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VOLUME 24 , ISSUE 6 ( June, 2020 ) > List of Articles

Pediatric Critical Care

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

Duangtip Tiacharoen, Rojjanee Lertbunrian, Jarin Veawpanich, Nattanicha Suppalarkbunlue, Nattachai Anantasit

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

DOI: 10.5005/jp-journals-10071-23465

License: CC BY-NC 4.0

Published Online: 22-10-2020

Copyright Statement:  Copyright © 2020; The Author(s).


Abstract

Aims: The prolonged use of benzodiazepines and opioids can lead to an increase in the incidence of withdrawal syndrome. One of the known risk factors is the lack of a sedative-weaning protocol. This study established a sedative-weaning protocol and compared this protocol with the usual care of weaning in high-risk critically ill children. Materials and methods: This was an open-label, randomized controlled trial in a tertiary-care hospital. We recruited children aged 1 month to 18 years who had received intravenous sedative or analgesic drugs for at least 5 days. The exclusion criteria were patients who had already experienced the withdrawal syndrome. We established a weaning protocol. Eligible patients were randomly divided into the protocolized (intervention) and usual care (control) groups. The primary objective was to determine the prevalence of the withdrawal syndrome compared between two groups. Results: Thirty eligible patients were enrolled (19 in the intervention and 11 in the control group). Baseline characteristics were not significantly different between both the groups. The prevalence of the withdrawal syndrome was 84% and 81% of patients in the intervention and control group, respectively. The duration of the initial weaning phase was shorter in the intervention group than in the control group (p value = 0.026). The cumulative dose of morphine solution for rescue therapy in the intervention group was statistically lower than that in the control group (p value = 0.016). Conclusion: The implementation of the sedative-weaning protocol led to a significant reduction in the percentage of withdrawal days and length of intensive care unit stay without any adverse drug reactions. External validation would be needed to validate this protocol. ClinicalTrials.gov identifier: NCT03018977

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  1. Katz R, Kelly HW, Hsi A. Prospective study on the occurrence of withdrawal in critically ill children who receive fentanyl by continuous infusion. Crit Care Med 1994;22(5):763–767. DOI: 10.1097/00003246-199405000-00009.
  2. Franck LS, Naughton I, Winter I. Opioid and benzodiazepine withdrawal symptoms in paediatric intensive care patients. Inten Crit Care Nurs 2004;20(6):344–351. DOI: 10.1016/j.iccn.2004.07.008.
  3. Ista E, van Dijk M, Gamel C, Tibboel D, de Hoog M. Withdrawal symptoms in critically ill children after long-term administration of sedatives and/or analgesics: a first evaluation. Crit Care Med 2008;36(8):2427–2432. DOI: 10.1097/CCM.0b013e318181600d.
  4. Best KM, Boullata JI, Curley MA. Risk factors associated with iatrogenic opioid and benzodiazepine withdrawal in critically ill pediatric patients: a systematic review and conceptual model. Pediatr Crit Care Med 2015;16(2):175–183. DOI: 10.1097/PCC.0000000000000306.
  5. Fonsmark L, Rasmussen YH, Carl P. Occurrence of withdrawal in critically ill sedated children. Crit Care Med 1999;27(1):196–199. DOI: 10.1097/00003246-199901000-00052.
  6. Fernández-Carrión F, Gaboli M, González-Celador R, Gómez de quero-Masía P, Fernández-De miguel S, Murga-Herrera V, et al. Withdrawal syndrome in the pediatric intensive care unit. incidence and risk factors. Med Intensiva 2013;37(2):67–74. DOI: 10.1016/j.medine.2012.02.010.
  7. Tobias JD. Tolerance, withdrawal, and physical dependency after long-term sedation and analgesia of children in the pediatric intensive care unit. Crit Care Med 2000;28(6):2122–2132. DOI: 10.1097/00003246-200006000-00079.
  8. Best KM, Asaro LA, Franck LS, Wypij D, Curley MA. Randomized evaluation of sedation titration for respiratory failure baseline study I. patterns of sedation weaning in critically ill children recovering from acute respiratory failure. Pediatr Crit Care Med 2016;17(1):19–29. DOI: 10.1097/PCC.0000000000000572.
  9. Best KM, Wypij D, Asaro LA, Curley MA. Randomized evaluation of sedation titration for respiratory failure study I. patient, process, and system predictors of iatrogenic withdrawal syndrome in critically ill children. Crit Care Med 2017;45(1):e7–e15. DOI: 10.1097/CCM.0000000000001953.
  10. Franck LS, Harris SK, Soetenga DJ, Amling JK, Curley MA. The withdrawal assessment tool-1 (WAT-1): an assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients. Pediatr Crit Care Med 2008;9(6):573–580. DOI: 10.1097/PCC.0b013e31818c8328.
  11. Curley MA, Harris SK, Fraser KA, Johnson RA, Arnold JH. State behavioral scale: a sedation assessment instrument for infants and young children supported on mechanical ventilation. Pediatr Crit Care Med 2006;7(2):107–114. DOI: 10.1097/01.PCC.0000200955.40962.38.
  12. Altman DG, Schulz KF, Moher D, Egger M, Davidoff F, Elbourne D, et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med 2001;134(8):663–694. DOI: 10.7326/0003-4819-134-8-200104170-00012.
  13. Oschman A, McCabe T, Kuhn RJ. Dexmedetomidine for opioid and benzodiazepine withdrawal in pediatric patients. Am J Health Syst Pharm 2011;68(13):1233–1238. DOI: 10.2146/ajhp100257.
  14. Ista E, van Dijk M, Gamel C, Tibboel D, de Hoog M. Withdrawal symptoms in children after long-term administration of sedatives and/or analgesics: a literature review. “assessment remains troublesome”. Intensive Care Med 2007;33(8):1396–1406. DOI: 10.1007/s00134-007-0696-x.
  15. Robertson RC, Darsey E, Fortenberry JD, Pettignano R, Hartley G. Evaluation of an opiate-weaning protocol using methadone in pediatric intensive care unit patients. Pediatr Crit Care Med 2000;1(2):119–123. DOI: 10.1097/00130478-200010000-00005.
  16. Meyer MM, Berens RJ. Efficacy of an enteral 10-day methadone wean to prevent opioid withdrawal in fentanyl-tolerant pediatric intensive care unit patients. Pediatr Crit Care Med 2001;2(4):329–333. DOI: 10.1097/00130478-200110000-00009.
  17. Siddappa R, Fletcher JE, Heard AM, Kielma D, Cimino M, Heard CM. Methadone dosage for prevention of opioid withdrawal in children. Paediatr Anaesth 2003;13(9):805–810. DOI: 10.1046/j.1460-9592.2003.01153.x.
  18. Berens RJ, Meyer MT, Mikhailov TA, Colpaert KD, Czarnecki ML, Ghanayem NS, et al. A prospective evaluation of opioid weaning in opioid-dependent pediatric critical care patients. Anesth Analg 2006;102(4):1045–1050. DOI: 10.1213/01.ane.0000202395.94542.3e.
  19. Jeffries SA, McGloin R, Pitfield AF, Carr RR. Use of methadone for prevention of opioid withdrawal in critically ill children. Can J Hosp Pharm 2012;65(1):12–18. DOI: 10.4212/cjhp.v65i1.1098.
  20. Giby K, Vaillancourt R, Varughese N, Vadeboncoeur C, Pouliot A. Use of methadone for opioid weaning in children: prescribing practices and trends. Can J Hosp Pharm 2014;67(2):149–156. DOI: 10.4212/cjhp.v67i2.1342.
  21. Dervan LA, Yaghmai B, Watson RS, Wolf FM. The use of methadone to facilitate opioid weaning in pediatric critical care patients: a systematic review of the literature and meta-analysis. Paediatr Anaesth 2017;27(3):228–239. DOI: 10.1111/pan.13056.
  22. Honey BL, Benefield RJ, Miller JL, Johnson PN. Alpha2-receptor agonists for treatment and prevention of iatrogenic opioid abstinence syndrome in critically ill patients. Ann Pharmacother 2009;43(9):1506–1511. DOI: 10.1345/aph.1M161.
  23. Srinivasan V, Pung D, O'Neill SP. Conversion from prolonged intravenous fentanyl infusion to enteral methadone in critically ill children. World J Clin Pediatr 2017;6(2):110–117. DOI: 10.5409/wjcp.v6.i2.110.
  24. Carnevale FA, Ducharme C. Adverse reactions to the withdrawal of opioids and benzodiazepines in paediatric intensive care. Inten Crit Care Nurs 1997;13(4):181–188. DOI: 10.1016/s0964-3397(97)80012-2.
  25. Bowens CD, Thompson JA, Thompson MT, Breitzka RL, Thompson DG, Sheeran PW. A trial of methadone tapering schedules in pediatric intensive care unit patients exposed to prolonged sedative infusions. Pediatr Crit Care Med 2011;12(5):504–511. DOI: 10.1097/PCC.0b013e3181fe38f5.
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