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Kolmar AR, Bravo D, Fonseca RA, Kramer MA, Wang J, Guilliams KP, Fuller BM. Impact of Benzodiazepines on Outcomes of Mechanically Ventilated Pediatric Intensive Care Patients: A Retrospective Cohort Study. Crit Care Explor 2025; 7:e1255. [PMID: 40293788 PMCID: PMC12040031 DOI: 10.1097/cce.0000000000001255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2025] Open
Abstract
IMPORTANCE Benzodiazepines are the most frequently used sedatives in PICUs, but they are increasingly associated with negative outcomes. Understanding their impact on patient outcomes is critical to provide better sedative management for patients. OBJECTIVE Our objective was to determine the impact of midazolam and lorazepam on clinical outcomes among subjects requiring mechanical ventilation in the PICU. We hypothesized that subjects receiving benzodiazepines for tolerance of mechanical ventilation will demonstrate worse clinical outcomes when compared with those not receiving benzodiazepines. DESIGN Single-center, retrospective cohort study. SETTING AND PARTICIPANTS PICU of a tertiary-care medical center. One thousand fifty-four pediatric participants requiring invasive mechanical ventilation between June 2018 and December 2022. Participants were categorized into those who received benzodiazepine-inclusive sedation regimens (n = 747) and those who received nonbenzodiazepine regimens (n = 307). INTERVENTIONS None. MAIN OUTCOMES AND MEASURES Subjects were sorted into groups of benzodiazepine-sedative regimens (midazolam and lorazepam, only lorazepam) or nonbenzodiazepine-sedation regimens. The primary outcome was ventilator-free days (VFDs). Statistical analysis was performed using multivariable linear regression and propensity-score matching. RESULTS Subjects receiving continuous and/or intermittent benzodiazepines had fewer VFDs compared with the nonbenzodiazepine group (median 21.0 vs. 26.7; p < 0.001). The benzodiazepine group had fewer ICU-free and hospital-free days, higher delirium scores, and a greater need for withdrawal-tapering medications. This was redemonstrated in subjects only receiving intermittent benzodiazepines as well. Younger subjects were more likely to receive benzodiazepines. CONCLUSIONS AND RELEVANCE Our study demonstrates an association between children receiving both continuous and intermittent benzodiazepine sedation and worse clinical outcomes. These patients have fewer VFDs and longer length of stay, higher doses of nonbenzodiazepine sedatives, and increased need for withdrawal tapering medications and antipsychotics. It is unclear in this retrospective study if the outcomes were worse because the subjects received benzodiazepines or because subjects receiving benzodiazepines were sicker and thus required benzodiazepines in their analgosedative regimen. Further investigation is warranted into the impact of benzodiazepines on patient outcomes, nonpharmacologic management of sedation, improvement in bedside assessment of analgosedation, and optimal balance between over- and under-sedation.
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Affiliation(s)
- Amanda R. Kolmar
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, MO
| | - Daniela Bravo
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, MO
| | - Ricardo A. Fonseca
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Michael A. Kramer
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, MO
| | - Jinli Wang
- Center for Biostatistics and Data Science, Washington University School of Medicine, St. Louis, MO
| | - Kristin P. Guilliams
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, MO
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
- Department of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Brian M. Fuller
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO
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Madden K, Wolf M, Tasker RC, Figueroa J, McCracken C, Hall M, Kamat P. Antipsychotic Drug Prescription in Pediatric Intensive Care Units: A 10-Year U.S. Retrospective Database Study. J Pediatr Intensive Care 2024; 13:46-54. [PMID: 38571986 PMCID: PMC10987219 DOI: 10.1055/s-0041-1736523] [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: 07/10/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022] Open
Abstract
Delirium recognition during pediatric critical illness may result in the prescription of antipsychotic medication. These medications have unclear efficacy and safety. We sought to describe antipsychotic medication use in pediatric intensive care units (PICUs) contributing to a U.S. national database. This study is an analysis of the Pediatric Health Information System Database between 2008 and 2018, including children admitted to a PICU aged 0 to 18 years, without prior psychiatric diagnoses. Antipsychotics were given in 16,465 (2.3%) of 706,635 PICU admissions at 30 hospitals. Risperidone (39.6%), quetiapine (22.1%), and haloperidol (20.8%) were the most commonly used medications. Median duration of prescription was 4 days (interquartile range: 2-11 days) for atypical antipsychotics, and haloperidol was used a median of 1 day (1-3 days). Trend analysis showed quetiapine use increased over the study period, whereas use of haloperidol and chlorpromazine (typical antipsychotics) decreased ( p < 0.001). Compared with no antipsychotic administration, use of antipsychotics was associated with comorbidities (81 vs. 65%), mechanical ventilation (57 vs. 36%), longer PICU stay (6 vs. 3 days), and higher mortality (5.7 vs. 2.8%) in univariate analyses. In the multivariable model including demographic and clinical factors, antipsychotic prescription was associated with mortality (odds ratio [OR] = 1.09, 95% confidence interval [CI]: 1.02-1.18). Use of atypical antipsychotics increased over the 10-year period, possibly reflecting increased comfort with their use in pediatric patients. Antipsychotics were more common in patients with comorbidities, mechanical ventilation, and longer PICU stay, and associated with higher mortality in an adjusted model which warrants further study.
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Affiliation(s)
- Kate Madden
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Michael Wolf
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Robert C. Tasker
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Janet Figueroa
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, United States
| | - Pradip Kamat
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
- Division of Critical Care, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, United States
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Kolmar AR, Paton AM, Kramer MA, Guilliams KP. Differences in Delirium Evaluation and Pharmacologic Management in Children With Developmental Delay: A Retrospective Case-Control Study. J Intensive Care Med 2024; 39:170-175. [PMID: 37563949 PMCID: PMC10938448 DOI: 10.1177/08850666231194534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Delirium is associated with increased mortality and cost, decreased neurocognition, and decreased quality of life in the pediatric intensive care unit (PICU) population. The Cornell Assessment for Pediatric Delirium (CAPD) is used in PICUs for delirium screening but lacks specificity in children with developmental delay (DD). Within a cohort of children receiving pharmacologic treatment for intensive care unit (ICU) delirium, we compared delirium scoring and medication management between children with and without DD. We hypothesized that CAPD scores and treatment decisions would differ between DD and neurotypical (NT) patients. In this retrospective case-control study, we queried the medical record of patients admitted to our PICU with respiratory failure from June 2018 to March 2022 who received antipsychotics typically used for ICU delirium. Antipsychotics prescribed for home use were excluded. Nonparametric statistics compared demographics, CAPD scores, medication choice, dosing (mg/kg), and medication continuation after discharge between those with and without DD based on the ICD-10 codes. Twenty-one DD admissions and 59 NT admissions were included. Groups did not significantly differ by demographics, LOS, drug, or initial dosage. DD patients had higher median CAPD scores at admission (17 vs 13; P = .02) and treatment initiation (18 vs 16.5; P = .05). Providers more frequently escalated doses in DD patients (13/21 vs 21/59; P = .04) and discharged them home on new antipsychotics (7/21 vs 5/59; P = .01). DD patients experience delirium screening and management differently than NT counterparts. Providers should be aware of baseline elevated scores in DD patients and carefully attend to indications for dosage escalation. Further work is needed to understand if prolonged duration, even after hospital discharge, benefits patients, or represents potential disparity in care.
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Affiliation(s)
- Amanda R Kolmar
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Anneliese M Paton
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Michael A Kramer
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Kristin P Guilliams
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Department of Neurology, Division of Pediatric and Developmental Neurology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Mallinckrodt Institution of Radiology, Division of Neuroradiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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Bradford CV, Fung MY, Wang A, Benefield EC, Bashqoy F, Neely SB, Johnson PN. Delirium Assessment Treatment Strategies in Critically Ill Pediatric Patients: A Pediatric Pharmacy Association Practice-Based Research Network Survey Study. J Pediatr Pharmacol Ther 2023; 28:540-552. [PMID: 38130349 PMCID: PMC10731945 DOI: 10.5863/1551-6776-28.6.540] [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: 11/01/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2023]
Abstract
OBJECTIVES The purpose of this study was to describe overall screening, prevention, and treatments for pediatric delirium at various neonatal intensive care units (NICUs), cardiac intensive care units (CICUs), and pediatric intensive care units (PICUs) from the Pediatric Pharmacy Association (PPA) membership. The primary objective was to identify the number of respondents that had a defined delirium-based protocol. The secondary objectives included identification of delirium assessment tools used, first- and second-line delirium treatment options, and monitoring practices for antipsychotics for delirium management. METHODS A cross-sectional questionnaire was distributed to PPA members from February 8, 2022, to March, 25, 2022. Comparisons between the NICUs, PICUs, and CICUs were conducted by using chi-square tests, with a priori p value of <0.05. RESULTS The questionnaire was completed by 84 respondents at 62 institutions; respondents practiced in the PICU or mixed PICU (n = 48; 57.1%), CICU (n = 13; 15.5%), and NICU (n = 23; 27.4%). Sixty-one respondents (72.6%) noted their units routinely screen for delirium, and there was a significant difference between the respondents of different units that use a delirium scoring tool (p < 0.01). Only 33 respondents (39.3%) had a defined delirium protocol, and there was no difference between units (p = 0.31). The most common agents used for delirium treatment were quetiapine and risperidone. There was variability in the monitoring used between respondents, but the majority (n = 74; 88%) monitor electrocardiograms to assess the corrected QT interval, but practice variability existed. CONCLUSIONS Most respondents did not have a defined delirium protocol. Variations were noted in the treatment options and monitoring for critically ill pediatric patients with delirium.
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Affiliation(s)
- Caitlyn V. Bradford
- Department of Pharmacy Practice (CVB), Philadelphia College of Pharmacy, Saint Joseph’s University, Philadelphia, PA
| | - Mon-Yee Fung
- Department of Pharmacy (M-YF), University of Michigan MOTT Children’s Hospital, Ann Arbor, MI
| | - Alexander Wang
- Department of Pharmacy (AW), Children’s National Hospital, Washington, DC
| | | | - Ferras Bashqoy
- Department of Pharmacy (FB), Hassenfeld Children’s Hospital at NYU Langone Health, New York City, NY
| | - Stephen B. Neely
- Department of Pharmacy: Clinical and Administrative Sciences (SBN, PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Peter N. Johnson
- Department of Pharmacy: Clinical and Administrative Sciences (SBN, PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Abstract
The care of the critically ill child often includes medications used for the relief of pain and anxiety. Children have key differences in pharmacokinetics and pharmacodynamics compared with adults that should always be considered to achieve safe medication use in this population. Pain must be addressed, and sedative use should be minimized when possible. Our understanding of sedation safety is evolving, and studies have shown that minimizing exposure to multiple medications can reduce the burden of delirium and iatrogenic withdrawal.
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Affiliation(s)
- Kevin Valentine
- Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Suite 4900, Indianapolis, IN 46202, USA.
| | - Janelle Kummick
- Butler University College of Pharmacy and Health Sciences, Riley Hospital for Children, 705 Riley Hospital Drive, Room W6111, Indianapolis, IN 46202, USA
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Sanchez REA, Wrede JE, Watson RS, de la Iglesia HO, Dervan LA. Actigraphy in mechanically ventilated pediatric ICU patients: comparison to PSG and evaluation of behavioral circadian rhythmicity. Chronobiol Int 2021; 39:117-128. [PMID: 34634983 DOI: 10.1080/07420528.2021.1987451] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Sleep disruption is common in pediatric intensive care unit (PICU) patients, but measuring sleep in this population is challenging. We aimed to evaluate the utility of actigraphy for estimating circadian rhythmicity in mechanically ventilated PICU patients and its accuracy for measuring sleep by comparing it to polysomnogram (PSG). We conducted a single-center prospective observational study of children 6 months - 17 years of age receiving mechanical ventilation and standard, protocolized sedation for acute respiratory failure, excluding children with acute or historical neurologic injury. We enrolled 16 children and monitored them with up to 14 days of actigraphy and 24 hours of simultaneous limited (10 channel) PSG. Daily actigraphy-based activity profiles demonstrated that patients had a high level of nighttime activity (30-41% of total activity), suggesting disrupted circadian activity cycles. Among n = 12 patients with sufficient actigraphy and PSG data overlap, actigraphy-based sleep estimation showed poor agreement with PSG-identified sleep states, with good sensitivity (94%) but poor specificity (28%), low accuracy (70%,) and low agreement (Cohen's kappa = 0.2, 95% CI = 0.08-0.31). Using univariate linear regression, we identified that Cornell Assessment of Pediatric Delirium scores were associated with accuracy of actigraphy but that other clinical factors including sedative medication doses, activity levels, and restraint use were not. In this population, actigraphy did not reliably discern between sleep and wake states. However, in select patients, actigraphy was able to distinguish diurnal variation in activity patterns, and therefore may be useful for evaluating patients' response to circadian-oriented interventions.
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Affiliation(s)
| | - Joanna E Wrede
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA.,Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington, USA
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA.,Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Horacio O de la Iglesia
- Department of Biology, University of Washington, Seattle, Washington, USA.,Graduate Program in Neuroscience, University of Washington, Seattle, Washington, USA
| | - Leslie A Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
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