1
|
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.
Collapse
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
| | | | | |
Collapse
|
2
|
Long DA, Gibbons KS, Stocker C, Ranger M, Alphonso N, Le Marsney R, Dow B, Schults JA, Graydon C, Shehabi Y, Schibler A. Perioperative dexmedetomidine compared to midazolam in children undergoing open-heart surgery: A pilot randomised controlled trial. CRIT CARE RESUSC 2023; 25:33-42. [PMID: 37876986 PMCID: PMC10581262 DOI: 10.1016/j.ccrj.2023.04.007] [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: 10/26/2023]
Abstract
Objective There is a need for evidence on the best sedative agents in children undergoing open heart surgery for congenital heart disease. This study aimed to evaluate the feasibility and safety of dexmedetomidine in this group compared with midazolam. Design Double blinded, pilot randomized controlled trial. Setting Cardiac operating theatre and paediatric intensive care unit in Brisbane, Australia. Participants Infants (≤12 months of age) undergoing their first surgical repair of a congenital heart defect. Interventions Dexmedetomidine (up to 1.0mcg/kg/hr) versus midazolam (up to 80mcg/kg/hr), commenced in the cardiac operating theatre prior to surgery. Main outcome measures The primary outcome was the time spent in light sedation (Sedation Behavior Scale [SBS] -1 to +1); Co-primary feasibility outcome was recruitment, retention and protocol adherence. Secondary outcomes were use of supplemental sedatives, ventilator free days, delirium, vasoactive drug support, and adverse events. Neurodevelopment and health-related quality of life (HRQoL) were assessed at 12 months post-surgery. Results Sixty-six participants were recruited. The number of SBS scores in the light sedation range were greater in the dexmedetomidine group at 24 hours, 48 hours, and overall study duration (0-14 days) versus the midazolam group (24hr: 76/170 [45%] vs 60/178 [34%], aOR 4.14 [95% CI 0.48, 35.92]; 48hr: 154/298 [52%] vs 122/314 [39%], aOR 6.95 [95% CI 0.77, 63.13]; 0-14 days: 597/831 [72%] vs 527/939 [56%], aOR 3.93 [95% CI 0.62, 25.03]). Feasibility was established with no withdrawals or loss to follow-up at 14 days and minimal protocol deviations. There were no differences between the groups relating to clinical, safety, neurodevelopment or HRQoL outcomes. Conclusions The use of dexmedetomidine was associated with more time spent in light sedation when compared with midazolam. The feasibility of conducting a blinded RCT of midazolam and dexmedetomidine in children undergoing open heart surgery was also established. The findings justify further investigation in a larger trial. Clinical trial registration ACTRN12615001304527.
Collapse
Affiliation(s)
- Debbie A. Long
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Australia
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Australia
| | - Kristen S. Gibbons
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Australia
| | - Christian Stocker
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Australia
| | - Michael Ranger
- Department of Anaesthesia and Pain Management, Queensland Children's Hospital, Australia
| | - Nelson Alphonso
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Australia
- Department of Cardiac Surgery, Queensland Children's Hospital, Australia
| | - Renate Le Marsney
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Australia
| | - Belinda Dow
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Australia
| | - Jessica A. Schults
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Australia
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Australia
- School of Nursing, Midwifery and Social Work, The University of Queensland, Australia
| | - Cameron Graydon
- Department of Anaesthesia and Pain Management, Queensland Children's Hospital, Australia
| | - Yahya Shehabi
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | - Andreas Schibler
- Wesley Medical Research Institute, Australia
- Critical Care Research Group, St. Andrew's War Memorial Hospital, Australia
| |
Collapse
|
3
|
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: 160] [Impact Index Per Article: 80.0] [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.
Collapse
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
| |
Collapse
|
4
|
Lee JJ, Price JC, Gewandter J, Kleykamp BA, Biagas KV, Naim MY, Ward D, Dworkin RH, Sun LS. Design and reporting characteristics of clinical trials investigating sedation practices in the paediatric intensive care unit: a scoping review by SCEPTER (Sedation Consortium on Endpoints and Procedures for Treatment, Education and Research). BMJ Open 2021; 11:e053519. [PMID: 34649849 PMCID: PMC8522672 DOI: 10.1136/bmjopen-2021-053519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To conduct a scoping review of sedation clinical trials in the paediatric intensive care setting and summarise key methodological elements. DESIGN Scoping review. DATA SOURCES PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature and grey references including ClinicalTrials.gov from database inception to 3 August 2021. STUDY SELECTION All human trials in the English language related to sedation in paediatric critically ill patients were included. After title and abstract screening, full-text review was performed. 29 trials were eligible for final analysis. DATA EXTRACTION A coding manual was developed and pretested. Trial characteristics were double extracted. RESULTS The majority of trials were single centre (22/29, 75.9%), parallel group superiority (17/29, 58.6%), double-blinded (18/29, 62.1%) and conducted in an academic setting (29/29, 100.0%). Trial enrolment (≥90% planned sample size) was achieved in 65.5% of trials (19/29), and retention (≥90% enrolled subjects) in 72.4% of trials (21/29). Protocol violations were reported in nine trials (31.0%). The most commonly studied cohorts were mechanically ventilated patients (28/29, 96.6%) and postsurgical patients (11/29, 37.9%) with inclusion criteria for age ranging from 0±0.5 to 15.0±7.3 years (median±IQR). The median age of enrolled patients was 1.7 years (IQR=4.4 years). Patients excluded from trials were those with neurological impairment (21/29, 72.4%), complex disease (20/29, 69.0%) or receipt of neuromuscular blockade (10/29, 34.5%). Trials evaluated drugs/protocols for sedation management (20/29, 69.0%), weaning (3/29, 10.3%), daily interruption (3/29, 10.3%) or protocolisation (3/29, 10.3%). Primary outcome measures were heterogeneous, as were assessment instruments and follow-up durations. CONCLUSIONS There is substantial heterogeneity in methodological approach in clinical trials evaluating sedation in critically ill paediatric patients. These results provide a basis for the design of future clinical trials to improve the quality of trial data and aid in the development of sedation-related clinical guidelines.
Collapse
Affiliation(s)
| | - Jerri C Price
- Anesthesiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Jennifer Gewandter
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Bethea A Kleykamp
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Katherine V Biagas
- Pediatrics, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Maryam Y Naim
- Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Denham Ward
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Robert H Dworkin
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Lena S Sun
- Anesthesiology and Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| |
Collapse
|
5
|
Deng S, Yu Y. Effects of Dexmedetomidine as an Analgesic Adjuvant for Surgery of Femur Fracture: A Systematic Review and Meta-Analysis. Pharmacology 2021; 106:453-461. [PMID: 34167123 DOI: 10.1159/000515788] [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: 09/18/2020] [Accepted: 03/10/2021] [Indexed: 11/19/2022]
Abstract
Patients who undergo surgery of femur fracture suffer the excruciating pain. Dexmedetomidine (DEX) is a unique α2-adrenergic receptor agonist with sedative and analgesic properties, whose efficacy and safety are still unclear for surgery of femur fracture. Randomized controlled trials comparing the effects of addition of DEX to general or local anesthesia in surgery of femur fracture were searched from MEDLINE, EMBASE, and the Cochrane Library database. Patients who received DEX infusion had a significant longer time to rescue analgesia compared with those without DEX coadministration. DEX treatment seemed to reduce the visual analog score; however, the significance did not reach any statistical difference. DEX as an analgesic adjuvant did not reduce the onset of sensory block time, shorten the time to achieve maximum sensory block level, and provide a longer duration of sensory block. The difference in mean sedation scores between 2 groups was not statistically significant. As for adverse effects, DEX therapy significantly increased the rate of hypotension. In conclusion, dexmedetomidine as a local anesthetic adjuvant in femur fracture surgery had a longer duration of rescue analgesia. However, the incidence of hypotension was markedly increased in these patients. It was worth noting that the evidence was of low to moderate quality.
Collapse
Affiliation(s)
- Shan Deng
- Anesthesiology Department, Tianjin Hospital, Tianjin, China,
| | - Yonghao Yu
- Anesthesiology Department, Tianjin Medical University General Hospital, Tianjin, China
| |
Collapse
|
6
|
Abstract
BACKGROUND Targeted drug development efforts in patients with CHD are needed to standardise care, improve outcomes, and limit adverse events in the post-operative period. To identify major gaps in knowledge that can be addressed by drug development efforts and provide a rationale for current clinical practice, this review evaluates the evidence behind the most common medication classes used in the post-operative care of children with CHD undergoing cardiac surgery with cardiopulmonary bypass. METHODS We systematically searched PubMed and EMBASE from 2000 to 2019 using a controlled vocabulary and keywords related to diuretics, vasoactives, sedatives, analgesics, pulmonary vasodilators, coagulation system medications, antiarrhythmics, steroids, and other endocrine drugs. We included studies of drugs given post-operatively to children with CHD undergoing repair or palliation with cardiopulmonary bypass. RESULTS We identified a total of 127 studies with 51,573 total children across medication classes. Most studies were retrospective cohorts at single centres. There is significant age- and disease-related variability in drug disposition, efficacy, and safety. CONCLUSION In this study, we discovered major gaps in knowledge for each medication class and identified areas for future research. Advances in data collection through electronic health records, novel trial methods, and collaboration can aid drug development efforts in standardising care, improving outcomes, and limiting adverse events in the post-operative period.
Collapse
|
7
|
Reinert JP, Lang A, Veronin M. Dexmedetomidine as an adjunctive analgaesic in the perioperative setting: A review of the literature. J Perioper Pract 2021; 31:223-229. [PMID: 33906497 DOI: 10.1177/1750458920971108] [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: 11/17/2022]
Abstract
Though arguably past the initial phase of the opioid epidemic, opioid-sparing or opioid-eliminating pain management regimens remain beneficial for patients and practitioners alike. Providing adequate analgaesia without relying on opioids is especially advantageous in the operative setting, as patients may be able to recover without deep levels of sedation or the need for a high amount of opioid medications. Despite being used primarily as a sedative over the past 20 years, dexmedetomidine, a centrally acting alpha2-agonist, possesses analgaesic properties, though its use has been limited by its well-described cardiovascular suppressive effects. The objective of this review was to determine the efficacy and safety of adjunctive dexmedetomidine for the purposes of analgaesia in the perioperative setting.
Collapse
Affiliation(s)
- Justin P Reinert
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Andrew Lang
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Michael Veronin
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| |
Collapse
|
8
|
Gulla KM, Sankar J, Jat KR, Kabra SK, Lodha R. Dexmedetomidine vs Midazolam for Sedation in Mechanically Ventilated Children: A Randomized Controlled Trial. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2124-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
9
|
McPherson C, Ortinau CM, Vesoulis Z. 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: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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.
Collapse
Affiliation(s)
- Christopher McPherson
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
- Department of Pharmacy, St. Louis Children's Hospital, St. Louis, MO, USA.
| | - Cynthia M Ortinau
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Zachary Vesoulis
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Cavaliere F, Biancofiore G, Bignami E, De Robertis E, Giannini A, Grasso S, Piastra M, Scolletta S, Taccone FS, Terragni P. A year in review in Minerva Anestesiologica 2018. Critical care. Experimental and clinical studies. Minerva Anestesiol 2020; 85:95-105. [PMID: 30632731 DOI: 10.23736/s0375-9393.18.13524-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Franco Cavaliere
- Institute of Anesthesia and Intensive Care, Sacred Heart Catholic University, Rome, Italy -
| | - Gianni Biancofiore
- Transplant Anesthesia and Critical Care, University School of Medicine, Pisa, Italy
| | - Elena Bignami
- Division of Anesthesiology, Critical Care and Pain Medicine, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Edoardo De Robertis
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University of Naples, Naples, Italy
| | - Alberto Giannini
- Unit of Pediatric Anesthesia and Intensive Care, Ospedale dei Bambini, ASST - Spedali Civili di Brescia, Brescia, Italy
| | - Salvatore Grasso
- Division of Anesthesiology and Resuscitation, Department of Emergency and Organ Transplantation (DETO), Aldo Moro University of Bari, Policlinic Hospital, Bari, Italy
| | - Marco Piastra
- Pediatric Intensive Care Unit and Trauma Center, University Policlinic A. Gemelli IRCCS Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Sabino Scolletta
- Unit of Resuscitation, Critical Care, Anesthesia and Intensive Care, University Hospital of Siena, Siena, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Pierpaolo Terragni
- Division of Anesthesia and General Intensive Care, Department of Medical, Surgical and Experimental Sciences, Sassari University Hospital, University of Sassari, Sassari, Italy
| |
Collapse
|
12
|
Zuppa AF, Nicolson SC, Wilder NS, Ibla JC, Gottlieb EA, Burns KM, Stylianou M, Trachtenberg F, Ni H, Skeen TH, Andropoulos DB. Results of a phase 1 multicentre investigation of dexmedetomidine bolus and infusion in corrective infant cardiac surgery. Br J Anaesth 2019; 123:839-852. [PMID: 31623840 PMCID: PMC6993105 DOI: 10.1016/j.bja.2019.06.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 06/01/2019] [Accepted: 06/19/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Dexmedetomidine (DEX) is increasingly used intraoperatively in infants undergoing cardiac surgery. This phase 1 multicentre study sought to: (i) determine the safety of DEX for cardiac surgery with cardiopulmonary bypass; (ii) determine the pharmacokinetics (PK) of DEX; (iii) create a PK model and dosing for steady-state DEX plasma levels; and (iv) validate the PK model and dosing. METHODS We included 122 neonates and infants (0-180 days) with D-transposition of the great arteries, ventricular septal defect, or tetralogy of Fallot. Dose escalation was used to generate NONMEM® PK modelling, and then validation was performed to achieve low (200-300 pg ml-1), medium (400-500 pg ml-1), and high (600-700 pg ml-1) DEX plasma concentrations. RESULTS Five of 122 subjects had adverse safety outcomes (4.1%; 95% confidence interval [CI], 1.8-9.2%). Two had junctional rhythm, two had second-/third-degree atrioventricular block, and one had hypotension. Clearance (CL) immediately postoperative and CL on CPB were reduced by approximately 50% and 95%, respectively, compared with pre-CPB CL. DEX clearance after CPB was 1240 ml min-1 70 kg-1. Age at 50% maximum clearance was approximately 2 days, and that at 90% maximum clearance was 18 days. Overall, 96.1% of measured DEX concentrations fell within the 5th-95th percentile prediction intervals in the PK model validation. Dosing strategies are recommended for steady-state DEX plasma levels ranging from 200 to 1000 pg ml-1. CONCLUSIONS When used with a careful dosing strategy, DEX results in low incidence and severity of adverse safety events in infants undergoing cardiac surgery with cardiopulmonary bypass. This validated PK model should assist clinicians in selecting appropriate dosing. The results of this phase 1 trial provide preliminary data for a phase 3 trial of DEX neuroprotection. CLINICAL TRIALS REGISTRATION NCT01915277.
Collapse
Affiliation(s)
- Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nicole S Wilder
- Department of Anesthesiology, C.S. Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Juan C Ibla
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Erin A Gottlieb
- Department of Pediatric Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Kristin M Burns
- Heart Development and Structural Diseases Branch, Division of Cardiovascular Sciences, Bethesda, MD, USA
| | - Mario Stylianou
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Hua Ni
- New England Research Institutes, Watertown, MA, USA
| | - Tera H Skeen
- Department of Pediatric Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Dean B Andropoulos
- Department of Pediatric Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA.
| |
Collapse
|