially regarding the therapeutic regimens used for sedation and analgesia. Midazolam doses ranged from 0.05mg/kg/hour to 0.3mg/kg/hour. Morphine also varied considerably, from 10mcg/kg/hour to 30mcg/kg/hour, between studies. Among the 12 selected studies, the most commonly used scale for the identification of withdrawal symptoms was the Sophia Observational Withdrawal Symptoms Scale. In three studies, there was a statistically significant difference in the prevention and management of the withdrawal syndrome due to the implementation of different protocols (p < 0.01 and p < 0.001). CONCLUSION There was great variation in the sedoanalgesia regimen used by the studies and the method of weaning and evaluation of withdrawal syndrome. More studies are needed to provide more robust evidence about the most appropriate treatment for the prevention and reduction of withdrawal signs and symptoms in critically ill children. PROSPERO REGISTER CRD 42021274670.
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Affiliation(s)
- Kassiely Klein
- Postgraduate Program in Child and Adolescent Health, Faculdade de
Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS),
Brazil
| | - Jéssica Silveira Pereira
- Postgraduate Program in Pathology, Universidade Federal de Ciências
da Saúde de Porto Alegre - Porto Alegre (RS), Brazil
| | - Kátia Adriana Lins Jaines Curtinaz
- Postgraduate Program in Child and Adolescent Health, Faculdade de
Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS),
Brazil
| | - Leonardo Bigolin Jantsch
- Department of Health Sciences, Universidade Federal de Santa Maria,
Campus Palmeira das Missões - Palmeira das Missões (RS), Brazil
| | - Neila Santini de Souza
- Department of Health Sciences, Universidade Federal de Santa Maria,
Campus Palmeira das Missões - Palmeira das Missões (RS), Brazil
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Klein K, Pereira JS, Curtinaz KALJ, Jantsch LB, de Souza NS, Carvalho PRA. Strategies for the management and prevention of withdrawal syndrome in critically ill pediatric patients: a systematic review. Rev Bras Ter Intensiva 2022; 34:507-518. [PMID: 36888832 PMCID: PMC9987009 DOI: 10.5935/0103-507x.20220145-pt] [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: 04/22/2022] [Accepted: 09/21/2022] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To verify strategies for the prevention and treatment of abstinence syndrome in a pediatric intensive care unit. METHODS This is a systematic review in the PubMed database®, Lilacs, Embase, Web of Science, Cochrane, Cinahl, Cochrane Database Systematic Review and CENTRAL. A three-step search strategy was used for this review, and the protocol was approved in PROSPERO (CRD42021274670). RESULTS Twelve articles were included in the analysis. There was great heterogeneity among the studies included, especially regarding the therapeutic regimens used for sedation and analgesia. Midazolam doses ranged from 0.05mg/kg/hour to 0.3mg/kg/hour. Morphine also varied considerably, from 10mcg/kg/hour to 30mcg/kg/hour, between studies. Among the 12 selected studies, the most commonly used scale for the identification of withdrawal symptoms was the Sophia Observational Withdrawal Symptoms Scale. In three studies, there was a statistically significant difference in the prevention and management of the withdrawal syndrome due to the implementation of different protocols (p < 0.01 and p < 0.001). CONCLUSION There was great variation in the sedoanalgesia regimen used by the studies and the method of weaning and evaluation of withdrawal syndrome. More studies are needed to provide more robust evidence about the most appropriate treatment for the prevention and reduction of withdrawal signs and symptoms in critically ill children. PROSPERO REGISTER CRD 42021274670.
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Affiliation(s)
- Kassiely Klein
- Postgraduate Program in Child and Adolescent Health, Faculdade de
Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS),
Brazil
| | - Jéssica Silveira Pereira
- Postgraduate Program in Pathology, Universidade Federal de Ciências
da Saúde de Porto Alegre - Porto Alegre (RS), Brazil
| | - Kátia Adriana Lins Jaines Curtinaz
- Postgraduate Program in Child and Adolescent Health, Faculdade de
Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS),
Brazil
| | - Leonardo Bigolin Jantsch
- Department of Health Sciences, Universidade Federal de Santa Maria,
Campus Palmeira das Missões - Palmeira das Missões (RS), Brazil
| | - Neila Santini de Souza
- Department of Health Sciences, Universidade Federal de Santa Maria,
Campus Palmeira das Missões - Palmeira das Missões (RS), Brazil
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23
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Visoiu M. Evolving approaches in neonatal postoperative pain management. Semin Pediatr Surg 2022; 31:151203. [PMID: 36038217 DOI: 10.1016/j.sempedsurg.2022.151203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Neonates experience significant moderate and severe postoperative pain. Effective postoperative pain management in neonates is required to minimize acute and long-term effects of neonatal pain. Protecting the developing nervous system from persistent sensitization of pain pathways and developing primary hyperalgesia is essential. Opioids and acetaminophen are commonly analgesics used for pain control. Regional anesthesia provides adequate intraoperative and postoperative analgesia in neonates. It decreases exposure to opioids, reduces adverse drug effects, and facilitates early extubation. It suppresses the stress response and can prevent long-term behavioral responses to pain. The most common blocks performed in neonates are neuraxial blocks. Using ultrasound increased the number of peripheral nerve blocks performed in neonates. Recently, various peripheral nerve blocks (paravertebral, transverse abdominis plane, rectus sheath, quadratus lumborum, erector spinae plane blocks) were safely used. Many studies support analgesic efficacy but highlight neonates' unpredictability and variability of fascial blocks.
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Affiliation(s)
- Mihaela Visoiu
- Associate Professor of Anesthesiology and Perioperative Medicine, Department of Anesthesiology and Perioperative Medicine; UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA, United States of America.
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24
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Michel J, Sauter L, Neunhoeffer F, Hofbeck M, Kumpf M, Paulsen F, Schmidt A, Fuchs J. Sedation practices during high dose rate brachytherapy for children with urogenital and perianal rhabdomyosarcoma. J Pediatr Surg 2022; 57:1432-1438. [PMID: 33189299 DOI: 10.1016/j.jpedsurg.2020.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/19/2020] [Accepted: 10/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND A novel concept for an organ-preserving treatment of pediatric urogenital and perianal rhabdomyosarcoma includes high dose rate brachytherapy following surgical tumor resection. For the duration of the brachytherapy of 6 days plus 2-day recovery break the patients are not allowed to move and are kept under deep sedation, which can lead to difficult weaning from mechanical ventilation, withdrawal, delirium, and prolonged hospital stay. The aim of this study was to evaluate a protocol which includes a switch from fentanyl to ketamine 3 days prior to extubation to help ensure a rapid extubation and transfer from PICU. METHODS Patients who underwent surgical tumor resection of rhabdomyosarcoma and subsequent brachytherapy were treated according to a standardized protocol. We evaluated doses of fentanyl, midazolam and clonidine, time of extubation, length of PICU stay and occurrence of withdrawal symptoms and delirium. We compared fentanyl dose at time of extubation, duration of weaning from mechanical ventilation and time to discharge from PICU with patients after isolated severe traumatic brain injury. RESULTS Twentytwo patients (age 39.9 ± 29.8 months) were treated in our PICU to undergo brachytherapy. Extubation was performed 21.6 ± 13.5 h after the last brachytherapy session with an average fentanyl dose of 1.5 ± 0.5 µg/kg/h and patients were discharged from PICU 58.4 ± 30.3 h after extubation, which all is significantly lower compared to the control group (extubation after 88.0 ± 42.2 h, p < 0.001; fentanyl dose at the time of extubation 2.5 ± 0.6 µg/kg/h, p < 0.001; PICU discharge after 130.1 ± 148.4 h, p < 0.009). Withdrawal symptoms were observed in 9 patients and delirium in 13 patients. CONCLUSION A standardized analgesia and sedation protocol including an opioid break, scoring systems to detect withdrawal symptoms and delirium, and tapering plans contributes to successful early extubation and discharge from PICU after long-term deep sedation.
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Affiliation(s)
- Jörg Michel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany.
| | - Luisa Sauter
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany
| | - Frank Paulsen
- Department of Radiation Oncology, University Hospital, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - Andreas Schmidt
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany
| | - Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tübingen, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany
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25
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Suliman NA, Moklas MAM, Taib CNM, Hidayat Baharuldin MT, Chiroma SM. Erythroxylum cuneatum prevented cellular adaptation in morphine-induced neuroblastoma cells. Cent Nerv Syst Agents Med Chem 2022; 22:108-117. [PMID: 35578883 DOI: 10.2174/1871524922666220516151121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 01/13/2022] [Accepted: 02/09/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Chronic morphine stimulates prolonged stimulation of opioid receptors, especially µ-opioid subtype (MOR), which in turn signals cellular adaptation. However, the sudden termination of morphine after chronic intake causes withdrawal syndrome. OBJECTIVES Hence, this study was designed to find an alternative treatment for the morphine withdrawal using the alkaloid leaf extract of Erythroxylum cuneatum (E. cuneatum), done on morphine-exposed neuroblastoma cell lines. METHODS SK-N-SH, a commercialised neuroblastoma cell line, was used in two separate study designs; the antagonistic and pre-treatment of morphine. The antagonistic treatment was conducted through concurrent exposure of the cells to morphine and E. cuneatum or morphine and methadone for 24 h. The pre-treatment design was carried out by exposing the cells to morphine for 24 h, followed by 24 h exposures to E. cuneatum or methadone. The cytosolic fraction was collected and run for protein expression involved in cellular adaptation; mitogen-activated protein (MAP)/extracellular signal-regulated (ERK) kinase 1/2 (MEK 1/2), extracellular signal-regulated kinase 2 (ERK 2), cAMP-dependent protein kinase (PKA) and protein kinases C (PKC). RESULTS The antagonistic treatment showed the normal level of MEK 1/2, ERK 2, PKA and PKC by the combination treatment of morphine and E. cuneatum, comparable to the combination of morphine and methadone. Neuroblastoma cells exposed to morphine pre-treatment expressed a high level of MEK 1/2, ERK 2, PKA and PKC, while the treatments with E. cuneatum and methadone normalised the expression of the cellular adaptation proteins. CONCLUSION E. cuneatum exerted anti-addiction properties by lowering the levels of cellular adaptation proteins, and its effects are comparable to that of methadone (an established anti-addiction drug).
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Affiliation(s)
- Noor Azuin Suliman
- Faculty of Medicine, Universiti Sultan Zainal Abidin, Kampus Kota, Jalan Sultan Mahmud, 20400 Kuala Terengganu, Terengganu, Malaysia
| | - Mohamad Aris Mohd Moklas
- Department of Human Anatomy, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Malaysia
| | - Che Norma Mat Taib
- Department of Human Anatomy, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Malaysia
| | | | - Samaila Musa Chiroma
- Department of Human Anatomy, Faculty of Basic Medical Sciences, University of Maiduguri, Borno state, Nigeria
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26
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Achuff BJ, Lemming K, Causey JC, Sembera KA, Checchia PA, Heinle JS, Ghanayem NS. Opioid Weaning Protocol Using Morphine Compared With Nonprotocolized Methadone Associated With Decreased Dose and Duration of Opioid After Norwood Procedure. Pediatr Crit Care Med 2022; 23:361-370. [PMID: 34982761 DOI: 10.1097/pcc.0000000000002885] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Opioids are used to manage pain, comfort, maintain devices, and decrease oxygen consumption around Norwood palliation (NP), but in high dose and prolonged exposure, they increase risk of tolerance and iatrogenic withdrawal syndrome (IAWS). Variability in practice for IAWS prevention potentially increases opioid dose and duration. We hypothesize that protocolized weaning with morphine (MOR) versus nonprotocolized methadone (MTD) is associated with reduction in opioid exposure. DESIGN A before-versus-after study of outcomes of patients weaned with protocolized MOR versus nonprotocolized MTD including subset analysis for those patients with complications postoperatively. Primary endpoints include daily, wean phase, and total morphine milligram equivalent (MMEq) dose, duration, and, secondarily, length of stay (LOS). SETTING Quaternary-care pediatric cardiac ICU. PATIENTS Neonates undergoing single-ventricle palliation. INTERVENTIONS Introduction of IAWS prevention protocol. MEASUREMENTS AND MAIN RESULTS Analysis included 54 patients who underwent the NP in 2017-2018 including the subset analysis of 34 who had a complicated postoperative course. The total and wean phase opioid doses for the MTD group were significantly higher than that for the MOR group: 258 versus 22 and 115 versus 6 MMEq/kg; p < 0.001. Duration of opioid exposure was 63 days in the MTD group and 12 days in MOR group (p < 0.001). Subanalysis of the complicated subset also identifies higher total and wean dose for MTD group (293 vs 41 and 116 vs 7 MMEq/kg; p < 0.001) with a longer duration (65 vs 22 days; p = 0.001). Within the subset, LOS was 55% longer in the MTD group than that in the MOR group (150 vs 67 d; p = 0.01) and not different in the uncomplicated group. CONCLUSIONS After complex NP, a protocolized opioid weaning using MOR versus MTD is associated with 65% shorter opioid duration, 10-fold decreased dose, and shortened LOS.
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Affiliation(s)
| | | | - Jamie C Causey
- Pediatric Critical Care, Baylor College of Medicine, Houston, TX
| | | | - Paul A Checchia
- Pediatric Critical Care, Baylor College of Medicine, Houston, TX
| | - Jeffrey S Heinle
- Pediatric Critical Care, Baylor College of Medicine, Houston, TX
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27
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Standardized Scoring Tool and Weaning Guideline to Reduce Opioids in Critically Ill Neonates. Pediatr Qual Saf 2022; 7:e562. [PMID: 35720868 PMCID: PMC9197367 DOI: 10.1097/pq9.0000000000000562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/02/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Pain impacts brain development for neonates, causing deleterious neurodevelopmental outcomes. Prescription opioids for analgesia or sedation are common; however, prolonged opioid exposure in neonates is associated with neurodevelopmental impairment. Balancing the impact of inadequate pain control against prolonged opioid exposure in neonates is a clinical paradox. Therefore, we sought to decrease the average days of opioids used for analgesia or sedation in critically ill neonates at a level IV Neonatal Intensive Care Unit by 10% within 1 year. Methods A multidisciplinary quality improvement team used the model for improvement, beginning with a Pareto analysis, and identified a lack of consistent approach to weaning opioids as a primary driver for prolonged exposure. The team utilized 2 main interventions: (1) a standardized withdrawal assessment tool-1 and (2) a risk-stratified opioid weaning guideline. Results We demonstrated a reduction in mean opioid duration from 34.3 to 14.1 days, an increase in nursing withdrawal assessment tool-1 documentation from 20% to 90%, and an increase in the documented rationale for daily opioid dose in provider notes from 20% to 70%. Benzodiazepine use did not change. Conclusion Standardized withdrawal assessments combined with risk-stratified weaning guidelines can decrease opioid use in critically ill neonates.
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28
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Rosen DM, Alcock MM, Palmer GM. Opioids for acute pain management in children. Anaesth Intensive Care 2022; 50:81-94. [PMID: 35172638 DOI: 10.1177/0310057x211065769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Opioids are integral to multimodal analgesic regimens in children with moderate to severe acute pain. Throughout normal childhood there are marked changes in physiology, and social and psychological development that influence the perception and expression of pain, the pharmacology of opioids, and how they are used. A multidimensional pain assessment is key to guiding appropriate opioid prescribing. Most of the commonly used opioids in adults are used in children, with the increasing exception of codeine (as a result of regulatory change), and are generally well tolerated. Patient groups at increased risk of ventilatory impairment include neonates and those with obstructive sleep apnoea, severe neurodevelopmental conditions, trisomy 21, and severe epilepsy. Slow-release opioids are not recommended for general use, but may be used in select populations, for example, following scoliosis surgery, major trauma or burns. Prescribing and administration errors are a major issue in paediatrics generally; the potential consequences of opioid prescribing or administration errors are serious, particularly following hospital discharge. Opioids prescribed at discharge are frequently in excess of a child's analgesic requirements; three to five days supply appears sufficient for the majority of common paediatric operations. Discharge opioid prescriptions have been linked to long-term opioid use in adolescents with risk factors. Misuse of prescription opioids by adolescents is also concerning, with prevalence estimates ranging from 1.1% to 20%. Caregivers have a tendency to underdose opioids in their children; caregiver education may improve appropriate administration. Caregivers must also be provided with instructions on safe storage and disposal of unused opioids.
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Affiliation(s)
- Derek M Rosen
- Department of Anaesthesia and Pain Management, Queensland Children's Hospital, Brisbane, Queensland, Australia.,University of Queensland, Queensland, Brisbane, Australia
| | - Mark M Alcock
- Department of Anaesthesia and Pain Management, Queensland Children's Hospital, Brisbane, Queensland, Australia.,University of Queensland, Queensland, Brisbane, Australia
| | - Greta M Palmer
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
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29
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Recommendations for analgesia and sedation in critically ill children admitted to intensive care unit. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2022. [PMCID: PMC8853329 DOI: 10.1186/s44158-022-00036-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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30
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Smith HAB, Besunder JB, Betters KA, Johnson PN, Srinivasan V, Stormorken A, Farrington E, Golianu B, Godshall AJ, Acinelli L, Almgren C, Bailey CH, Boyd JM, Cisco MJ, Damian M, deAlmeida ML, Fehr J, Fenton KE, Gilliland F, Grant MJC, Howell J, Ruggles CA, Simone S, Su F, Sullivan JE, Tegtmeyer K, Traube C, Williams S, Berkenbosch JW. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatr Crit Care Med 2022; 23:e74-e110. [PMID: 35119438 DOI: 10.1097/pcc.0000000000002873] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
RATIONALE A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available. OBJECTIVE To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility. DESIGN The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to. METHODS Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence. RESULTS The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements. CONCLUSIONS The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.
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Affiliation(s)
- Heidi A B Smith
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
- Division of Pediatric Cardiac Anesthesiology, Vanderbilt University Medical Center, Department of Anesthesiology, Nashville, TN
| | - James B Besunder
- Division of Pediatric Critical Care, Akron Children's Hospital, Akron, OH
- Department of Pediatrics, Northeast Ohio Medical University, Akron, OH
| | - Kristina A Betters
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK
- The Children's Hospital at OU Medical Center, Oklahoma City, OK
| | - Vijay Srinivasan
- Departments of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Anne Stormorken
- Pediatric Critical Care, Rainbow Babies Children's Hospital, Cleveland, OH
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH
| | - Elizabeth Farrington
- Betty H. Cameron Women's and Children's Hospital at New Hanover Regional Medical Center, Wilmington, NC
| | - Brenda Golianu
- Division of Pediatric Anesthesia and Pain Management, Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
| | - Aaron J Godshall
- Department of Pediatrics, AdventHealth For Children, Orlando, FL
| | - Larkin Acinelli
- Division of Critical Care Medicine, Johns Hopkins All Children's Hospital, St Petersburg, FL
| | - Christina Almgren
- Lucile Packard Children's Hospital Stanford Pain Management, Palo Alto, CA
| | | | - Jenny M Boyd
- Division of Pediatric Critical Care, N.C. Children's Hospital, Chapel Hill, NC
- Division of Pediatric Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael J Cisco
- Division of Pediatric Critical Care Medicine, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA
| | - Mihaela Damian
- Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA
- Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Mary L deAlmeida
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA
- Division of Pediatric Critical Care, Emory University School of Medicine, Atlanta, GA
| | - James Fehr
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
- Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA
| | | | - Frances Gilliland
- Division of Cardiac Critical Care, Johns Hopkins All Children's Hospital, St Petersburg, FL
- College of Nursing, University of South Florida, Tampa, FL
| | - Mary Jo C Grant
- Primary Children's Hospital, Pediatric Critical Care Services, Salt Lake City, UT
| | - Joy Howell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | | | - Shari Simone
- University of Maryland School of Nursing, Baltimore, MD
- Pediatric Intensive Care Unit, University of Maryland Medical Center, Baltimore, MD
| | - Felice Su
- Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA
- Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Janice E Sullivan
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Chani Traube
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - Stacey Williams
- Division of Pediatric Critical Care, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - John W Berkenbosch
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY
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31
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Hazwani T, Al Ahmady A, Kazzaz Y, Al Smari A, Al Enizy S, Alali H. Implementation of a sedation protocol: a quality improvement project to enhance sedation management in the paediatric intensive care unit. BMJ Open Qual 2022; 11:bmjoq-2021-001501. [PMID: 34980589 PMCID: PMC8724811 DOI: 10.1136/bmjoq-2021-001501] [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: 03/19/2021] [Accepted: 12/21/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Proper sedation is integral to ensuring the safety and comfort of children on mechanical ventilation (MV). Sedation protocols help to achieve this goal and reduce the duration of MV. We have observed varied sedation approaches, sedation score targets and sedative use by our physicians, which were manifested as oversedation and undersedation with associated accidental extubation. Hence, we aimed to implement a standardised sedation protocol and assess its impact on mechanically ventilated paediatric patients. METHODS A multidisciplinary quality improvement team was formed to develop and implement a standardised sedation protocol for mechanically ventilated paediatric patients. COMFORT-Behaviour (COMFORT-B) Scale score was used to assess the sedation targets and define undersedation, oversedation or adequate sedation. Our goal was to achieve adequate sedation during 90% of the sedation period. Based on the model for improvement methodology, we used plan-do-study-act cycles to develop, test and implement the new sedation protocol. RESULTS There was an immediate percentage increase in COMFORT-B Scale scores within the target sedation level, which was associated with a gradual decrease in the need for intermittent sedation doses over sedation infusion in the preimplementation, improvement and control phases (6.3, 4.9 and 3.1 sedation doses/12 hours/patient, respectively) to achieve adequate sedation target. CONCLUSIONS The standardisation of sedation protocols was safe and efficient, and improved the sedation quality in mechanically ventilated paediatric patients.
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Affiliation(s)
- Tarek Hazwani
- Department of Pediatrics, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia .,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Arwa Al Ahmady
- Nursing Service, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Yasser Kazzaz
- Department of Pediatrics, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abeer Al Smari
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Pharmaceutical Care Services, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Seham Al Enizy
- Nursing Service, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Hamza Alali
- Department of Pediatrics, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Mondardini MC, Daverio M, Caramelli F, Conti G, Zaggia C, Lazzarini R, Muscheri L, Azzolina D, Gregori D, Sperotto F, Amigoni A. Dexmedetomidine for prevention of opioid/benzodiazepine withdrawal syndrome in pediatric intensive care unit: Interim analysis of a randomized controlled trial. Pharmacotherapy 2021; 42:145-153. [PMID: 34882826 DOI: 10.1002/phar.2654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 11/07/2021] [Accepted: 11/10/2021] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Maria Cristina Mondardini
- Pediatric Anesthesia and Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Bologna IRCCS S. Orsola Polyclinic, Bologna, Italy
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University-Hospital, Padua, Italy
| | - Fabio Caramelli
- Pediatric Anesthesia and Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Bologna IRCCS S. Orsola Polyclinic, Bologna, Italy
| | - Giorgio Conti
- Pediatric Intensive Care Unit and Pediatric Trauma Center, Department of Anesthesia and Intensive Care, Catholic University of Rome, A Gemelli Polyclinic, Rome, Italy
| | - Cristina Zaggia
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University-Hospital, Padua, Italy
| | - Rossella Lazzarini
- Pediatric Anesthesia and Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Bologna IRCCS S. Orsola Polyclinic, Bologna, Italy
| | - Lidia Muscheri
- Pediatric Intensive Care Unit and Pediatric Trauma Center, Department of Anesthesia and Intensive Care, Catholic University of Rome, A Gemelli Polyclinic, Rome, Italy
| | - Danila Azzolina
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University-Hospital of Padua, Padua, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University-Hospital of Padua, Padua, Italy
| | - Francesca Sperotto
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University-Hospital, Padua, Italy.,Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University-Hospital, Padua, Italy
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Qiu J, Xie M. Influence of ketamine versus fentanyl on pain relief for pediatric orthopedic emergencies: A meta-analysis of randomized controlled studies. Medicine (Baltimore) 2021; 100:e27409. [PMID: 34678869 PMCID: PMC8542162 DOI: 10.1097/md.0000000000027409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/16/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION The comparison of ketamine with fentanyl for pain control of pediatric orthopedic emergencies remains controversial. We conduct a systematic review and meta-analysis to explore the influence of ketamine versus fentanyl on pain management among pediatric orthopedic emergencies. METHODS We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through September 2020 for randomized controlled trials assessing the effect of ketamine versus fentanyl on pain management for pediatric orthopedic emergencies. RESULTS Five randomized controlled trials are included in the meta-analysis. Overall, compared with fentanyl for pediatric orthopedic emergencies, ketamine led to similar change in pain scores at 15 to 20 minutes (standard mean difference = -0.05; 95% confidence interval [CI] = -0.38 to 0.28; P = .77) and 30 minutes (standard mean difference = 0.11; 95% CI = -0.20 to 0.42; P = .49), as well as rescue analgesia (RR = 0.90; 95% CI = 0.54 to 1.51; P = .69), but revealed the increase in nausea/vomiting (RR = 2.65; 95% CI = 1.13 to 6.18; P = .02) and dizziness (RR = 3.83; 95% CI = 1.38 to 10.60; P = .01). CONCLUSIONS Ketamine may be similar to fentanyl in terms of the analgesic efficacy for pediatric orthopedic emergencies.
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Harris J, Tibby SM, Endacott R, Latour JM. Neurally Adjusted Ventilator Assist in Infants With Acute Respiratory Failure: A Literature Scoping Review. Pediatr Crit Care Med 2021; 22:915-924. [PMID: 33852545 DOI: 10.1097/pcc.0000000000002727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To map the evidence for neurally adjusted ventilatory assist strategies, outcome measures, and sedation practices in infants less than 12 months with acute respiratory failure using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidance. DATA SOURCES CINAHL, MEDLINE, COCHRANE, JBI, EMBASE, PsycINFO, Google scholar, BNI, AMED. Trial registers included the following: ClinicalTrials.gov, European Union clinical trials register, International Standardized Randomized Controlled Trial Number register. Also included were Ethos, Grey literature, Google, dissertation abstracts, EMBASE conference proceedings. STUDY SELECTION Abstracts were screened followed by review of full text. Articles incorporating a heterogeneous population of both infants and older children were assessed, and where possible, data for infants were extracted. Fifteen articles were included. Ten articles were primary research: randomized controlled trial (n = 3), cohort studies (n = 4), retrospective data analysis (n = 2), case series (n = 1). Other articles are expert opinion (n = 2), neurally adjusted ventilatory assist updates (n = 1), and a literature review (n = 2). Three studies included exclusively infants. We also included 12 studies reporting jointly on infants and children. DATA EXTRACTION A standardized data extraction tool was used. DATA SYNTHESIS Key findings were that evidence related to neurally adjusted ventilatory assist ventilation strategies in infants and related to specific primary conditions is limited. The setting of neurally adjusted ventilatory assist level is not consistent, and how to optimize this mode of ventilation was not documented. Outcome measures varied considerably, most studies focused on improvements in respiratory and physiological variables. Sedation use is variable with regard to medication type and dose. There is an indication that less sedation is required in patients receiving neurally adjusted ventilatory assist, but no conclusive evidence to support this. CONCLUSIONS This review highlights a lack of standardized strategies for neurally adjusted ventilatory assist ventilation and sedation practices among infants with acute respiratory failure. Studies were limited by small sample sizes and a lack of focus on specific patient groups. Robust studies are needed to provide evidence-based clinical recommendations for the use of neurally adjusted ventilatory assist in infants with acute respiratory failure.
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Affiliation(s)
- Julia Harris
- Department of Advanced and Integrated Practice, London South Bank University, London, United Kingdom
- Department of Children's Nursing, School of Nursing and Midwifery, Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, United Kingdom
| | - Shane M Tibby
- Pediatric Intensive Care, Evelina London Children's Hospital, London, United Kingdom
| | - Ruth Endacott
- Department of Children's Nursing, School of Nursing and Midwifery, Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, United Kingdom
- School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, VIC, Australia
| | - Jos M Latour
- Department of Children's Nursing, School of Nursing and Midwifery, Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, United Kingdom
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Muirhead R, Kynoch K, Peacock A, Lewis PA. Safety and effectiveness of parent- or nurse-controlled analgesia in neonates: a systematic review. JBI Evid Synth 2021; 20:3-36. [PMID: 34387281 DOI: 10.11124/jbies-20-00385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
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.
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Affiliation(s)
- Renee Muirhead
- Neonatal Critical Care Unit, Mater Misericordiae Limited, Brisbane, QLD, Australia School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, QLD, Australia The Queensland Centre for Evidence Based Nursing and Midwifery: A JBI Centre of Excellence, Mater Misercordiae Limited, South Brisbane, QLD, Australia
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Dokken M, Rustøen T, Diep LM, Fagermoen FE, Huse RI, A. Rosland G, Egerod I, Bentsen GK. Iatrogenic withdrawal syndrome frequently occurs in paediatric intensive care without algorithm for tapering of analgosedation. Acta Anaesthesiol Scand 2021; 65:928-935. [PMID: 33728643 DOI: 10.1111/aas.13818] [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: 11/11/2020] [Revised: 03/03/2021] [Accepted: 03/06/2021] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Mette Dokken
- Division of Emergencies and Critical Care Paediatric Intensive Care Section Oslo University Hospital ‐ Rikshospitalet Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Tone Rustøen
- Division of Emergencies and Critical Care Department of Research and Development Oslo University Hospital Oslo Norway
- Department of Nursing Science Faculty of Medicine Institute of Health and Society University of Oslo Oslo Norway
| | - Lien M. Diep
- Department of Biostatistic and Epidemiology Oslo University Hospital Oslo Norway
| | - Frode E. Fagermoen
- Division of Emergencies and Critical Care Department of Anesthesiology Oslo University Hospital ‐ Rikshospitalet Oslo Norway
| | - Rakel I. Huse
- Division of Emergencies and Critical Care Paediatric Intensive Care Section Oslo University Hospital ‐ Rikshospitalet Oslo Norway
| | - Gudny A. Rosland
- Division of Emergencies and Critical Care Paediatric Intensive Care Section Oslo University Hospital ‐ Rikshospitalet Oslo Norway
| | - Ingrid Egerod
- Intensive Care Department University of CopenhagenRigshospitalet Copenhagen Denmark
| | - Gunnar K. Bentsen
- Division of Emergencies and Critical Care Department of Anesthesiology Oslo University Hospital ‐ Rikshospitalet Oslo Norway
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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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Harkin M, Miller J, Lim SY, Neely S, Walsh C, Johnson PN. "Reply: Conversion From Continuous Infusion Fentanyl to Hydromorphone in the Pediatric Intensive Care Unit". Ann Pharmacother 2021; 56:370-371. [PMID: 34165365 DOI: 10.1177/10600280211028672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Maura Harkin
- Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Jamie Miller
- Oklahoma Children's Hospital, Oklahoma City, OK, USA.,University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | | | - Stephen Neely
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Christina Walsh
- Oklahoma Children's Hospital, Oklahoma City, OK, USA.,University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | - Peter N Johnson
- Oklahoma Children's Hospital, Oklahoma City, OK, USA.,University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Khera T, Rangasamy V. Cognition and Pain: A Review. Front Psychol 2021; 12:673962. [PMID: 34093370 PMCID: PMC8175647 DOI: 10.3389/fpsyg.2021.673962] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/26/2021] [Indexed: 01/14/2023] Open
Abstract
Cognition is defined as the brain's ability to acquire, process, store, and retrieve information. Pain has been described as an unpleasant sensory or emotional experience, and for experiencing pain consciously, cognitive processing becomes imperative. Moreover, evaluation of pain strongly depends on cognition as it requires learning and recall of previous experiences. There could be a possible close link between neural systems involved in cognition and pain processing, and studies have reported an association between pain and cognitive impairment. In this narrative review, we explore the available evidence that has investigated cognitive changes associated with pain. We also examine the anatomical, biochemical, and molecular association of pain and neuro-cognition. Additionally, we focus on the cognitive impairment caused by analgesic medications. There is a need to improve our understanding of pathophysiology and cognitive impairment mechanisms associated with chronic pain and its treatment. This area provides a diverse opportunity for grounding future research, aiding institution of timely interventions to prevent chronic pain and associated cognitive decline, ultimately improving patient care.
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Affiliation(s)
- Tanvi Khera
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Valluvan Rangasamy
- Department of Anesthesia Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
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Egbuta C, Mason KP. Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit. J Clin Med 2021; 10:1847. [PMID: 33922824 PMCID: PMC8122992 DOI: 10.3390/jcm10091847] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA;
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Hughes KM, Thorndyke A, Tillman EM. Incidence of Corrected QT Prolongation With Concomitant Methadone and Atypical Antipsychotics in Critically Ill Children. J Pediatr Pharmacol Ther 2021; 26:271-276. [PMID: 33833629 DOI: 10.5863/1551-6776-26.3.271] [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: 02/12/2020] [Accepted: 09/17/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the safety of the combination of methadone and an atypical antipsychotic in PICU patients. METHODS This was a retrospective observational cohort pilot study in a single-center PICU in an academic children's hospital. Children 1 month to 18 years of age were included if they received methadone, were then initiated on an atypical antipsychotic (i.e., quetiapine or risperidone), and had EKG monitoring before and after medication initiation. RESULTS Prolongation of the corrected QT (QTc) interval occurred in 5 of the 34 included patients when an atypical antipsychotic was added to methadone. Of the 5 patients who had a prolonged QTc interval, 4 (80%) were older than 12 years and had a median weight of 91.3 kg. There were statistical differences between age and weight when comparing patients who experienced QTc prolongation, but no differences in sex, ethnicity, electrolyte deficiencies, number of additional QTc-prolonging medications, and number of additional drug-drug interactions were identified. When comparing atypical antipsychotics, 9.5% of patients receiving risperidone had a prolonged QTc interval, versus 23% of patients receiving quetiapine (p = 0.04). The net change in QTc interval after initiation of methadone was 0.19 milliseconds (IQR: -3, 15), which increased after atypical antipsychotic initiation to 4 milliseconds (IQR: -16, 15). CONCLUSIONS Our pilot trial suggests there is no clinically significant difference in incidence of QTc prolongation with addition of atypical antipsychotics to methadone.
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Lim SY, Miller JL, Henry E, Heltsley R, Woo S, Johnson PN. Analysis of fentanyl pharmacokinetics, and its sedative effects and tolerance in critically ill children. Pharmacotherapy 2021; 41:359-369. [PMID: 33604895 DOI: 10.1002/phar.2515] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/25/2021] [Accepted: 01/29/2021] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Fentanyl pharmacokinetic and pharmacodynamic data are limited in mechanically ventilated children. This study aimed to assess the fentanyl pharmacokinetics (PK), the sedation outcome, and the development of tolerance in children receiving fentanyl continuous infusion. METHODS This study included children admitted to the pediatric or cardiovascular intensive care unit between January 1 and October 31, 2016, who were >30 days to <18 years of age, receiving ventilatory support via endotracheal tube or tracheostomy, and receiving a fentanyl infusion. Population PK analysis was performed using a nonlinear mixed-effects model. The relationship between initial sedation outcome using State Behavioral Scale (SBS) and fentanyl exposure was assessed, and the observations consistent with tolerance were described. RESULTS Seventeen children, with a median age of 0.83 years (range: 0.1-12) and weight of 8.7 kg (range: 3.4-52), were included. The fentanyl PK was adequately described by a weight-based allometry model with the power of 0.75 for clearance (CL=89.8 L/hr/70 kg) and distributional CL, and 1 for volumes of distribution. In infants <6.6 months, age was an additional factor for CL (31.4 L/h/70 kg) to account for age-related maturation. Seven of twelve nonparalyzed patients achieved goal sedation, defined as >80% of SBS scores ≤0 per 24 h, on the first day of fentanyl infusion with a median plasma concentration of 1.29 ng/ml (interquartile range: 0.78-2.05). Eight of the nine tolerant patients developed tolerance within a day of reaching goal sedation. CONCLUSION Different weight-based fentanyl dosing rates may be required for infants and children of different ages to achieve similar plasma concentrations. Using SBS scores may guide the dosing titration of fentanyl that resulted in plasma concentrations within the therapeutic range of 1-3 ng/ml. For those who developed tolerance to fentanyl and/or a sedative, it was noted one day after goal sedation was achieved.
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Affiliation(s)
- Sin Yin Lim
- Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Jamie L Miller
- Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Emilie Henry
- Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | | | - Sukyung Woo
- Department of Pharmaceutical Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, USA
| | - Peter N Johnson
- Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Harkin M, Miller JL, Lim SY, Neely SB, Walsh CK, Johnson PN. Conversion From Continuous Infusion Fentanyl to Continuous Infusion Hydromorphone in the Pediatric Intensive Care Unit. Ann Pharmacother 2021; 55:1439-1446. [DOI: 10.1177/10600280211003170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background: Opioid rotations from fentanyl to hydromorphone may reduce opioid/sedative exposure in critically ill children. Objective: The primary objective was to determine the conversion percentage from fentanyl to hydromorphone infusions using equianalgesic conversions (0.1 mg fentanyl = 1.5 mg hydromorphone). Secondary objectives included identification of the median time and hydromorphone rate at stabilization (defined as the first 24-hour period no hydromorphone rates changed, 80% of State Behavioral Scale [SBS] scores between 0 and −1, and <3 hydromorphone boluses administered). Additional outcomes included a comparison of opioid/sedative requirements on the day of conversion versus the three 24-hour periods prior to conversion. Methods: This retrospective study included children <18 years old converted from fentanyl to hydromorphone infusions over 6.3 years. Linear mixed models were used to determine if the mean cumulative opioid/sedative dosing differed from the day of conversion versus three 24-hour periods prior to conversion. Results: A total of 36 children were converted to hydromorphone. The median conversion percentage of hydromorphone was 86% of their fentanyl dose (interquartile range [IQR] = 67-100). The median hydromorphone rate at stabilization was 0.08 mg/kg/h (IQR = 0.05-0.1). Eight (22%) were stabilized on their initial hydromorphone rate; 8 (22%) never achieved stabilization. Patients had a significant decrease in opioid dosing on the day of conversion versus the 24-hour period prior to conversion but no changes in sedative dosing following conversion. Conclusion and Relevance: A median 14% fentanyl dose reduction was noted when transitioning to hydromorphone. Further exploration is needed to determine if opioid rotations with hydromorphone can reduce opioid/sedative exposure.
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Affiliation(s)
- Maura Harkin
- Oklahoma Children’s Hospital at OU Health, Oklahoma City, OK, USA
| | - Jamie L. Miller
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Sin Yin Lim
- University of Wisconsin School of Pharmacy, Madison, WI, USA
| | - Stephen B. Neely
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | | | - Peter N. Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Ilhan E, Pacey V, Brown L, Spence K, Gray K, Rowland JE, White K, Hush JM. Neonates as intrinsically worthy recipients of pain management in neonatal intensive care. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2021; 24:65-72. [PMID: 33034802 DOI: 10.1007/s11019-020-09982-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/01/2020] [Indexed: 06/11/2023]
Abstract
One barrier to optimal pain management in the neonatal intensive care unit (NICU) is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are (1) vulnerable to pain and harm, and (2) completely dependent on others for pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate's family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers.
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Affiliation(s)
- Emre Ilhan
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia.
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Ground Floor, 75 Talavera Road, Sydney, NSW, 2109, Australia.
| | - Verity Pacey
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia
| | - Laura Brown
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia
| | - Kaye Spence
- Children's Hospital at Westmead, Grace Centre for Newborn Intensive Care, Sydney, NSW, Australia
- School of Nursing and Midwifery, Western Sydney University, Parramatta, NSW, Australia
| | - Kelly Gray
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia
| | - Jennifer E Rowland
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia
| | - Karolyn White
- Research Ethics and Integrity, Macquarie University, Sydney, NSW, Australia
| | - Julia M Hush
- Faculty of Medicine, Health and Human Sciences, Department of Health Professions, Macquarie University, Sydney, NSW, Australia
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Geven BM, Maaskant JM, Ward CS, van Woensel JBM. Dexmedetomidine and Iatrogenic Withdrawal Syndrome in Critically Ill Children. Crit Care Nurse 2021; 41:e17-e23. [PMID: 33560432 DOI: 10.4037/ccn2021462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Iatrogenic withdrawal syndrome is a well-known adverse effect of sedatives and analgesics commonly used in patients receiving mechanical ventilation in the pediatric intensive care unit, with an incidence of up to 64.6%. When standard sedative and analgesic treatment is inadequate, dexmedetomidine may be added. The effect of supplemental dexmedetomidine on iatrogenic withdrawal syndrome is unclear. OBJECTIVE To explore the potentially preventive effect of dexmedetomidine, used as a supplement to standard morphine and midazolam regimens, on the development of iatrogenic withdrawal syndrome in patients receiving mechanical ventilation in the pediatric intensive care unit. METHODS This retrospective observational study used data from patients on a 10-bed general pediatric intensive care unit. Iatrogenic withdrawal syndrome was measured using the Sophia Observation withdrawal Symptoms-scale. RESULTS In a sample of 102 patients, the cumulative dose of dexmedetomidine had no preventive effect on the development of iatrogenic withdrawal syndrome (P = .19). After correction for the imbalance in the baseline characteristics between patients who did and did not receive dexmedetomidine, the cumulative dose of midazolam was found to be a significant risk factor for iatrogenic withdrawal syndrome (P < .03). CONCLUSION In this study, supplemental dexmedetomidine had no preventive effect on iatrogenic withdrawal syndrome in patients receiving sedative treatment in the pediatric intensive care unit. The cumulative dose of midazolam was a significant risk factor for iatrogenic withdrawal syndrome.
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Affiliation(s)
- Barbara M Geven
- Barbara M. Geven is a pediatric intensive care nurse and clinical epidemiologist, Amsterdam UMC/Emma Children's Hospital, University of Amsterdam, Amsterdam, the Netherlands
| | - Jolanda M Maaskant
- Jolanda M. Maaskant is a senior nurse researcher and clinical epidemiologist, Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam UMC/University of Amsterdam
| | - Catherine S Ward
- Catherine S. Ward is a general and pediatric anesthesiologist, Amsterdam UMC/Emma Children's Hospital
| | - Job B M van Woensel
- Job B.M. van Woensel is medical director of the pediatric intensive care unit, Amsterdam UMC/Emma Children's Hospital
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Identifying the Neurodevelopmental Differences of Opioid Withdrawal. Cell Mol Neurobiol 2021; 41:1145-1155. [PMID: 33432504 DOI: 10.1007/s10571-020-01035-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 12/28/2020] [Indexed: 01/01/2023]
Abstract
Stopping opioid medications can result in a debilitating withdrawal syndrome in chronic users. Opioid withdrawal can occur at all ages, but mechanistic understanding of this condition is predominantly derived from adult studies. Here, we examined whether there are age-dependent differences in the behavioural phenotype and cellular indices of opioid withdrawal. We tested this by assessing the behavioural and cFos response (a surrogate marker for neuronal activation) to morphine withdrawal in C57BL/6J mice across key developmental stages-neonatal, adolescent, and adulthood. Mice in all age groups received escalating doses of morphine (10-50 mg/kg) over 5 days and withdrawal was precipitated by a single injection of the opioid receptor antagonist naloxone (2 mg/kg) two hours after the last morphine dose. In adult and adolescent mice, withdrawal behaviours were robust, with age-related differences in autonomic and somatic signs. In both groups, cFos expression was increased in spinally projecting neurons within the Periaqueductal Grey (PAG), Rostro-ventromedial Medulla (RVM), and Locus Coeruleus. Neonatal animals displayed both a distinct behavioural withdrawal and cFos expression profile. Notably, in young animals cFos expression was increased within the PAG and LC, but decreased in the RVM. In summary, naloxone challenge precipitated robust opioid withdrawal behaviours across all developmental stages with neonatal animals displaying differences in withdrawal behaviours and unique neuronal activation patterns within key brainstem regions.
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Practical approaches to sedation and analgesia in the newborn. J Perinatol 2021; 41:383-395. [PMID: 33250515 PMCID: PMC7700106 DOI: 10.1038/s41372-020-00878-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/06/2020] [Accepted: 11/12/2020] [Indexed: 11/08/2022]
Abstract
The prevention, assessment, and treatment of neonatal pain and agitation continues to challenge clinicians and researchers. Substantial progress has been made in the past three decades, but numerous outstanding questions remain. In this setting, clinicians must establish safe and compassionate standardized practices that consider available efficacy data, long-term outcomes, and research gaps. Novel approaches with limited data must be carefully considered against historic standards of care with robust data suggesting limited benefit and clear adverse effects. This review summarizes available evidence while suggesting practical clinical approaches to pain assessment and avoidance, procedural analgesia, postoperative analgesia, sedation during mechanical ventilation and therapeutic hypothermia, and the issues of tolerance and withdrawal. Further research in all areas represents an urgent priority for optimal neonatal care. In the meantime, synthesis of available data offers clinicians challenging choices as they balance benefit and risk in vulnerable critically ill neonates.
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Chen J, Salerno D, Breslin N, Chowdhury T, Lobritto S, Martinez M, Goldner D, Vittorio J. Concomitant tacrolimus and ketorolac therapy in pediatric liver transplant recipients: Teaching old dogma new tricks. Clin Transplant 2020; 35:e14141. [PMID: 33145821 DOI: 10.1111/ctr.14141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/24/2020] [Indexed: 11/29/2022]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ketorolac, are effective analgesic medications, but concerns for nephrotoxicity have limited their role for pain control following pediatric liver transplantation (LT). Calcineurin inhibitors (CNIs) and NSAIDs share a similar mechanism of nephrotoxicity, and concomitant administration is traditionally discouraged. A retrospective review of pediatric LT recipients was conducted between 1/1/2015 and 12/31/2019 at a single center. Patients were stratified based on receipt of ketorolac. The primary outcome was the incidence of acute kidney injury (AKI). Secondary outcomes included serum creatinine, urine output, estimated glomerular filtration rate, bleeding incidence, oral morphine milligram equivalents, and hospital length of stay (LOS). The incidence of AKI was similar between the two groups with 25.8% of patients in the ketorolac group versus 29.2% of patients in the nonketorolac group (p = .475) meeting criteria in the first 10 days post-transplant. Opioid requirements were less in the ketorolac group (p < .001), who also demonstrated shorter LOS compared with nonketorolac patients (p = .033). Concurrent CNI and ketorolac use did not result in an increased incidence of AKI in the early post-LT period and resulted in significantly lower opioid requirements along with a decreased hospital LOS.
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Affiliation(s)
- Justin Chen
- Department of Pharmacy, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - David Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| | - Nadine Breslin
- Department of Pharmacy, North Shore University Hospital, Manhasset, NY, USA
| | - Tasnim Chowdhury
- College of Pharmacy and Health Sciences, St. John's University, Queens, NY, USA
| | - Steven Lobritto
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Mercedes Martinez
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Dana Goldner
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Jennifer Vittorio
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
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Pankaj A, Oraka K, Caraballo-Rivera EJ, Ahmad M, Zahid S, Munir S, Gurumurthy G, Okoeguale O, Verma S, Patel RS. Recreational Cannabis Use and Risk of Prescription Opioid Overdose: Insights from Pediatric Inpatients. Cureus 2020; 12:e11058. [PMID: 33224654 PMCID: PMC7676440 DOI: 10.7759/cureus.11058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objectives Our first goal is to evaluate the prevalence of hospital admissions for prescription opioid overdose (POD) in pediatric inpatients, and next goal is to measure the independent association between cannabis use disorders (CUD) and POD. Methods We used the nationwide inpatient sample (NIS) and included 27,444,239 pediatric inpatients (age ≤ 18 years), and 10,562 (0.04%) were managed primarily for POD. The odds ratio (OR) of the association of variables in POD inpatients was measured using the binomial logistic regression model that was adjusted for demographic confounders and psychiatric comorbidities. Results Adolescents have higher odds (OR 10.75, 95% CI 10.16-11.36) of POD-related hospitalization compared to children ≤ 12 years. Whites formed the significant proportion (67%), and those from low-income families (<50th percentile) had higher likelihood for POD-related hospitalization. The most prevalent psychiatric comorbidities were mood disorders (44.3%) and anxiety disorders (14.6%). Prevalent comorbid substance use disorders (SUDs) included cannabis (14.2%), tobacco (13.1%), and opioid (9.4%). A higher odds of association with POD-related hospitalizations were seen in pediatric inpatients with comorbid opioid (OR 8.79, 95% CI 8.08-9.56), tobacco (OR 1.58, 95% CI 1.47-1.70), and cannabis (OR 1.68, 95% CI 1.57-1.81) use disorders. Conclusion The prescription opioid is a bridge to opioid abuse/dependence, thereby increasing the risk of other SUDs like tobacco (by 58%) and cannabis (by 68%). Regulating the easy availability of prescription opioids and also improving the existing prescription trends are an essential way to reduce this problem. Finally, awareness and counseling are recommended strategies for harm reduction/rehabilitation among the pediatric population.
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Affiliation(s)
- Amaya Pankaj
- Pediatric Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | | | | | - Munazza Ahmad
- Medicine, Lahore Medical & Dental College, Lahore, PAK
| | - Shaheer Zahid
- Psychiatry, Saint James School of Medicine, Park Ridge, USA
| | - Sadaf Munir
- Psychiatry, Jersey Shore University Medical Center, Neptune, USA
| | | | - Onose Okoeguale
- Psychiatry, Vinnytsia National Medical University, Vinnytsia, UKR
| | - Shikha Verma
- Psychiatry and Behavioral Sciences, Rogers Behavioral Health, Kenosha, USA
| | - Rikinkumar S Patel
- Psychiatry and Behavioral Sciences, Oklahoma State University, Tulsa, USA.,Psychiatry, Griffin Memorial Hospital, Norman, USA
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Conrad P, Meyer S, Whiting J, Connor JA. Iatrogenic withdrawal syndrome in specialty pediatric critical care. Appl Nurs Res 2020; 55:151284. [DOI: 10.1016/j.apnr.2020.151284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/01/2020] [Accepted: 05/07/2020] [Indexed: 11/28/2022]
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